chbare

Good luck, I hope your tour is safe and bings you home without incident. Take care over there, chbare.

ERDoc, it is rather complex. As I remember INH inhibits several hepatic pathways that alter Vitamin B6 metabolism. B6 is metabolized to it's active form by the substances that are inhibited by INH. This leads to a reduction of a substance called pyridoxal-5-phosphate (P5P). P5P is needed for the production of an enzyme called l-glutamic acid decarboxylase. This enzyme is critical in the conversion of glutamic acid to GABA. GABA is decreased and glutamic acid increases. (glutamic acid is an excitatory neurotransmitter) The brain is over stimulated and prone to seizures. I will have to do a little research to go into more depth on the pathways and specific pathology. I do know of reports of people having seizures that take therapeutic levels, I ASSumed she may have overdosed. Thank you for calling me on that. Take care, chbare. Edit: PS, sorry I have not been around to post sooner. I just got back from an out of town trip. Take care, chbare.

Docomd600, I am an old fan of SOAP notes and POMR. I use a slightly modified version, SOAPE. S-Subjective 0-Objective A-Assessment P-Plan E-Eval/Re-eval Take care, chbare.

Strippel, all feelings about theories of trauma management aside, this looks like a case of people not communicating. You service and medical director need to deal with the surgeon directly and get everybody on the same page. Take care, chbare.

Dustdevil, you are correct. You could call NMS a chemical induced type of heat stroke. Securing the ABC's and rapid cooling is paramount married with rapid transport. In addition, I wanted to give the ALS providers something to work with, so the scenario I gave was a very severe case of NMS. In addition, I wanted everybody to see some of the complications of this syndrome and how it would have been managed after the patient left the care of the EMS crew. This case was nearly identical to a case that I saw in nursing school, of course the hospital had an ICU and the patient was simply transported to the unit, RSI'd and managed on site. You bring out a good point that good BLS could have sustained this patient. Not all cases of NMS are this severe and I would bet a few cases fall through the cracks as simply being called viral syndrome or seizure disorder. So, good assessment skills and an understanding of pathophysiology of your patient, their condition, and medications could actually help make the correct diagnosis. I wanted to wait a while before placing this post, so a few more people would see the scenario. And yes, if you service does not have a thermometer that can check rectal temps, they need to do a system check. Take care, chbare.

New Mexico has a nearly identical setup. :roll: Take care, chbare.

1EMT-P, I believe the Army now requires NREMT-Basic for all 91W series MOS'. I am employed as a nurse for both a hospital and ground ambulance transfer service, neither of which require EMT credentials. I am registered as an I/85 and plan to re register. Plus, I have a special set of scrubs that I wear when I am scheduled to work with Paramedics. The scrubs have the NREMT-I patch on them and, and the going joke is that the Nurse is now only about 1000 hours away from being a Paramedic, and taking their jobs away from them. Take care, chbare.

We need human studies on Poly-Heme. We need to find out one way or the other just how effective Poly-Heme and other oxygen carrying fluids are. Take care, chbare.

JakeEMT, no problem. Take care, chbare.

I believe over aggressive fluid management causes more harm than good, (hemodilution, blowing out clots, messing up clotting factors) This is especially true in the patient who has internal noncompressible bleeding. However, it is nice to have an IV started with blood tubing so PRBC's can be rapidly infused if needed. A saline lock is nice for a secondary or third IV site. Take care, chbare.

Nice job everybody!! He does need IV fluids and his renal status needs close monitoring. His labs and UA indicate Rhabo.., a complication of NMS. He needs a foley, fluids, and diuretics to prevent renal failure. 12 lead shows sinus tachycardia. Good job on catching the sux A potential side effect of sux in addition to hyperkalemia (especially with renal failure) is malignant hyperthermia. I hope everybody had fun with this scenario. Take care, chbare.

Scaramedic, I have been hearing allot about the new testing. I hope it works out. Take care, chbare.

AnthonyM83, no ECT available, but you have your labs. The patient is recieving NS via IV and per a prior post he was given a bolus to increase his B/P. You have got you labs per above and the CT is negative. Dopamine agonist meds are on board. This is a tough case. In fact this was the first thing I experienced during my first day of my first psych rotation in nursing school. Take care, chbare.

AZCEP, the patient is given etomidate and vercronium iv and intubated with a 8.0 ETT 23 cm at the lip. No epigastric sounds and bilateral lung sounds with good rise and fall. You use capnometry and an esophageal intubation detector as secondary confirmation devices. His sats increase to 100% with PPV and you notice is is much easier to bag now that he patient is paralyzed. IV fluids are bolused and his B/P remains around 110/50, pulse decreases to 105-110 and strong. You also give a benzo of your choice for ongoing sedation. ( why did we not use succnyl... during the intubation?) CBC-normal except a WBC of 13.8 & neutrophils of 9, SMA 12; Potassium- 5.9, Sodium-133, Chloride- 92, BUN 35, Creat 2.1, BGL 129, and all others WNL. ABG indicates metabolic acidosis. Tox screen is negative. You also decide to run a Ck & myoglobin- Both are very elevated and UA indicates myoglobinuria. CXR is clear with proper ETT placement noted. What do you think. Take care, chbare.

