hammerpcp

yay

nerd.

Agreed, I initially was also thinking that as part of the differential. The Pt has no nuchal rigidity, and a negative LP. In scenario world that's a rule out I think. Also there was no complaints of headache, and a hx of three days of GI symptoms followed by neuro probs is a little slow onset.....at least for bacterial meningitis.

I am going with my original diagnoses of peritonitis. Sz caused by all or one or a combination of the following: hypotension, hypoxia, toxins in blood from ruptured intestine, fever. Lets get the docs to look at his abdomen.

Did we ask if his abdomen is distended at all? is there any rigidity or masses?

So to recap: 4am called to residence for 12 y/o male, 60lbs, altered LOC, laboured resps, febrile w/ NVD x 3 days. Pt found supine on bed, hot, dry flushed. Moderate respiratory distress. Opens eyes and withdraws from painful stimulus and is verbalizing innapropriate/incomp. words. Pt has had a "stomach flu" times 3 days with NVD, diffuse abdo pain increasing on palp, hyperactive bowel sounds, decreased food intake, fever, and decreased urine output. Pt had soup for dinner and was lethargic and irritable prior to going to bed. Side note: Why is mom trying to rouse pt at 4 am? previously healthy, no allergies, no meds. Initial VS: pulse 148 weak RR 28 laboured BP 90/40 Sats 88% Temp 103.2 f BG normal (? I think) Pupils equal and reactive but sluggish LS? Pt has been self administering tylenol since onset of symptoms. NOT: CO poisoning trauma drugs/alcohol Prescription drugs menningitis Pt now having sz activity autonomic hyperdysreflexia. 8)

OOoooohhhhhhhh............very funny!

Well......I am pretty much done at this point. I will transport and continue to monitor VS etc. Unless any changes enroute? Now for the bloodwork!

Alrighty then. So we are thinking either infection/sepsis/SIRS, or a toxidrome of some sort. Are there any medications in the house? It isn't your run of the mill anticholinergic or cholinergic OD in any case. Tube size for a 12 y/o 60lb child. Probably a 6.0. 60lbs is a pretty small guy.

I don't get it. Is he watching Chinese television or something?

Continue fluid bolus, 5mg valium IV, cont to assist vents with BVM and prepare to intubate. Find out more about 'strange' behaviour. Was he confused/irritable/irrational? What OTC meds has he been taking? Did he have pain in his abdomen at any point? Has there been any blood in his stools? Is he still vomiting even with the decreased food/fluid intake? What about urination? Any neuro deficits in extremities? Nucal rigidity?

He has an infection! Lung sounds? cough? sputum? diarrhea? Aspiration pneumonia for 100 Alex. What is meningitis? maybe SARS. Probably septic. Peritonitis? Oh! Rabies! Does he have any hx? Start some NS anyway. Does he need ventilatory support?

You guys have got to put that to music. Since you were probably sitting behind her you can always just lean forward and breath heavily into her ear once you've run out of things to say.

I am not sure if this is what you were describing Fiznat but to do a modified 12 lead in order to get a good look at the right ventricle you move V4 to the same place but on the left side of the chest and you move V5 which becomes V8 to the back level with v6 at the midscapular line and V6 becoems V9 level with V6 as well on the left paravertebral line (on the spine). In our local protocols a modified 12 lead ECG is indicated if there is ST segment elevation in the inferior leads and/or ST segment depression in the septal leads. The modified twelve lead gives you a good picture of the distal RCA and the back of the heart. not spell checked for my convenience.

How much does she weigh? Unless she is huge then we are carrying her out. We don’t have any fancy shmancy ATVs here anyway. The pole stretcher would work well. If she is huge we can always use the good ol' rolling sticks placed under the pt or perhaps a hard stretcher type scoop or something. Al far as the snake goes how do you know she was bitten and it isn't an open fracture? This woman may be the unluckiest person in the world. Maybe we should just leave her there to die so that she doesn't have to suffer anymore.

Woosh.

