woman down

[Angel]

I'm bored so here's a scenario

It's the middle of a sunny afternoon and you are dispatched to a bus stop for an unresponsive female. as you and the engine pull up, you see bus security wave you in and hes pointing to the patient.

that's all you get for now.

 

[NomadicMedic]

Initial assessment. Vitals. BG. 12 lead.

 

[Angel]

as you walk up to the patient she is slumped to the side, she does not wake up or make any eye contact as you call out "Ma'am" you notice some "belly breathing" but it appears shallow.

vitals: P 106 weak, regular, R ~4 and shallow, BP 118/74, BGL 132
4 lead: S-Tach 12 lead: same

your nearest hospital is approx 18 mins away, with no traffic

 

[NomadicMedic]

Pupils? Skin signs? Pulse ox.

NPA and BVM while you get out the Narcan.

 

[DrParasite]

how old is she? any odor of alcohol? anything in her pockets (needles, medications, etc)? how are her pupils? any signs of trauma? any witnesses see what happened prior to this incident?

initial differential diagnosis would be an overdose.

initial intervention would be a BVM to increase her respirations. see if some narcan helps her respirations. if not, consider tubing her and taking her to the hospital.

 

[Angel]

sorry forgot about her age, you estimate her age to be 30 years old

skin sx: warm and dry
pupils: 2, both inside (ambulance) and outside
SpO2: 89%

no odor of ETOH but as you're loading her into the back of the ambulance, someone hands you a purse. Captain comes up and states per security she was there ~15 mins and he thought she was sleeping but wasn't able to wake her up so called 911

you initiate NPA and BVM, SpO2 increases to 100%

now heres the question, what route are you going to give the narcan? IV or IN?

 

[chaz90]

IN Narcan, dose of ~1 mg. Patiently continue using BVM while hooked up to EtCO2 and monitor for increase in spontaneous resps. If the initial IN dose doesn't start to increase resps after ~10 minutes, consider use of titrated IV Narcan and be looking towards intubation if that doesn't work.

 

[Angel]

1mg IN narcan does not work and after 2 attempts you can not get an IV

your partner continues bagging without difficulty

 

[chaz90]

Hmm. IN Narcan doesn't work to even slightly increase respiratory effort? Evidently this is a route based scenario. Well, not to get too bogged down on one pathway, but this lady still screams OD. Give some IM Narcan, have someone else try for an IV in unconventional sites, look for an EJ, or go for an IO if you must. If the Narcan through any and all routes continues to fail, we're going to have to have some kind of IV/IO access for intubation anyway.

 

[STXmedic]

I'm with Chaz, IM narcan and get a line. She screams OD.

What's in her purse? Any pill bottles in it, or anything to hint towards medical conditions. Any track marks on her?

Further vitals- temp? EtCO2 (I'm sure it's high, but I'd have her on one anyway), is she responsive to pain? If so, to what extent? ie localizing, withdraw, etc. Does she arouse with pain and able to follow commands? Any obvious signs of facial droop?

 

[DesertMedic66]

Hmm. IN Narcan doesn't work to even slightly increase respiratory effort? Evidently this is a route based scenario. Well, not to get too bogged down on one pathway, but this lady still screams OD. Give some IM Narcan, have someone else try for an IV in unconventional sites, look for an EJ, or go for an IO if you must. If the Narcan through any and all routes continues to fail, we're going to have to have some kind of IV/IO access for intubation anyway.

Same treatment that I would do. Continue to bag the patient with an NPA in place. If IN Narcan had no effect I would go to IM as I have another provider look for other IV sites (foot, ankle, EJ). If I still have no line established and the IM Narcan gives no response then I am going to drill the patient. Either proximal tibia or humoral. For my area I would have to contact base in order to titrate Narcan to respiratory dive but still keep the patient under, so I would have someone on the phone talking to the doc.

I don't know if anyone has asked but what was in the purse? Does the patient have any track marks? Why can't the IV be established (lack of veins or scar tissue)?

I would also consider securing an airway on the patient better than an NPA.

 

[Angel]

I'm with Chaz, IM narcan and get a line. She screams OD.

What's in her purse? Any pill bottles in it, or anything to hint towards medical conditions. Any track marks on her?

Further vitals- temp? EtCO2 (I'm sure it's high, but I'd have her on one anyway), is she responsive to pain? If so, to what extent? ie localizing, withdraw, etc. Does she arouse with pain and able to follow commands? Any obvious signs of facial droop?

you check her bag and find two big pill bottles with the labels ripped off.
one has a "V~" on it. extra points if you know what it is without looking it up. and the other one you are not sure. no track marks, veins are not prominent and difficult to palp, my go to is 18G, maybe something smaller?

So, I think were about done with this scenario?

 

[DesertMedic66]

you check her bag and find two big pill bottles with the labels ripped off.
one has a "V~" on it. extra points if you know what it is without looking it up. and the other one you are not sure.

So, I think were about done with this scenario?

It's defiantly Viagra. It's the only one that makes sense..

 

[STXmedic]

I think we were done when Chaz gave narcan...

 

[LACoGurneyjockey]

Lupus. And Somas are her ideal treatment for it.

 

[Akulahawk]

The fact that she's got pinpoint pupils says she's possibly an opiate OD. However, could she have taken a benzo and an opiate? If she accidentally ODs on both... the narcan won't touch a benzo's effects.

 

[STXmedic]

Doesn't really change the treatment, though. Narcan doesn't work, then airway maintenance/breathing support and transport. I don't think anybody is going to be giving flumazenil in the field (or likely in the ED...)

 

[Angel]

It's defiantly Viagra. It's the only one that makes sense..

lol howd you know

ok were done and heres my take:


in this case route wasnt the biggest issue, it was dose. here our standard dose for adults is 2mg increments up to 6mg. with 2 mg IN she had a 1 point increase in GCS, 4mg IN and ~7 mins she began to open her eyes, start breathing on her own with NRB and started mumbling. by the time we got to the ER she was awake and able to answer some questions. we identified the bottles as vicodin (like viagra but different) and soma never did figure out how much she took though.

i like that some of you were aggressive with the airway and wanted to intubate right away, because i didnt even consider it until later (silly intern) . but she was getting more responsive.

also the only reason i wouldnt have IOd her even after missing the IV attempts is because an IV isnt critical for ODs, (since we can give it so many other routes) if she wouldve deteriorated or arrested then yes, but otherwise they are a last resort for unstable patients.

 

[STXmedic]

also the only reason i wouldnt have IOd her even after missing the IV attempts is because an IV isnt critical for ODs, (since we can give it so many other routes) if she wouldve deteriorated or arrested then yes, but otherwise they are a last resort for unstable patients.

Narcan can be given IN, yes. Anecdotally (from my personal experience, and from others here having similar experience) IN is very variable and unreliable, though. I don't even consider IN anymore except for certain situations because its been so unpredictable for me. As for IO, I'd probably only still if I needed to give meds for intubation. If it's just for narcan, I'm fine with IM.

 

[Angel]

ive never given it IM before, roughly how long does it take for you to see changes?
is your dosing different for IV/IN vs IM? i know here if its IM we are supposed to give .2mg/kg max of 6 but it comes in 2mg/2ml so we just stick with that