DartmouthDave

Hello, Excellent thought. The patient's appearance could fit a Dystonic Reaction. Her current medications are Tly #3 and Serax. No antipsychotic or antiemtic medication use. She is a clean living Lululemon Mom. She is lucid with stiff arms and fanning fingers and toes. Her mouth is puckered in an 'o' shape. She is breathing fast and deep. A very fit patient with a good set of lungs. The symptoms developed when her membranes ruptured and she became very anxious. This was compounded by the panicing (who thanks to JM) is in the room next door. Also, what other assessments could we do here as well? Cheers.......

Hello, The husband is moved out if the room and the anxiety level drops greatly. You do an assessment of the patient. She is able to open her eyes and looks at your. She has some trouble talking because her mouth is 'cramping'. She says her arms and legs feel 'numb' and 'cramped up'. VS are: BP: 150/90 HR: 110 NSR Resp: 34 Rapid and deep SpO2: 99% Temp: 37.5 A head-to-toe assessment findings: General Impression: A fit looking 29 year-old women who is obviously pregnant. An old hospital ID band in noted on her right arm. CNS: Her arms are still rigid and her fingers and toes are fanning outwards. Her mouth if fixed in an 'O' shape. She is lucid but says she can not get her arms and legs to, 'Do what she wants them to.' Her pupils are 5mm and reactive. She is quite anxious and is complaining of numbness in her arms and legs. Resp: Lungs clear as a bell. She is taking large deep breaths. CVS: Skin pink/warm/dry EKG shows Sinus Tachycradia ABD: Quite pregnant History: The husband is able to offer some history. This is her third pregnancy. The first two went to term and were delivered vaginally without complications. He thinks that his wife is at 38 weeks right now. For the last two weeks she has been seen at the hospital three times. The last time two days ago. Her chief complaint during these visits were lower back pain and left flank pain. No problems were found and the pain was due to the baby's position. She was given a script for Tyl#3 and Oxazepam 15MG QHS for trouble sleeping. Her last GP visit was last week. The husband isn't sure what was said. But, his wife said everything seemed fine. She has no medical history. Cheers....

Hello, You are an ALS crew (ACP/PCP) in a town of 70,000 people. ALS and BLS backup is available. Fire First Responders are available as well. It is winter and the weather and roads are quite bad. You have spent the morning on minor MVA's and collecting up the town drunks who are getting cold. You are dispatched to a new subdivision on the edge of town (30 minutes from the hospital due to evil weather.....you arrive in 10 minutes) for a pregnant women in 'active labour'. On arrival you and your partner are ushered into a large bedroom. There is a hint of panic in the air. The husband is very flustered. He states that this is his wife's third pregnancy. Everything has been going well until the last two weeks. His wife has been having a great deal of lower back and hip pain. Warm baths seem to help. When she got out of the tub her 'water' broke. The husband helped her to bed. He states that she was very weak. Once she got on the bed she had a seizure. Which has been going on for 10 minutes or more!! The wife is laying on the bed naked. Her eyes are closed. She quite tachypnea (rate 30's). Her skin appears pink and sweaty. He arms and legs a flexed abnormally. Her toes are curling outwards. Her fingers are fanning outwards and her arms appear rigid. The patient's mouth pursed in a tight circle and her eye lips are twitching. The patient's abdomen appears very pregnant. Their also is some staining on the bed sheets that look pinkish. The two other children are upstairs with the patient's mother. Cheers....

Hello, Good one. I have never seen Variant Angina. Time to look it up. Cheers

Hello, I like you thought. It could be LV strain from the patient's HTN. According to the LIFE study that I found on Google LV strain is defined as, "...as a downsloping convex ST segment with inverted asymmetrical T-wave opposite to the QRS axis in leads V5 and/or V6." The T-waves are opposite the QRS axis in V5 and V6. However, the concave ST is missing. Still, a solid thought. However, can strain cause conduction delays? Could. I don't know. Maybe, coronary perfusion is limited during diastole? My CCU/CVICU experience is limited. Cheers.... Cheers...

Hello, Hmmmm...no access to my work account to look up the Journal. So, I will guess... Virchow's Triad has no predictive value?

Hello, Argyll Robertson Pupil (Prostitute's Pupil).....'accommodates but dose not react' =) Most common cause Syphilis...hence the name. Other causes I can not recall off hand. Ok.... Lesion that appear on the hand due to Endocarditis? Cheers....

