HappyParamedicRN
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Had a call today, just wondering what other paramedics would have done...
69 year old male PMH of Chronic renal failure (last dialyis the day before), CHF, Heart transplant (15 years ago), HTN, and Non insulin dependent diabetes.
Got called for the altered mental status. Upon arrival the wife states patient was just discharged yesterday from a major hospital after being transferred there. He was at a community hopsital for a complaint of shortness of breath and they could not figure out why (r/o PE, pneumonia) sent to tertiary care for further testing adn they too could not find anything and assumed he was possible fluid overloaded secondary to his CRF. Discharged yesterday home.
Wife reports last night patient became increasingly confused, was getting out of bed and just standing up without reason. Altered mental status became worse prompting a call to 911. On our arrival patient is alert and oriented x 3, sitting on the edge of a bed with slight increase in work of breathing and an isolated complaint of s.o.b. Eyes were noted to be deviated up. He denied pain or discomfort and was pale, warm, and dry. FD unable to get a saturation prior to putting him on a NRM. Lung sounds were clear and equal bilaterally with good air movement slight crackles heard in the bases. Radial pulses were weak, but patient had shunts in both arms (one working and an old one).
VS in the house: 112/80
HR high 80s
RR 24-26
Sat: unable to obtain, pt on a NRM
Paitent was extricated and on entering the truck patinet became more confused and has a significant increase in his work of breathing. Lung sounds now absent bilaterally. Paitent using accessory muscle and druing transport patient became restless and uncooperative. He stated multiple times "I cannot breath, help me" and was pulling off the NRM. In my state we do not have RSI and cannot even sedate to facilitate intubation.
Vitals: 90/p HR in the 90s sinus, no ectopy. RR 32-36 . Lowest oxygen sat was 93% on NRM; however he would not keep the probe on towards the end of transport. Unable to obtain 12 lead because of combativeness. Patient now a bit mottled. No longer following commands.
Just as we were about to pull into the hospital driveway patient became non-verbal and then becamse unresponsive with some non-purposeful flexion in his upper extremiteis with strong stimuli. No seizure activity present, he moaned once wtih the painful stimuli as well. Resps became more gasping so I opted to attempt oral intubation even though he was semi conscious.
Bagged him with a BVM and then got the tube on the first attempt, he was an easy airway. No gag reflex; however once we started bagging him he began fighting us alittle bit, but thankfully we were at the hospital so they could sedate him as soon as we hit the room, which they did.
The doctor seemed a little confused as to why we tubed him, although I explained the whole senerio to him which he was half listening to. I have no doubt that this guy needed a tube though.
Would you have tubed this guy without being able to sedate him? Would you have tubed this guy at all?
What do you think about his lung sounds and such a significant change over a 5 minute period?
I hesitated on giving him albuterol because I was worried that he may have filled up with CHF when he put those legs up and may have had severe bronchospasm from that. I hesitated to treat him for CHF thoughbecause of his BP and the fact that his lungs were so dim I couldn't here sh*t. He had no hx of COPD or asthma that the wife stated. No inhalers. I was also wondering if there was a neuro component to this since the AMS started last night with no reports of s.o.b. and as stated previosly his eyes deviated upward which I have never seen before. Or was he in a metabolic acidosis that was causing the tachypnea and AMS... He was a mystery.
Post intubation ETCO2 was 69, which leads me to believe that this indeed may have been resp failure, but I am wondering if there was more to him. He had no "shark fin" on his end tidal wave for though for someone with barely any air movement at all. No frothy pink fluid up the tube either.
Any ideas?
Happy
69 year old male PMH of Chronic renal failure (last dialyis the day before), CHF, Heart transplant (15 years ago), HTN, and Non insulin dependent diabetes.
Got called for the altered mental status. Upon arrival the wife states patient was just discharged yesterday from a major hospital after being transferred there. He was at a community hopsital for a complaint of shortness of breath and they could not figure out why (r/o PE, pneumonia) sent to tertiary care for further testing adn they too could not find anything and assumed he was possible fluid overloaded secondary to his CRF. Discharged yesterday home.
Wife reports last night patient became increasingly confused, was getting out of bed and just standing up without reason. Altered mental status became worse prompting a call to 911. On our arrival patient is alert and oriented x 3, sitting on the edge of a bed with slight increase in work of breathing and an isolated complaint of s.o.b. Eyes were noted to be deviated up. He denied pain or discomfort and was pale, warm, and dry. FD unable to get a saturation prior to putting him on a NRM. Lung sounds were clear and equal bilaterally with good air movement slight crackles heard in the bases. Radial pulses were weak, but patient had shunts in both arms (one working and an old one).
VS in the house: 112/80
HR high 80s
RR 24-26
Sat: unable to obtain, pt on a NRM
Paitent was extricated and on entering the truck patinet became more confused and has a significant increase in his work of breathing. Lung sounds now absent bilaterally. Paitent using accessory muscle and druing transport patient became restless and uncooperative. He stated multiple times "I cannot breath, help me" and was pulling off the NRM. In my state we do not have RSI and cannot even sedate to facilitate intubation.
Vitals: 90/p HR in the 90s sinus, no ectopy. RR 32-36 . Lowest oxygen sat was 93% on NRM; however he would not keep the probe on towards the end of transport. Unable to obtain 12 lead because of combativeness. Patient now a bit mottled. No longer following commands.
Just as we were about to pull into the hospital driveway patient became non-verbal and then becamse unresponsive with some non-purposeful flexion in his upper extremiteis with strong stimuli. No seizure activity present, he moaned once wtih the painful stimuli as well. Resps became more gasping so I opted to attempt oral intubation even though he was semi conscious.
Bagged him with a BVM and then got the tube on the first attempt, he was an easy airway. No gag reflex; however once we started bagging him he began fighting us alittle bit, but thankfully we were at the hospital so they could sedate him as soon as we hit the room, which they did.
The doctor seemed a little confused as to why we tubed him, although I explained the whole senerio to him which he was half listening to. I have no doubt that this guy needed a tube though.
Would you have tubed this guy without being able to sedate him? Would you have tubed this guy at all?
What do you think about his lung sounds and such a significant change over a 5 minute period?
I hesitated on giving him albuterol because I was worried that he may have filled up with CHF when he put those legs up and may have had severe bronchospasm from that. I hesitated to treat him for CHF thoughbecause of his BP and the fact that his lungs were so dim I couldn't here sh*t. He had no hx of COPD or asthma that the wife stated. No inhalers. I was also wondering if there was a neuro component to this since the AMS started last night with no reports of s.o.b. and as stated previosly his eyes deviated upward which I have never seen before. Or was he in a metabolic acidosis that was causing the tachypnea and AMS... He was a mystery.
Post intubation ETCO2 was 69, which leads me to believe that this indeed may have been resp failure, but I am wondering if there was more to him. He had no "shark fin" on his end tidal wave for though for someone with barely any air movement at all. No frothy pink fluid up the tube either.
Any ideas?
Happy
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