DartmouthDave

Hello, You are dispatched to a well kept suburban house. On arrivial you meet with the police and the patient's mother. She says she hasn't seen or spoken to her daughter or baby for three days and she is worried. The police open the door and you enter the house. You find a 28 year-old women laying prone on the kitchen floor and the house smells of urine. Cheers....

Hello, Excellent discussion so far. I read the thread and I was wondering if the code status and level of intervention was addressed? Thank you, DD

Hello, The patient's wife is a NP with critical care expereince. Here is a better article: http://thechronicleh...-ns-man-s-death Personally, leaving the wife on the highway and returning to the ski hill was odd.A very sad case.Cheers

Hello, Looks good to me. Just one question: Why such a small tube? Cheers

Hello, Interesting. I am going to look this up on Up To Date. Cheers!

Hello, I am not sure why he is blue. I will think about this. However, what I do know: 1) I do not like his temp (35.9). Hypothermia (non-environmental) is always worrysome. 2) An elevated WBC and he is on steriods. 3) He got Cephalexin. Abx for a CAP (community aquired pneumonia) 1+2+3 = septic/pneumonia as opposed COPDE? Mobey is lost in rural Alberta. So, I assume a long transport time. I wouldn't be keen on a confused blue man for a long haul without a ABG to see what his Pa0, PaCo2 and lactate are. Then think about a tube. And, a better IV than one #22. If it was a shrot transport (30-45 minutes) I would be less cautious. Cheers

Hello, ER Doc stated: "What allergy medcine did he take?" His behaviour could be due to their anticholinergic effect. Also, a TIA 18 months ago? He is only 41. Can we get a little more information on this? Lastly, with such a rapid onset. Being normal (but stressed) to a waxing and waning LOC with periods of bizarre behaviour would make me lean away from some of the slow more insidious causes presented. Thank you PS... NYparamedic43 thank you for post a case study.

Hello, Fecalith: A hard stony mass of feces. A fecalith can obstruct the appendix, leading to appendicitis. Fecaliths also can obstruct diverticuli. Called also a coprolith and stercolith. From fecal + -lith for stone. lol..... Here is a new one I heard the other day: Channelopathies: Inherited diseases caused by defects in cell proteins called ion channels. Cheers

Hello, An other good one is ICU Rounds by Dr. Jeffery Guy. He started out as a Paramedic. Here is his web site: http://www.burndoc.net/ His pod casts can be found on iTunes. Cheers

Hello, A quick question for those in the know. With volume-cycled ventilation a shorter I-time means an increased flow rate and in turn an increased peak pressures. Is this increased peak pressure just due to the resistance of the ET and the circuit? Or, is this increased pressure transmitted to the lung? Cheers

Hello, V.O.M.I.T. acroynym? I have never heard of it. Cheers

Hello, Nice scenario FireEMT2009. Difficult to describe and define chest pain in a diabetic women with dyspnea. Stable VS currently. Things to add: 1) Check BP in both arms and quality of pulses 2) Any history of illness in recent history? Treatment: 1) Supportive care and transport as noted above. My DDx list: 1) MI 2) Thorasic Anerysum 3) PE (small) 4) MSK pain I am sure I could come up with a few more. But, I am blanking right now. Cheers

Hello, According to 'Pharmacology in Nursing Practice' (4th edition) noval or atypical class antipsychotic, "...do not appear to cause EPS, including tardive dyskinesia." So, I think we can rule that out. Also, I was thinking, were the tabs extended release (ER) or sustained release (SR)? I have seen a few cases in which there was a rapid decline once the mass or SR or XR tabs started to break down. For example, a fellow who took a load of Diltizem SR crashed fast. Or, a lady who took a pile of Lithium SR that suddenly crashed fast. It could be a central Ach (muscarnic blocking) effect going on here. Altered LOC, sluggish pupils, dilated pupils, and weakness. The only thing that dose not fit is the temperature. But, it could be environmental as noted above. But, I think he is too sick for some central Ach effects. Considering, these drugs are, '...characterized by a high therapeutic index with respects to morality.' (Pharm Text) This also hold true to what I have seen. I have seen many antipsychotic OD (by over zealous staff....and patients!!) and supportive care is all that is needed. However, all antipsychotic agents may cause Neuroleptic Malignant Syndrome (NMS). The FEVER mnemonic I have heard used for NMS. A mnemonic used to remember the features of NMS is FEVER.[7] F – Fever ---->Maybe E – Encephalopathy ---->Yes V – Vitals unstable ---->yes E – Elevated enzymes (elevated CPK) --->Unknown R – Rigidity of muscles ----> The posturing could be abnormal tone...so a maybe As for new treatment ideas....maybe Cogentin, or Benadryl I guess. Cheers