Hello, 1. ACS (negative Tn) 2. PE (negative D-Dimmer) 3. Zebra? -->We have treated for ACS (ASA, Plavix, NTG, O2, Metoprolol, Enoxaparin) and drawn labs. -->We have treated reasonably well for a PE. Maybe start a Heparin infusion as opposed to Enoxaparin. If possible, an echo/ultra sound (depending on what is available and what staff is available) and take a look at the right ventricles. I am not an expert on this but I know sometimes a PE will cause RV dysfunction. Or any other odd cardiac things gooing on. -->No CT scanner I assume? -->What is CMP???? I have read about the S1Q3T3(invert) rule but I have never seen it or had much luck with it. Again, if he is pain free and stable lets not transfer this fellow until a Dx is hammer down some more. I assume the flight would be a long haul to Germany? Or, as a civilian dose a private company fly him to Saudia Arabia?? (I will have to call my brother he worked in KAF as a NO). -->Is there a Zebra we are missing? I get tunnel vision sometime. Cheers

Hello, No cath lab I assume! =) Also, I may be overly fatigued, but are those Q-waves in V1 to V3? Add Plavix 300mg PO, Enoxaparin 1mg/kg, change from NTG SL to IV. Maybe top up the Lopressor (5mg was given) to a total of 15mg. Review the labs (Hgb, lytes). Top up Mg and K if need be. Consult a friend. Any way to get hands on an old 12-lead? Was one done for a medical on a civilian contractor? Not too family contractors in A'stan. I would like to know if this is an old or new BBB. Maybe take a look with an Echo/US as well. Any family members have MI young? Odd that this is the first time he 'ever felt this way.' I am not saying that a patient can not have a big MI out of the blue. But, usually, they have angina, worsening SOB, fatigue, et al......before the big STEMI. Also, his age. Possible.....but not common. If her was 56.....different story. Wait...see if the pain come back. Repeat the Troponin in 4 hours with an other 12-lead. Be conservative. If it is a STEMI treat with TNK. Cheers

Hello, A BMI of 30. Must have been Chair Force (Air Force).... 2-3 drinks a night. Now, was that before he went overseas or while overseas? As for sudden on set chest pain I will go with: - PE (big guy sitting at a desk for long hours) - Thorasic Aortic Aneurysm - ACS I would do the work up as posted above. Plus, check BP in both arms and if possible, is there an iSTAT (Tn-I) available in the clinic. Cheers

Hello, Herbie1, I am talking about Vasopressin (Pitressin). As opposed to giving Epinephrine 1mg IV give Vaopressin 40 units IV during the code. Like when this poor fellow coded on CM. In theory, this may cause the varacies to constrict and diminish the bleeding. A two-for-one deal. As opposed to a vasopressor such as Levophed, Phenylepherine and Dopamine. Stuff like that. Which you are 100% correct would be a bad idea before that tank is filled so to speak. Correct me if I am misunderstanding what you are saying. Chbare, All of the SB tubes that I have seen were inserted in smaller hospitals (not sure how) and were transfer to us. One was secured to a hockey helment and two to the ET tube. Basically, the labs were corrected and the tubes were pulled and the patients scoped. I agree 100% that messing around with a SB in the pre-hospital setting or by unskilled hands in the hospital is a bad idea. KM, Good to know. All the SB that I have seen are just laying around. Most, looked like they were made in 1942. Lastly.... =) One problem that we did have with one patient was excessive pressure in the SB. There was some esophageal ischemia. Also, deflating the tube seems to pull off all the clotting that has formed as well. Cheers...

Hello, Interesting. Inderal IV. I have never seen it used for varices. I am going to look that up. Always like to pick up something new. One never knows when it will come in handy. Could IV Metoprolol be used as well? If for example Inderal was not available? Sorry, I wasn't too clear with my Vaso post. There is a Vaso Shock dose and a Vaso Varices dose. At the high end of the Varices dose the patient will get 30 units an hour or so. Now, in a code secondary to a bleed push Vaso 40 units IV. In theory, it may help with ROSC and the bleed. For most ALS units (not a CCT team) this may be the only possible drug that could be helpful. Basically, what was clarified by previous posters. I have seen three SB tubes. I have never put one in. In theory, they slide in like an OG. The one thing I have always wonder is how!! They are much more flacid than an oralgastric tube. How do you keep it from curling up. Just wondering. Second question. Securing the SB tube. They need a little tension to keep the gastric ballon in place. The three times I have seen a SB tube the patient was tubed. Two had the SB secured to the ET tube. One, to a hockey helment. Now, how would you secure a SB tube to a patient that isn`t intubated........just wondering! Cheers