I think you definitely should have checked for a Babinski reflex. Otherwise you did good. I probably would have guessed at the pneumonia as a working dx from the get go, mostly because of the skin. Did she have any hx of cough or sputum? Oh, I forgot she was in a NH so yo probably wouldn't know. Anyhoo, ntg wont hurt, beta agonist may or may not have helped, although it may have been a good idea to try it, and lasix definitely wouldn't help and is not reversible so good call holding off on it. Several ER docs I have come into contact with recently during my training have mentioned that the differential dx between COPD and CHF is often a very difficult one and that they would not rely on a clinical dx alone. They do the blood work and the chest x-ray before administering anything. So don't sweat it man. Beta 2 agonist though. Hmmmm....I understand your concern with the cardiac side effects but it may have been worth a go. I just learned a wicked awesome way to nebulize meds while ventilating with a BVM.

CPAP would probably be a good idea actually. However the problem doesn't lie with our BH but rather with our tax base. Our service does not carry this nifty little device unfortunately.

Oh, you're in big trouble now mister! Unfortunately there is absolutely no truth to your statement. It would be nice if we could say that one particular thing, and recently occurring thing no less, is to blame for the cheapening of human life. the fact of the matter is that, as I believe you have pointed out previously, that if we go back to fundamentals of life, the weak do not survive. Also, those with weak parents do not survive. ("weak" is not being used here in any judgmental way, only for lack of a better word. "Weak" is used to describe the failure to survive. That's all.) Murder existed long before abortion was legalized. Abortions occurred long before they were legalized. The difference is that women can now have a fairly good chance of surviving the procedure with reproductive organs intact. Infanticide is hardly a new idea either. In fact I counter your argument by saying that human life is held in much higher esteem in this mode3rn world then it ever was in the past. What do you think happened to malformed or mentally retarded children 200 years ago? Do you think they were actively integrated into society? Were there equal opportunity trash bins? You all seem to forget what the alternative to welfare and social assistance is. Never mind the huge existing inequalities especially in American society but imagine if it was not only possible but common for people to have no income? Can you imagine what having NO income means for your life, your health, your future, you’re offspring? How can you condemn a woman for attempting to kill a parasite that will have a retched life and ruin any chance for her to improve her life….and in the same breath say that this same woman should not have any support by society? It just isn’t logical. Let’s take these people off social assistance and see how the infanticide and unwanted pregnancy rate rises. Oh sorry lady, I know you have no shelter and nothing to eat but why didn’t you take birth control?!! Ridiculous. Also, men have a sweet escape from this whole issue. In fact it’s a non-issue for them. A young man can be ignorant and irresponsible and uneducated or whatever but he will never have to face the problem of having a parasitic growth ruining his life. In fact he can disappear and forget any responsibility. This woman is just trying to do the same. I am not condoning her actions but rather I am trying to offer some understanding because after reading all these posts that seems to be what is most lacking. This is a societal problem people, your society, and you are your society. In conclusion…..abortion is not the cause of any of these problems. If I didn’t know you Dust I might be annoyed at your stupidity but since I know you are not a stupid person I believe that you don't even really believe this. As long as I am digging myself a hole here I figure why stop now? Adoption is something I just don’t get. Why would you want the offspring of someone who cannot care for their offspring? According to me in the vast majority of cases a failure to be able to care for your offspring indicates a failure in life and therefore more then likely a failure in genetics ,biology and environment. Also, how healthy do you think a baby is going to be that has been incubated by someone who doesn’t want it. Why would I quit smoking and drugs and take my folic acid and maternal vitamins to ensure the health of a being that I don’t want and don’t want to raise? The motivation is much less. Anyhoo, I have good genes and functioning reproductive organs and am willing to provide you with offspring for a price. :twisted: Excellent point Dwayne. You just saved me a lot of time. Yay Dwayne! /me waving my flag and recruiting cheerleaders. :hello1: Hahaha! Spoken like a true Texan! Perhaps there is a point to that but it’s much more likely that there isn’t. How well is your death penalty working as a deterrent Mr. Texas? What form of punishment is more severe then death?

