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DartmouthDave

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Everything posted by DartmouthDave

  1. Hello, You are dispatched for an urgent transfer of a 47 year-old burn patient to the local university hospital (1 hour away). You are greeted by the ER RN and she tells you that the patient was welding when he had a seizure and set himself on fire at a local construction site. Workers quickly extinguished the flames with jackets and blankets. However, he has sustained burns to his hands, arms, and chest. He was intubated with difficultly by the ER Dr. A left femoral central line has been inserted after three failed attempts on the right side. He also has a #18IV in each AC and the patient is sedated with a Morphine (5mg/hr) and Versed (5mg/hr). You enter the trauma bay and hear a gurgling sound coming from the patient's mouth. He is shaking weakly. He has been in the department for 2 hours now. His VS are: HR 120 Sinus Tachycardia BP 90/40 SpO2 100% Temp 35.6 C
  2. Hello, As it turned out the patient had Familial Dyslipemia (I need to read up on this more but in essence you develop dyslipemia due to genetic factors). Her pancreatitis was due to dyslipemia. Which I have seen before but never in somebody so young. In hindsight, it was felt that the abdo pain was due to pancreatic flair ups. The ST elevations resolved when her pressure improved. However, angio showed significant three vessel disease and an echo showed dyskensia as well. It is quite a rare cause of MI in the young. There are a few case studies out there. I read one in the Saudi Medical Journal about a 17 year-old with an STEMI due to genetic dyslipemia. The blood was brownish due to all the lipids in the blood. Almost like mixing blood and some Propofol together. It was a rather odd sight that I have never experienced before. They treated her DPL with Plasmaphereis (again…a first for me). It looked like pure fat being pulled out of her blood. I just felt like sharing this because it was an unusual situation. How often do you find a 24 year-old with CAD and DPL? Cheers
  3. No u/s on the ambulance. Also, I would know what to do with one at the moment. =) I will say that Kiwiology is correct with pancreatitis. With IV fluids and some pain control of choice the patient settles and VS improve some. HR 100 with ST elevations BP 90/60 SpO 98% The husband is on scene and you are loading up and getting ready to transport to the local teaching hospital (10 minutes away). The husband provides some more information. His wife is healthy other than on again off again episodes of stomach pain that goes away when she rests, stops eatting and take some pain pills. She never drinks or smokes. So, what is the etiology of her pancreatitis? The brownish blood? (sorry, it is hard to describe it here online) Have to run. The little ones want to break out the bikes. Cheers
  4. Hello, Her LMP was normal. She missed the last one and took a home pregnancy test and it was positive. She has no PV bleeding or discharge. Her abdomen is slightly distended, firm and very tender to the touch. The pain started out a vague and grew and grew and localized in her ULQ and URQ. She also had pain in her right shoulder. The emesis isn't bloody. You insert one IV (#18) with difficulty and start a fluid bolus. You notice an odd brownish colour to the blood. Her husband arrives on scene. Pain control? ST elevation? STEMI? Cheers
  5. Hello, She is white and she just found out she was pregant three days ago with a home test. She is sheduled to see her GP in a day or so. She has no children. She has had a three year history of abdominal pain and has seen numerious Dr. She said that she has Functional Bowel Syndrome. But, she isn't sure what that means. Her nomal pain pattern is vague dull abdominal pain that comes and goes and usually last for a day or so. Her pain is controlled by Hydromorphone pills which she takes on rare occassions but those things are bad for you. However, today, the pain has become more intense and localized to the abdomen. She says it is the 'Worse pain of her life!!!!' and she says 'Don't touch it!!!' You try and get more history (ETOH,Meds, ect...) but she barfs and says it hurts too #@#%@ much to talk and starts to cry. The PCP conects her to the monitor: HR 120 with ST elevations in V1 ---> V4 and the occassional PVC / Pulse is weak and skin is moist and cool to the touch BP 80/P Resp 30's SpO2 98% on room air Temp 36.0 BGL 10.0 Cheers. Good luck. This is based on a patient that came through our ICU a few months back.