AnthonyM83, Good, we are working on getting his temp down. Unfortunately, a severe episode of NMS like this is going to need definitive care. There is a high possibility that he may develop a problem that is usually associated with severe dehydration and crush injuries. Your driver takes a wrong turn and now we are in the land of OZ. You have a magic ambulance with all of the ALS supplies and meds you could ever think about giving. In addition you have full laboratory capabilities. What do you want to do about his airway, and what other treatments and tests would you like? Take care, chbare.

TechMedic05, correct you got the diagnosis. NMS is a rare complication of neuroleptic medications such as haldol. (especially haldol) I believe it occurs in up to 1% up people who take neuroleptics. It can occur after the fist dose of medicine or in someone who has been on the medication for several years. The syndrome is thought to be a result of dopamine antagonization of the nigrostriatal pathway. Hyperthermia is thought to be a result of a blockade in the hypothalamus. S/S include muscle rigidity, (lead pipe rigidity) severe hyperthermia, altered mentation, and inability of the autonomic nervous system to adequately regulate hemodynamic status. (B/P, and HR will not be WNL) How will we treat this patient? AnthonyM83, you are doing good, this is a nightmare call for the EMT-B. Take care, chbare.

AnthonyM83, you notice that in addition to his contracted board like appearance, his chest wall muscles and jaw muscles are contracted and pretty tight as well. You do not insert an OPA because of the clenched jaw. The Nurse also tells you that the patients temp is up to 106 F. You continue bagging after repositioning the airway, but note it is still very difficult to bag the patient. AZCEP, you establish an IV and administer 25 mg of benadryl IVP. You do not note any significant change in the patients condition. On a side note; your transport time to the ER is 30 minutes. Any thing else? Take care, chbare.

PRPGfirerescuetech, I cannot speak for FireGirl911's education, but I graduated from a New Mexico approved EMT I course in February 2006. We were able to take the NREMT-I/85 written and practical exam. (and had too for the military) The anatomy, physiology, and pharmacology was pretty basic and the course was about 216 hours long. It was designed for Army National Guard Medics so it may have differed from the standard New Mexico EMT-I curriculum, but it was still a NM approved course. Take care, chbare.

Dustdevil, I could not have given any better advice. Take care, chbare.

The NCLEX is set up a little differently that the NREMT exams. Like the NREMT the goal of the NCLEX is to test someone to a minimum competency level. As you take the exam the questions get more complex and head toward the set minimum competency. If you start answering incorrectly, the questions become less complex. This game of getting more complex as you answer correctly and less complex as you answer incorrectly goes on until it is determined that you can consistently answer questions correctly in the minimum competency level or you cannot answer questions in the minimum competency level. One that is determined the computer will stop spitting out questions and you are done. This can be as little as 75 questions or over 200 questions. You are not graded on a percent correct, but solely on you ability to achieve the minimum standard for competency. It is a little complicated, but I hope that helps. Take care, chbare.

Sorry I did not post earlier, I worked last night and slept in a little. Thanks ERDoc for not giving it away. No Botox injections, he has received Haldol in the past without problems, no Hx. of TCA use, 02 Sat on room air is 86%, BGL-129mg/dl, B/P-80/44, Pulse-110-130 and weak, and a rectal temp is 105.3 F. The nurse is a new grad LPN and stated that about an hour after giving the Haldol injection she found the patient like this, she thought he might have had a seizure and called 911. You insert a nasal airway and begin PPV with a bag valve mask at 15 LPM, you note there is a lot of airway resistance and it is very difficult to bag the patient. Anything else? Take care, chbare.

The scene is secure and you are met at the door of the lock down unit by the patients Nurse. She tells you that the patient is a known schitzophrenic that has auditory and visual hallucinations he has been off of his meds and was admitted having hallucinations and behaving violently. The Nurse tells you that the patient has no allergies, no history of a seizure disorder, and no surgical history. He was given an injection of Haldol about an hour ago then developed what the Nurse thought were seizures. General impression finds the patient supine on the floor without evidence of trauma. You do not notice any tonic clonic activity, but the patient appears to be very stiff and board like. He has snoring and shallow respirations at about 10 per minute. He has a weak thready radial pulse at about 110. His skin appears flushed and feels hot to the touch. His eyes are closed but he moans and grimmaces with painful stimuli. What else would you like? Take care, chbare.

You are called to an inpatient psychiatric unit for a 63 year old male having seizures. What would you like to know? Take care, chbare.

Ridryder 911, I agree. The concept of EMS as a profession is long overdue. Take care, chbare.

Ridryder 911, I agree that credibility and reciprocity are two very strong advantages of the registry. I do not advocate doing away with the registry. I believe that they are probably the best organization to issue a national exam. I just think that every state should require everybody to take the same national exam. That way, at least everybody has been tested to a known minimal competency level regardless of where you took your course. Some day I would like to see Paramedics as licensed professionals and EMS officially recognized as a profession. Take care, chbare.