Hello, I was thinking. Vaso for shock mixed 15 units in 250 NS. With a dose between 0.01 and 0.05 units/min. I know that Vasopressin for varacies is mix much stronger (never used it myself) and administered at a higher dose. Not sure, but I thick the dose is .1 to .5 units/min. Tenfold. So.....when the patient coded Vasopressin could, in theory, fix two problems. That is if you had it. Just a random thought. Weak theory. Am I off base here? Cheers....

Hello, Tough call for sure. I can not think of any tricks for this fellow. Securing the airway to prevent aspiration of blood and pushing fluids. As for a Combitube I think it wouldn't protect the airway, or tamponade the bleeding. Also, with very forceful emesis I think there could be a risk of esphogeal repture. Dose anybody have any other thoughts on the combitube? If this fellow made it to the ED there are a few options: 1) Sengstaken-Blakemore Tube can be inserted down the esophagus and inflated. The ballon tamponades the varacies. Blakemore 2) Panto IV and an infusion 3) Octreotide IV and an infusion to drop portal hypertension 4) Vasopressin (Varices Dose) infusion 5) Blood products (PRBC, FFP, ect..) 6) Endoscopy treatment and surgical interevntions Even with all this stuff the 4-5 ESRD with bleeds that I have seen never do very well. So, really, I think you tried all that you could have. Cheers...

Hello, Good question. I think it is safe to that this lady is dry for several reasons. Increased work of breathing equals increased insatiable losses. The same can be said for the fever as well. Also, I am sure that this has had poor PO intake. Physical assessment and history also shows a sinus tachycardia with marginal BP. Plus, no overt signs of failure such as edema or JVD. In addition, if I remember correctly, no previous history of CHF. So, a 250, 500 or a 1000cc bolous of NS all would be acceptable. Depending upon protocol and transport time. You are correct about the lungs. It would be hard to tell if you are tipping the patient towards failure. However, an improving BP and a decreasing HR in general will indicate that you are heading in the right direction. Cheers

Hello, LEMON AIRWAY ASSESSMENT TOOL: http://emergency-medicine.jwatch.org/cgi/content/full/2005/216/1 The STARS folks came by were I work and used it with the sims. Just an assessment tool that is all. Cheers

Hello, VS? LOC? Motor/Sensory assessment? From the description of the injury airway sounds like an issues as noted by several posters. Even more so if you put the patient supine on a back board. Now, I am just throwing this out there; Could you transport the patient with a cervical collar on with the head of the stretch at 30 degrees of elevation (like Tniups suggested)? Or, as an other option lay the patient in the left (or right) lateral recumbent position? Thereby allowing safe clearance of airway? Most cervical injuries are stable enough to allow HOB at 30 degrees (with a collar) in the hospital setting. A truly unstable c-spine in general presents with deficits and even ideal care (backboard) things typically worsen as edema develops. Slightly unorthodox but easier than having possible airway issues during the flight. The reason I am throwing this out there is a LEMON airway assessment of this fellow shows three concerning issues. First, a jaw fracture with blood equals difficult airway. Maybe there is a high grade LeFort (II or III) fracture present. Second, it would be difficult to ventilate with a BVM if the RSI failed. Third, a supraglottic airway wouldn't be helpful here as well. This leaves a surgical airway which put you in a crap situation. Even worse, a failed surgical airway. There is an interesting case in which a CalStar crew missed a tube. Went surgical. Missed that. Then got a tube which was useless due to a large bleed hole in the patient's neck. =( There isn't a failure to oxygenate or ventilate here (with suctioning). So, a short hop to the local small hospital and possibly deal with things there if need be. Also, with a warning the small town hospital can call in extra staff (i.e. Anesthesia). Glide scope/bronchoscope or many other options. Tube there if needed. Also, a more detailed trauma work up is needed before the fixed wing crew arrives. CXR. AP Chest. Pelvic. And, with luck a Head CT. Cheers...