  6. Hello, You are a ACP/PCP crew responding to suburban home for a 24 year-old female complaining of abdominal pain, weakness and worsening shortness of breath. On arrival you find a 60kg female sitting on a coach in obvious distress: tachypena, pale, diaphoretic and in pain. There is a bucket by her side full of emesis. She mumbles that she is pregnant. She is alone and called 911 on her cell phone. He husband is at work but he is on the way home. Cheers
  7. Hello, No. In this situation a field amputation is not warranted. There is no guarantee that you or the flight team will be able to amputate the leg any faster that the Fire Services could extricate the patient. Second, there is no guarantee that the leg can be amputation with enough skill to prevent excessive bleeding and stress to the patient. Third, do you actually have the equipment needed to pull it off? Lastly, the patient is sick. But, how sick has yet to be determined. I have seen patient with horrific injuries turn out to be fairly stable while the one with a bump on the leg be gravely ill? Keep the patient warm, control pain, and fluids as needed. Also, as noted above, take a closer look at the second patient as well. Transport the entrapped patient ASAP to the trauma center. Transport the walking patient (barring any troublesome finding) to the local hospital. Cheers…
  8. Hello, Sounds like a good job to me. A temperature would be nice as well. Cheers
  9. Hello, Sorry to hear that Inthecity. I am glad the baby is doing well. =) I am a late to this thread and I just worked my way through 5 pages of posts. An excellent discussion. I would treat her with a MgSO4 loading dose and an infusion. I would give this some time to work before I would tube her. If the Mg breaks the seizurs (...or benzo..) she may not need a tube. She is young (high medabolic demand) and pregnant (reduced FRC and increased medabolic demand). Her time to desat will be very fast EVEN if she was preoxygenated. Tubing her would be high risk and with luck we may be able to avoid it. Second, their could be some other pathology here. HTN + head ache could be Posterior reversible encephalopathy syndrome (PRES), SAH, AVM, et al.... She need to get to a hospital more management. I would like to write more but it is time to run. Cheers
  10. Hello, In a King Air we would have the pilots wear gloves, masks and gowns while loading. The staff would wear gloves, gowns, and masks as well. For a walk on patient we would have them wear a mask, glove and gown. Then close the cabin door between the medical crew and the patient. On a side note I need to read up on chemical pneumonia änd airbag pneumonitis. Brain gym..... Thank you, Dave
  11. Hello, Maybe consider abx coverage for transfer. He had Advil 500mg (1800hrs) and Tyl 1gm in the ED. How is his pain control? Is he taking full breaths? If not, maybe some more pain control. Tradol IV if he is making pee or maybe a little Morphine. Have NIV (Bi-PAP/CPAP) as a backup plan. Isolation procations and prepare for transport. Cheers
  12. Hello, I am use to the term 'active' and 'passive' rewarming. We use 'passsive' rewarming for mild to moderate hypothermia patients with a goal of .5C increase an hour. 'Active' rewarming are things like ECMO, warm intrathorasic lavages abd abdominal lavages. Patients below 32-32C (I think) are unable to generate heat without assistance. I have never seen this done. But, I have had a few very cold patients that have be helped by these interventions. Cheers
  13. Hello, PCV +22 Fi02 .80 Rate 30 PEEP +14 Total PIP=36 Inspiration Time = .5 seconds iTime = 1.5 seconds So, the total cycle will be 2 seconds (30x2=60seconds). The decelerating pattern of PCV in theory improves the distribution of ventilation. However, I am unsure of PCV. I haven't used it too much. Again, I would phone a friend for some feedback on this one. Cheers
  14. Hello, A trial of PCV may be worth a go. In theory, PCV has a longer inspritory phase which increases the mean airway pressure and gas exchange. But, the evidence is mixed here and ARDS net supports VCV. A bronchoscopy could be worth a go. Take a look and clean things out. This is high risk in this situation. As for the other unique modes of ventilation (bi-level, APRV, et al.) I have no idea if they have been studied or have any role here. There is also HFO as well. But, I have only seen this done a few times and these patients are 1:1 for the RT's and few centers have this ability. Statins (Lipitor) has shown to improve long-term outcomes. Steroids may be helpful in the inflammatory stage. Keeping the patient's dry if possible may be useful in the immune/inflammatory stage. I even recall reading something about nebulized Heparin. There are also various drugs that can be used to drop the pulmonary arterial pressure. I think one is called Flolan and is side streamed in with the inspritory circuit. But, most of these will not help us now. You could also put the patient on ECHMO if the option is there. If this hospital can stabalize the patient he should stay there (i.e. HFO,ect..). If not, he should be transfer ASAP. This case reminds me of a young patient with ARDS that had a bad outcome due a very delayed transfer. Cheers
