What would you do in this situation?

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jdox0776

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911 call dispatched breathing problems. Pt had BP 200/110, RR 30 labored, diminished breath sounds bilaterally, tachypnic, diaphoretic peril, spO2 94%, glucose 208, seizure hx due to metabolic disorder (malabsorption of Calcium, potassium, magnesium)

Would you perform ECG (cardiac monitoring)? capnography waveform?, apply o2? IV access? Load and go VS stay and play?
 
How old is this patient? Male or female? Any other med Hx? HTN, DM, CHF? Any other symptoms, chest pain? Been sick lately? Has this been going on for days or hours?

If I was BLS I would probly O2 @2L, request ALS intercept and transport Code 2, no reason to hang around.

ALS interventions would depend on a more thorough Hx and physical exam.
 
What's the pulse rate? O2, maybe capo if I'm feeling fancy, 12-lead, and establish a saline lock just incase I need it later on, and then a nice drive to the ED.

Edit: I may also consider a breathing treatment.
 
Is this acute or slow onset? If slow-er onset, I'm thinking pneumonia. If lung sounds are diminished, could be so much buildup that you just don't notice the fluid. I'm NRB at 10-15 and coaching at this point. If they continue to degrade, BVM. If they don't degrade further, considering CPAP. Not much reason to stay and play. Code 1 to ED, upgrade if they continue to deteriorate. Curious of the answers to the other Hx questions?

I'd 12 lead if they have more history than the metabolic disorder and aren't a minor.
 
I would recommend seeking a lawyer's opinion, as was recommended on the other website where you asked this question.
 
ERDoc said:
I would recommend seeking a lawyer's opinion, as was recommended on the other website where you asked this question.
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That would be for legal advice. This is looking for practical advice. I would bet most scenarios on this forum are from real world calls, and the poster is looking for another opinion. There is nothing wrong with trying to better your practice.
 
I'll stay out of it, but on the other site, it ended up she was looking for legal advice to start a lawsuit and even had an RN relative chime in.
 
ERDoc said:
I'll stay out of it, but on the other site, it ended up she was looking for legal advice to start a lawsuit and even had an RN relative chime in.
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No worries, I don't mean to harp on you. Hopefully the OP has read the rules here and understands that they won't get any legal advice in the event that this escalated to a point beyond being a scenario.
 
No problem. I know I'm the new guy so it's all good. Unfortunately the other site underwent an upgrade (reverse perhaps) and the thread is gone.
 
beano said:
How old is this patient? Male or female? Any other med Hx? HTN, DM, CHF? Any other symptoms, chest pain? Been sick lately? Has this been going on for days or hours?

If I was BLS I would probly O2 @2L, request ALS intercept and transport Code 2, no reason to hang around.

ALS interventions would depend on a more thorough Hx and physical exam.
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39 yoa male, pulse 98, acute tachypnic onset, no hx of heart disease, hx metabolic disorder (malabsorption of calcium, potassium, magnesium) chest pain, slightly altered LOC, possibility metabolic levels were low as he had been out of his meds
 
jdox0776 said:
39 yoa male, pulse 98, acute tachypnic onset, no hx of heart disease, hx metabolic disorder (malabsorption of calcium, potassium, magnesium) chest pain, slightly altered LOC, possibility metabolic levels were low as he had been out of his meds
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What meds is he out of?

As I already stated, at the BLS level nothing much would change...maybe a little effort to actually make the intercept rather than just request it, depending on what the 12-lead says. Oh wait I dont have that I'm still BLS.

What was this guy up to when this all started happening?

Slightly altered make me a little less inclined to go Code2 although I don't know what slightly altered means. Is he altered or slow to respond? GCS? LOC?

How about a Neuro exam?

If I had all the toys I would certainly want a 12-lead, pulse ox and even capnography.

Not convinced this is an electrolyte problem...
 
Out of his Calcitriol for hypoparathyroidism, GCS 15 initially, fully conscious, alert/oriented initially then confusion (slow to respond), neuro intact. He had just awakened when it occurred.
 
Here is the rhythm, for leads II to III. No 12 lead was done.
 

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Is this a BLS or an ALS call? If it's a BLS call, we have to assume we have no EKG info, no IV access/drugs, no capnography. There isn't really much BLS is going to do for this patient besides calling for ALS intercept... And once the ALS gets there, there isn't much they can do either.

Rhythm strip looks like bad news bears. 12 lead, aspirin nitro transport to PCI facility most likely?
 
jdox0776 said:
I just wanted an opinion, not asking for legal advice, don't need it.
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Its a STEMI. I need 2 leads of greater than > 1 mm ST Elevation, and that looks like it would fit the bill. To ask again, is it an ALS or BLS response? If its BLS getting the 2 lead, then we know we need to get to a PCI center now. This will soon be a time dependent emergency (if you don't consider it one already), and ALS won't save this guy. If you can get an intercept now or en route with little to no delay, then hell yes, get a solid 12 lead and make sure. If it was originally an ALS response, I would've hoped for a 12 lead to start. But now its certainly needed.

Diminished lung sounds are interesting. But my guess here is that the breathing is so labored and shallow that it isn't worth much of a listen. If I can't get even a 5 lead now or very soon, be it mine or ALS, I'm code 3 to a PCI center (if it would make a difference in the area, naturally). Consider down grade if improvement is shown en route.
 
Grimes said:
Its a STEMI. I need 2 leads of greater than > 1 mm ST Elevation, and that looks like it would fit the bill. To ask again, is it an ALS or BLS response? If its BLS getting the 2 lead, then we know we need to get to a PCI center now. This will soon be a time dependent emergency (if you don't consider it one already), and ALS won't save this guy. If you can get an intercept now or en route with little to no delay, then hell yes, get a solid 12 lead and make sure. If it was originally an ALS response, I would've hoped for a 12 lead to start. But now its certainly needed.

Diminished lung sounds are interesting. But my guess here is that the breathing is so labored and shallow that it isn't worth much of a listen. If I can't get even a 5 lead now or very soon, be it mine or ALS, I'm code 3 to a PCI center (if it would make a difference in the area, naturally). Consider down grade if improvement is shown en route.
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I wouldn't call a STEMI by way of a 2 lead reading. Almost guarantee it is one, but you really should have a 12 lead.
 
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