Hello, So, the decision is made to tube this fellow (good call). The plan is to use a fiberoptic scope. The patient is given a small dose of Versed (2mg) and an awake laryscope is done. It is difficult to see the cords and there is tons of dried secreations coating the back of the throat and what can be seen of the cords. The EP feels confident that he can get the tube in. Back equipment is made ready. He is given Propofol 50mg and then Succinycholine 100mg. A #8 ET is passed without comlications. The tube is suctioned for think brown nasty junk. The patient develops profound post-intubation hypotension (77/40) and is given a bolous and Levophed is started at 10mcg/min. The patinet is placed on the ED's ventilator. No overtly high peak or plateau pressures. A good Vm is being given. The VS are as follows: GCS - sedated BP = 97/40 Map 57 HR = 144 (alram sounds.....VT...the monitor shows a wide complex tachycardia) SpO2 = 94% on the vent Urine = 0 CVP = 4 Cheers.....

Hello Vent, Sorry, I left out some information in my last post. This fellow is on a high flow oxygen mount that wide open. So, odds are he is getting around 60% or so. It isn't a dual system. Just a standard hospital wall mount. His Co2 has risen so he is getting tired as you know. His VS are worsening slightly as well. GCS 14 (Drowsy) BP=130/70 MAP=90 HR=130 SpO2=82% Urine output is still low. There was 20 out on arrival. Since then, nothing. CVP = 6 Fluid is a good idea. Sv02 is low. His Hgb is also marginal. But some fluid should help this. The ambulance has an LTV1000 (no graphic displays with this model...flow loops ect..)and 2 Mini Med III pumps. A CPAP mask for the LTV (I am sure they can do this...correct me if I am wrong). Plus a good selection of medications. A Zoll CTT monitor that can transduce CVP and an arterial line. So, yes, it would be very difficult to transport this patient in a back of an ambulance on high flow. Also, I wonder if the ambulances O2 tank has enough psi in it to last for a long drive. Cheers... PS....Don't read too much in to the gases. I am just making up the numbers to show resp alkalosis (resp failure) moving to a tried patient (working towards a resp acidosis). =) Hello Kiwi, OK, the hospital is willing to send a nurse or an RT. Your pick. The RT in this ED has intubated patients before but not for a long time (over 18 months). The RN has lots of ICU and ED experience. She worked in a larger hospital and move to a small town for a more mellow life. Also, the EP has not intubated in quite awhile as well. He can't leave because there isn't anybody to cover the ED or the admitted patients if something goes wrong. This is why there is trepidation about tubing this fellow. Cheers..... Summary of Discussion: So, give it a go with high flow O2 and hope all is well by the time you arrive at the university hospital? Or, get a tube? If so, what would be the safest way to do this? What medications? RSI? Is this BP elevated due to a stress response from the patient? He has had a 4-5 day history of poor intake. Or, is his volume fine? Low urine output as well. Give more fluid or not? (i.e. 1000cc plus or just maintenance rate of 125cc/hr) What extra staff do you want in the ambulance? Any lab concerns? Cheers....

Hello, The patient wants to be a Full Code. A triple lumen subclavian is inserted and checked with a CXR. The RT inserts an arterial line and a ABG and VBG is drawn. A CVP is transduced and it is 6. The ABG shows pH 7.35 CO2 45 CO2 60 and the VBG shows an saturation of 59%. A sputum C+S was not sent. Swabs have not been done. These are collected. Also, the patient is given Tamiflu PO as well. BNP is not available at the lab. Small hospital with limited resources. The EP isn't keen on intubation due to the difficult airway and the frail status of the patient. Though failing the patient should be able to tolerate the transfer on high flow O2. Cheers...

