Kaisu

so - Afghanistan eh? I take it that innies need not apply? Not that you can publicly state that - but it would seem culturally problematic.

This is an interesting case. My patients with high ammonia levels have all been patients with chronic liver disease. This causes the high ammonia levels, which in turn cause central nervous system and cognitive problems. These patients are combative, often incoherent. The encephalopathy is usually caused by the high ammonia levels, but can be caused by hypoxia as welI.

It makes sense to me that the general derangement of electrolytes that are the result of liver failure/dysfunction could easily cause cardiac arrythmias as well. I don't know enough about hepatic encephalopathy to comment further. Like you, I am waiting for the smart people to chime in.

Crazy Brits. It's a good thing they don't have guns.

its all learning. I know it hurts when some nurse gives you the gears. Gotta have a thick skin in this business. All in all, its a big win and you made it that way: 1 by learning the lesson and 2 by posting here so others can learn too. Props to you.

I watch for nostril flare. Sometimes, it you have a sheet or a blanket on their chest, the folds will move too. This is good from the attendants chair because then they are not aware they are being watched. I totally hear you about chest rise and fall.

Dwayne is correct - that was a very nice scenario. Well presented. Do not feel bad for missing it on the scene. There was very little you could have done to warm that patient. And thank you for an informative and educational first scenario.

What was the cause of the hypothermia?

Underactive thyroid (hypothyroidism), poor nutrition, stroke, severe arthritis, Parkinson's disease, trauma, spinal cord injuries, burns, disorders that affect sensation in your extremities (for example, nerve damage in the feet of people with diabetes), dehydration, and any condition that limits activity or restrains the normal flow of blood.

Was he hypothermic?

Im concerned about the bradycardia. What's his O2 sat? MAP?

Flattened affect is common in severe depression. But I think he's sick and I'm thinking beta blocker OD....

What are the meds? What are the vitals? What is the gentleman's medical history? Cardiac rhythm? and blood glucose?

- and don't be nervous. So far, so good :-)

edited for BGL in case some people don't consider that a vital sign

Pacemakers from several manufacturers can be commanded to deliver a deadly, 830-volt shock from someone on a laptop up to 50 feet away, the result of poor software programming by medical device companies.

http://www.networkwo...lert_2012-10-17

From Scooter and the boys at C.R.A.P. Ambulance...

City Rescue Ambulance has teamed up with LeCRAP At Home Language studio to bring you the latest innovation in Language Software! Now you can learn to communicate with your Chronic Inebriates with Drunkenese! Watch the amazing demonstration here and get yours today!!!!

He was in the steamer for the halibut

Awareness is simply the meta state that arises from an increasingly complex self-referential loop.

Nope - you get a pass... cause you're older than dirt

Hello Tyler... you are an interesting fellow... however, if you complain about getting old... I will kick your ass.....:-)

If you were the 300 lb volly, would you have stood up? I would have been ashamed.....

Going off topic a bit but you can rig a bag mask, PEEP valve and nasal cannula to provide CPAP. Simply attach the PEEP valve to the bag valve mask and attach to at least 15 LPM of Oxygen. Then, place nasal cannula on the patient running at 15 LPM. This will provide both flow and a constant pressure (CPAP). If anything, you can use it as a pre-oxygenation method prior to intubation.

This is how it's done:

http://emcrit.org/mi...-reoxygenation/

This is awesome. If I ever run with a service again that doesn't carry CPAP, I will just grab a PEEP valve from somewhere and know that I can care for the patient that needs it. I think I have found one item to carry in my alternate lifestyle bag besides my cigarettes and phone.

good on you. congrats and welcome to the fray

I should just wait for you to answer first chbare, and then pretend to know what you know... Thank you again.

Was this patient intubated in the ER? If he had deteriorated earlier, I think I would have RSI'd and intubated, The first ventilator setting is PEEP, and I don't see contraindications to this. Pulmonary fibrosis is obstructive, and thus fits the criteria for PEEP.

Excellent case - thanks for posting....

Question - Is the pressure/pain radiating to lower back typical of tamponade? in women?

And lets go for 100mcg fentanyl...no harm making her comfortable.

fentanyl can and often does decrease MAP. This patient cannot tolerate that. Anectodal though it may be, I find that pain and discomfort often support BP.