  15. Hello, Isn't 97.7F = 36.5C So, more or less normal. All I would do is ensure that the patient dosen't become hypothermic now or during the transfer. What dose the OR report say? EBL? A decompressive lap shouldn't have to much blood loss. With a SpO2 of 84% I would turn the FiO2 up to 100% and may creep up on the PEEP. I have been thinking about AC-PC (PCV). I have readed mixed stuff but the last study I read by the Spanish Lung Group said that PCV has no major clinical difference. Also, I am weak in this area. So, I think I will stay the course with AC-VC. A couple of questions: 1. I would turn the set rate up to 30 and sedated to the level to limit patient assisted breaths. Wouldn't this reduce the medabolic demand imposed by breathing? 2. I:E 1:3 Would a 1:1 ratio be better? Considering he is breathing 30 time a minute. One second in and one second out? 3. What is the PaCo2 right now? If it is still too hight I would increase the rate to 32 (max of 35). Again, would the I:E would need to be 1:1?? Here is my thinking at the moment. We are reaching the end of what we can do for lung protective ventilation. Even more so considering the limits of transport vent. It is time to pack up and roll to a centre that has HFO, ECHMO, Nova Lung, Folan and other complex stuff. Also, if posible, I would like to snag an RT for the transfer. DD
  16. Hello, He isn't hot and dry so not an anticholinergic toxidrome. He is sweaty but not agitated so it isn't a sympathometic toxidrome. He has no muscle regidity and isn't on any SSRI or antipsychotics so it isn't a Serotonin Syndrome or NMS. What is his temp? What I do know is he is symptomatic with his HTN. I would give him some Ativan SL and see if his BP and HR decrease. Then maybe some NTG. Prehaps, it could be hyperthyroidism? I know infection can cause Graves Disease......Not sure endocrine is a weak point. Cheers
  17. Hello, I am waffling on the fluid issue. I think you are right on the fluid issue. His Hgb is 10 g/dL (100g/L) so I am happy with this. Also, blood can worsen outcomes in sepsis. I think there is a big Australian study on this. But, I can't recall right now. It is cold, typically old and can worsen the immune/inflammatory response. I would only give blood for two reasons. One, if he was bleeding and his Hgb fell below 60 or if ST changes are seen on the EKG. Two, if his SvO2 is below 70% and his Hgb is below 100 as well. I agree that transport (unless it is a very short run) is dangerious unless his Ph starts correcting and the lactate is clearing. I would do an other ABG. If the pH and CO2 isn't correcting I would increase the rate to 32 with a max of 35. I would also have some Levophed ready as well. He will need deep sedation and Levophed may be needed to offset the hypotension. Cheers!!
  18. Hello, I looked at the flow sheet for the RT's and PBW Tidal Volume for a 5'9" patient is 424 (6cc/kg), 495 (7cc/kg) and 566 (8cc/kg). The IBW calulation: IBW= 50+.91(hight in cm - 152.4) So, 70kg?? A vt 420, 490 and 560. Now, I asked an RT and a Duck Bill pattern indicates ARDS. So, based on my expereince with ARDS net I would set the vent at :AC 30/550/.80/+14 and work down on the Vt until I get a airway pressure that I can live with. We have a low PEEP and a high PEEP parameters for ARDS. I would go with the high PEEP due to the uniformed ground glass look of the CXR. I am assuming that all the lung units have poor compliance. We like to keep the ARDS patients dry if possible. So, I want to see what the IVC u/s, CVP et al show. Plus see how our vent setting work out. Can I have a current set of VS? From my reading and expereince I know that ARDS has stages. Typically, the first stage is the exudative or wet stage from the immune/inflamtory response. Suction the patient PRN. His acidosis is mixed. The medabolic side is due to an ischemic gut (compartment syndrome), ARF (induced by the compartment syndrome) and poor perfusion. This will be hard to fix quick. But, i would like to see the lactate drop some. Good scenario... Too bad I am at work.....I have to run! Cheers
  19. Hello, Hmmmm... I don't know PV loops. Is the patient auto-peeping? Is it dynamtic hyperinflation? Without a COPD history I wouldn't think so. But, I would like to rule this out before I would go with my next plan. I have limited expereince running an ARDS net solo. I also have little expereince with CXR but this looks fluffy to me. Add to this a poor ABG and high airway pressures makes me lean towards ARDS. I would slowly increase the rate to 30 and drop the Vt 550. I would increase the PEEP to +14. I would be willing to drop the Vt lower if need be to reduce the airway pressures. I would also ensure a deep level of sedation so the patient would ride the vent and not trigger any assisted breaths. I would keep him deeper than I would in an ICU because of the stress imposed by a transfer. My goal would be a Sp02 88% or greater with a decrease in the CO2 (if possible). If possible, take a peek at the IVC with an u/s or shoot a CVP (weak) or do a SvO2 to see how the heart is doing and get an idea of the patient's volume status. Any recent VS? I don't want to tunnel in too much on the vent/lungs. Cheers