Hello, I based this scenario on a fellow that was transfered to the ICU awhile back. So, as a transfer there is time to sort things out. Also, I like this scenario because the key to its success will be a collaborative approach with the hospital's staff (MD, RN, RT). Plus, it is a situation that may rurual services may find themselves in. A complex patient in a small hospital in which the Paramedics become an important part of the hospital's team. Here are a few ponts to ponder: Resp status... tube or no tube? CPAP/Bi-PAP? What is the ABG telling us? CVS..... more fluid? less fluids? Look at a sespis protocol and see how it can fix this patient. Labs..... low K and Mg 40mEq KCL in 100 cc was given once... Needs more or less K or Mg? Any other labs to check? Social.... He is very sick. Prior to transport what should be addressed? Support.... The hospital isn't keen on sending staff. Maybe an RT or a RN...maybe =) Lastly, your ambulance is stocked with a wide range of drugs and equipment (i.e. IV pumps, CPAP, Transport ventilator). This is true. He has been in the ED for 2 hours. It is an hour or so to the receiving hospital. Is there more than needs to be done? Is he ready to go? Other Dx to be considered. This may not be a 911 scene call however there are few things prior to leaving that may maximize ones odds of success. I just wanted to give something a little different a go! Cheers...

Hello, Location: You are an ALS crew in a small town (population 5000). It is 1000hrs and you are dispatched for an urgent transfer to the local University Hospital. The University Hospital is 125km away. On Arrival: You are greeted by the ED staff and are given a report. Mr. Smith is a 67 year-old male with an extensive and complex medical history. He has had a MI in 1993 (NSTEMI),CABG in 1994 (4 vessels), PSVT, HTN, DM I, Dyslipidemia, Depression, Renal Insufficiency, Esophageal cancer that was managed surgically in 2008 with a Esophagectomy as well as Oropharyngeal Squamous Cell Carcinmona (OSCC)in 2009 that was managed with radiation and surgical interventions. Since 2008 the patient has had dysphagia and numerous aspiration pneumonia. He was made NPO. A PEG was insert in Dec 2009 and the patient was started on bolus feeds. However, he has still had trouble with aspirations. There were plans to advance the PEG in to the small bowel. For the past five days the patient has been feeling unwell. Chills, myalgia, fever, and a hacking cough with some think yellow sputum. His wife was concerned that he had a pneumonia. The patient has been refusing his tube feeds because he feels unwell. The patient did not want to go to the hospital and took some old antibiotics he had around the house. This morning he tried to eat. His wife started his tube feed at 0800hrs. Shortly after feeding began he started coughing and threw up. Gagged for awhile and trued 'blue'. He developed respiratory distress and was driven to the hospital by his wife. On Exam: The patient is sitting up in bed (75 degrees) and looks distressed but is lucid. Numerous old surgical scare are seen on the patients neck and jaw. He seems to have a poor range of motion as well. GCS 15 PEARL 4mm Strong x 4 BP 180é90 HR 120 Temp 38 EKG: Sinus Tachycardia with an old RBBB RR 34 SpO2 88% on 100% FiO2(humidified oxygen wide open) Lungs - course crackles Abd is soft Foley is in situ with 20cc of concentrated urine There are 2 IV. An 20 gauge in the left hand and a 18 gauge in the left arm CXR shows a white out on the right side and cloudy looking left side. Labs are limited. They show: WBC 24 Hgb 84 Na 137 K 2.9 Mg .85 ABG show (100% oxygen): Ph 7.45 CO 32 O2 64 BE 2.2 He has been Dx with Sepsis and aspiration pneumonia on a preexisting community acquired pneumonia. Treatment thus far: 1L NS bolus 40mEq KCL IV NS+20 KCL at 125cc Vancomycin 1gm Pip Taz 4.5 mg Zythromax 500mg Decompressed his gut via the PEG Zantac 150mg IV His medications are: ASA 80mg od Lopressor 50mg bid Lipitor 40mg od Ramipril 5mg od Sliding Scales Insulin tid Tyl prn Advil prn Lansoprazole po od Motilium 10mg po tid Cheers...

Hello, Sorry for the above post. I was AFK and when I came back it wouldn't let me edit. =( I never considered the issue of quality control or errors. From my experience I haven't seen any EMS services draw labs in the field. Or, use iSTAT technology. Cheers...

Hello, This case is based on a fellow that came through the hospital. I altered it to fit better as a case study. I picked a suburban/urban setting because I wanted to work with an environment that most poster would be familiar with. A major hospital 10-15 min away. Something like that. Now, with longer transport times (ground or air) starting abx would be essential. Early abx improves outcome. I agree with this 100%. Now, how to make this happen...that is an other story. Prehospital labs: I like this. It is a good idea. Makes for a smooth transition from EMS care to hospital care. Heck, if you are putting in a line pull a few tubes off as well. Toss in a few blood cultures as well, if needed Inexpensive. The skills are there. Cheers....