Sorry....have to run. At work right now. Cheers

Hello, A general reply for OZ, Kiwi, and Bieber. The sister is able to provide a good history for you. She was in the hospital for necrotizing fascitis of her low abdomen and peri area. She required an extensive ICU stay with many complications. It took 8 months before her abdomen was closed. The rest of the time was spent in rehab. She has been very weak since. Some days she can walk a few feet (chair to bed, ect...) but mostly gets around in an electric wheelchair. Her medical history: Obese, COPD, MI, CAD, HTN, DM II, Obstructive Sleep Apnea (OSA), OA, Depression, Anxiety, Ventricular Aneurysm, and Dyslipidemia HPI: She has been home from the rehab hospital for three weeks now. For the past two weeks she has been having dyspnea and wheezing. The dyspnea worsen when she lays back. A few days ago she developed a 'cold' and was coughing up greenish sputum and started on an Abx by her GP. You physical assessment reveals: GCS: 15/15 (Anxious++) Airway: thrush, otherwise normal Breathing: 28 with increased work of breathing/ pursed lips / indrawing around the clavical and trachea / wheezing+++ / very loud when she exhales / SpO2 is 85% on room air Circulation: -->HR: 120 S.Tachycardia -->BP: 160/100 -->Temp: 37.8 / Soaked in sweat A faint scar is seen on her neck. Her abdomen is a mass of scars with much of the muscle of her left leg removed. A suprapubic cath is in situ. Cheers

Hello, Effexor is a SNRI and is fairly well tolerated. I vaguely recall that Effexor toxicity may cause seizures. But, I am not sure of this. Like SSRI a SNRI may cause Serotonin Syndrome (agitation, hyperthermia, muscle rigidity). But, this is very rare and dose not quite fit the picture. Seroquil is a noval class anti-psychotic. It effects Dopamine, Anticholenergic, and Histamine receptors if I recall correctly. EPS and Tardive Dyskensia are potential side effects. Overdose tend to cause a decreased LOC (central ACH effects), low BP (Histamine I think) and possible prolonged QT or QRS. Here is what we know so far: BP: Slight HTN (Norepi effect from Effexor???) HR: NSR Temp: Hypothermia (Environmental??) LOC: Waxes and Wanes......all in all too low (ACh effects??) Pupils: In the 1st post they were 2mm and sluggish.....Are they blown now? Ach dilates. Ch will constrict pupils. Airway: Drooling.....Ch cause?? It could be an overdose. Still, a very quick drop in LOC considering he went out to close the gate. Maybe, he overdose early in the day and now the symptoms are now presenting. Or, it could be a CNS event happening. All I know is this fellow airway is at risk. Tube him now or later at the ED. Pop in an OG. If it is an OD supportive care until he wakes up. If a CT shows a bleed (et al...) NSx will take it from there. Anxious to see how it plays out. Cheers

Hello, You are dispatched for a 64 year-old female c/o trouble swallowing and SOB. On arrival you find a morbidly obese female who is diaphoretic with audible wheezing heard. She is sitting in a chair and leaning forward. There is a wheelchair and an electric lift in the corner. The patient's sister is present. She is the one who called 911. She says her sister was in the hospital for 16 months and didn't want an ambulance called. She also adds that the hospital discharge her sister too early!! Cheers

Hello, A rapid decline in LOC, abnormal flexion, dropping body temperature makes me lean towards a CNS cause. Such as a SAH, AVM, or maybe a brain tumor that has bleed or become symptomatic. An expanding tumor (frontal) could explain the personality changes and quick temper. Cheers

Hello, See well 20 minutes ago. Now, he has a GCS 6/15 with slight hypertension (130/90). I am think a CNS issue. Lets get some more information: Pupils? A break down of the GCS? Eye score? Verbal? Motor? See what the EKG shows? More or less.....what has been posted already. Cheers

Hello, I just read the whole thread. Pardon me if I am repeating a previous post I may have missed. This fellow has a failure to ventilate due to hyperinflation. So, ETCO2 won't be accurate. By this late stage, his minute ventilation will be very low. Low minute ventilation equals an increasing PaCO2. Also, bagging in the nebs I feel would be a bad idea. Again, bagging a tight asthmatic is looking for trouble. So, as posted by others, treating with Ventolin, MgSO4, and Steroids (for long term management) with some Epi on standby are all good ideas. I have no experience with ped asthma patients in the field. But, I have seen quite a few in the ED setting. All have responded to medical management.....after a long period of pucker factor that is. =) Mobey, how did things turn out at the ED with this patient? Cheers

Hello, I agree and disagree with you RM. Yes, identification and early goal direct therapy for sepsis improves outcomes. But, this could be achieved simply training Paramedic look for the SIRS/Sepsis criteria (low temp, high temp, high resp, high heart rate, low BP) as outlined in Surviving Sepsis. In fact, the last ED I worked at triage looked for patients that meet the SIRS/Sepsis criteria and would call a 'Code Sepsis' to ensure a rapid and efficient treatment. It was very effective and did not require the use of expensive point of care testing for lactate. Thank you,

Hello, Would a lactate level change the treatment a great deal? Would the cost be worth it? A lactate can be elevated by many things. Don't get me wrong. I like the gadgets. But, I don't see its utility for a short transport times. Cheers

Hello, I knew what you ment. LOL Cheers

Hello, Is the D50W give to to drop ICP? Interesting post so far. Cheers