  20. Hello, ET 8.0 The tube is a good size so that isn't accounting for the high pressures. Is the patient sedated enough to maintain patient-ventilator synchrony? Not fighting the vent? If he is well sedated that will not explaining the high pressures. Maybe use some Ketamine as sedation to improve compliance some. He is young with no CV risk factors. Vt=700 What is his ideal body weight? I would started with 8cc/kg by IBW. CXR & ABG Get somebody to look at the CXR (I am not very good at this) and see if it is patchy looking (ARDS) or wet. Check the ABG to see what his Hgb, lactate, PaCO2, PaO2 and calcualted the Pa02/FiO2 ratio. Maybe the A-a.......not that I actually remember how that works. =) I think his problem is a diffusion defect. His sats suck for a FiO2 of .80. Maybe an ALI/ARDS or a fat embolism or a TRALI (depending on how much blood products he may have had). I would start working through an ARDS net protocol. Start with a Vt of 8cc/kg and work down to 6cc/kg. Work up on the PEEP as per ARDSnet. Do some stepwise recruitment manuvers. I still would give a 1000cc bolus and hold on blood (until I see some numbers) and see how the vent manuvers work. I would also consider switching to PCV....I am not sure. This is getting outside of my area of expereince. Time to phone a friend. As for transport. I think his airway pressures and sats need to be corrected first. Cheers.... Time to run.. DD
  21. Hello, With femur fractures this patient is at risk of developing a fat embolism. Which, from my understanding, typically present 24 hours post injury. Dose he have a rash? First, I would work on his BP. His abdomen is open I assume so I would give him 1000cc of NS. What do his lungs sound like? What dose his WOB look like? What size tube? Tube depth? Any recent CXR or ABG? What are his PIP and Plateau Pressure? What is his Vt What is his FiO2? What is his PEEP? Next I would turn up his FiO2 and increase the set rate to 24 match the patient. Then I would sedate (...with cation...) to deep sedation (RASS -3). He is in a shock state and the ventilator should take on the medibolic demand imposed by breathing. Depending on how his lungs sound or how high we need to go on the FiO2 I would adjust his PEEP. Depending on his airway presures I would adjust his Vt. I would keep the ARDSnet in the back of my brain. Third, I would get to know the patient better. Get a formal report, chart review and detailed head-to-toe. Cheers =)
  22. Hello, I based this scenario on a patient I saw a few months back. The mother had DKA and was intubated for airway protection. This was difficult because she was profoundly acidotic, had marginal VS and stiff lungs. The baby was rehydrated and did well in a PedICU. Cheers
  23. Hello, Sorry for the slow response. Mobey, Her temp is 35.6 Kiwi, Edydawn , et al..... The patient's BP perks up with the bolus to 90/45 and the heart rate decreases to 135-140. With airway management (LMA, or good BVM) her SpO2 creeps up to 89-90%. You note course crackles in the the RML and LLL. The second ambualnce has arrived on scene. The infant is too weak to latch to a bottle. Their is a PedER 15 minutes away and a AdultER 20 minutes away. Thank you, DD PS... CWilliams 17: Sorry, I typed mmol/dL when I ment to type mmol/L. I can see how that would cause confusion if you are in the US. The solution is simple. You have to change to our way of doing things!! lol =)
  24. Hello, Ok...Kiwi and Lytefall, Her mouth is dry and her lips are cracked and smell of acetone. Some think emesis is suctioned from her mouth. She tolerates a LMA (...or EGD of choice...) and is easy to ventilated. Her lungs are clear and her stas perk up to 93%. A large IV is inserted and a bolus is started. Her blood glucose level is 38 mmol/dL. Her mother states that she has been a diabetic since she was young a needs insulin. She also has been battling a cold for the last week. The police bring the infant to you to assess. The infant is lethargic, with flacid muscle tone. His mouth is dry and the soilded diaper is dry. The skin tents when pinched and a quick bracial pulse check shows a rapid, regular rate of 150. He is breathing 50 time a minute. Cookie.... A second ambulance is on the way as Fire First responders. Cheers!!!
  25. Hello, The home is clean and well kept. There is no sign of a struggle or empty alcohol or pill bottles. The patient is in the prone position. You roll her over. She is breathing at a rapid and shallow rate in the high 30's. Their is dried emesis on her face, floor, and clothing. Her skin is cool to the touch and their is a weak but rapid radial pulse around 150 or so. In addition, you note dried urine on her pants and the smell of stale urine in the air. The patient is attached to the monitor. EKG: Sinus Tachycardia @150 BP: 84/30 Resp: 38 SpO2: 87% The patient's mother and the police look around the house and they find the 4 month-old infant upstairs in the crib. The police say the baby looks 'sick'. Cheers
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