Okay dokay. If you were going to intubate him (which is what I was thinking) what drugs would you give him? Also, is your only rational to intubate because purple = intubate? We don't carry albuterol and we wouldn't pour it down the tube if we did I am sure. Interesting point...the doc gave this pt mag sulf at the ER. For me the question about giving Epi sc or not was two fold. According to our protocols only asthmatic pts who are 50 y/o or younger can receive it for SOB non anaphylactic in nature. The rational for this according to me, is that older pts have a higher tendency towards CAD and subsequently more cardiac complications with Epi. Plus this guy was already pretty tachycardic. So the problem here of course is that I don't have a very good history on this guy and I don't know exactly how old he is, but he is in the fifty y/o vicinity. I think I would have at least attempted to tube this guy. The more I think about it the more sense it would have made. If he pinked up enough they could extubate him at the hospital. This is another call where the most difficult decision is whether to be aggressive or conservative.

Around here there are a lot of one way streets. The two main roads traveling across town from east to west are both four or five lanes and one way (in opposite directions). According to me, this creates a perfect atmosphere for running red lights for two main reasons; cars are traveling faster, and more importantly there are no cars turning left in the opposing direction when the light turns yellow. Anyhoo, they have red light cameras up every where and they'll get you a hefty 180$ ticket in the mail (so I hear, of course :wink: ). I've got to say, with no data to back me up, that I credit these cameras with reducing in-town fatalities. Another issue which has recently arisen with these cameras is the ambulance going through a red light. One of our medics was mailed a ticket for not coming to a complete stop at a red light, before proceeding through the intersection. The city (the employer) paid this ticket. From one pot into another I guess.....and we all received an email reminding us to come to a full stop before continuing through an intersection against the light.

I've heard it called "cellitis". I was initially wondering why someone would call an ambulance because they were fat; It's hardly an acute condition. Then it was explained to me. =P~

Holy Sh!t Are you telling me that all this time I could have been living large on welfare and all I had to do was have some offsrping? And here I am wasting all my time on education and crap like that trying to have a better life. WTF was I thinking? Seriously though folks. According to me it happens enough that women deliver children and seem to have been oblivious to the fact that they were even pregnant, that we can safely accept this as a reality that will not change. I offer a couple possible explanations; periods are not always regular for all women especially if you are undergoing excessive wt loss or an unhealthy lifestyle which is not unusual for the lower socio-economic classes for whatever reason (that is a whole other topic- but it has been proven that there is a definite correlation). Also, look around you - or in the mirror- North America. We are a bunch of pretty hefty individuals and it really isn't very hard to not notice the distribution of the fat changing form one body area to another. Never mind all the complicated psychological reasons. Regardless of the why, the truth of the matter remains that not all women are aware of being pregnant. Having accepted the problem we can now move onto finding solutions. I see two feasible solutions. The first, get those damn pharmaceutical companies doing some research on how to produce an oral contraceptive for men. Condoms just aren't filling the niche (no pun intended). And two, make abortion more easily accessible and affordable. The real question brought to mind here is why are these unwanted babies being born? Uhoh......

I also frequently come across this. As Rid said if you ask a few questions you can usually figure out whether it is an actual allergy or not, and thus whether you can administer ASA.

I actually had a pt who presented almost exactly like this scenario. I bagged her up while my partner prepared to intubate and her HR came right up as well as her BP and spontaneous respiratory rate. I can't remember what happened with this pt or what her final dx was either. Too bad. The only difference with this pt is that she continued to tolerate being intubated even with her improved vital signs. I think we were suspecting a CVA with other respiratory complications. So, although the answer has already been provided I was thinking one of two things for this pt. First I would try ventilating her, plain and simple. Then I was going to ask about Parkinson’s meds. I have had another pt who had just taken his levodopa and levocarb (I think it was) and who's BP abruptly dropped into his boots. He was also on beta blockers so there was no compensatory HR increase. A fluid bolus did it for this gentleman. No atropine, Dopamine or anything. It goes to show that there is no teacher like experience. I am learning that often the toughest call to make is whether to treat aggressively or conservatively. Neither is right in all situations.