chbare

Any history of trauma. I agree AZCEP, if there are no contraindications from history or meds we need to stop the seizure with benzo's. If this patient has actually been seizing for 10 minutes non stop, she's headed for status epilepticus. May want to have airway and RSI equipment ready.

Take care,

chbare.

ERDoc, conversion is a possibility,( but highly unlikely with the dilated pupils not being normal for the pt) but I am strongly considering other causes. There is no way this lady is going home. I am leaning toward some type of structural problem. Perhaps a small pituitary neoplasm putting pressure in all the right places, or perhaps a nasal/pharyngeal neoplasm not evident on the CT scan, or bilateral central retinal arterial occlusion. Hmmm, I will have to look into the possibility of a neoplasm. If the neoplasm is extracranial, (nasal/pharyngeal) this may mean mets.

Take care,

chbare.

Hmmm...

Well, I still cannot rule out conversion. I guess I should have asked this question much earlier, is the pupil dilation a new thing.

Thanks,

chbare.

What is my general impression, is the patient currently having a seizure and what does it look like? Is there a patent airway and does she have a pulse? What is the son looking for?

Thank you,

chbare.

Ridryder 911, I agree. If you work in an area that has multiple hospitals, you need to know your protocols and be able to triage your patients appropriately. We only have one hospital in our county, so we get all the calls. We have had problems with ambulance crews that run every call emergent (lights, sirens, speeding like a maniac) regardless of the patients condition, and I feel safer now that people are starting to use common sense.

Take care,

chbare.

EMS_Cadet, I would call this a trauma. However, light, sirens, and driving like a speed demon could end with me smashing into a soccer mom/dad van full of kids. My ER director has done a good job of decreasing all of the "emergent" calls in my county, and I honestly feel that the patient, EMT's, and streets are safer for this.

MedicRN, excellent call on things to assess.

I hope this helps.

Take care,

chbare.

Callthemedic, Hard to say. I hope ERDoc will give us some more info. Or, perhaps were overlooking something.

Take care,

chbare.

Callthemedic- I see your point. This patient has allot of different problems aside from the confusion and blindness. I have issues with the dilated pupils. This tells me possibly something metabolic (drug metabolites) or structural. I am leaning toward some kind of substance build up like you. I think it is a good idea to look for fresh track marks, maybe she is using drugs again If she is, try to find out what. I am with AZCEP's thinking. Get a thorough neurological exam (As the patients condition allows.) and try to rule out intracranial pathology the best we can.

Take care,

chbare.

AZCEP, I am not sure about the vertical vision loss. Quinine is toxic to the retina. I think retinal artery spasm is the current theory behind the S/S. S/S include; loss of visual fields, scotomata, progression to complete blindness, and pupil dilation. I think the vision loss starts around 9-10 hours following ingestion. However, I would also expect other S/S. The confusion can be related to quinine but are there C/O N/V, tinnitus, HA, or hearing loss. From a prior post we learned that she does not C/O HA. We have put her on the monitor and I would be curious to see what her Q-T interval is. Good call on checking for other Nero S/S and working the intracranial pathology route.

Callthemedic, I agree, this lady may be a little "cuko for coca puffs," and she is on some pretty potent medications.

RaceMedic, good call on the script and additional background.

Too bad this isn't the land of OZ and I could sprinkle magic fairy dust and produce a tonometer, slit lamp, portable lab, 12 lead ECG, and CT scanner!!!

On a side note, HX of HEP C. is she getting interferon TX? I have heard of people developing retinal hemorrhage after receiving interferon. Is she jaundiced? Could some of this be related to encephalopathy? Ammonia LV?

Take care everybody,

chbare.

I think we may be on to something with the quinine medik8. However, I cannot rule out other causes with the information I have. Does the patient c/o tinnitus? Is there a history of cinchonsim related to the quinine use, or a history of G-6-PD deficiency? (I hope there is no hx. of G-6-PD deficiency, but you never know) I doubt we would be able to obtain this info in the field, but you cannot go wrong trying if the situation permits. At this point I think transport would be a good idea. Put the patient in position of comfort , give her supplemental oxygen, establish an IV life line, and put her on the monitor. She may be prone to cardiac rhythm disturbances if this is in fact related to quinine, or any number of medical problems on that note.

Hopefully this will help us get to the bottom of this case.

chbare.

Quinine toxicity may account for the blindness and confusion. Has she taken more than her perscribed doses of medications or more than her usual doses of meds?

chbare.

Can we get any medical history on the patient? Does she take any medications or have any history of trauma? I would also like to get a set of vital signs and a blood sugar.

I am thinking out loud about the ddx's;

Allot of obstructive causes of vision loss result in sudden onset not gradual over days.

Perhaps an atypical presentation of glaucoma, acute closure with no pain or undiagnosed chronic angle closure. I know a fixed pupil in mid position with vision loss may suggest angle closure.

History of methanol ingestion? I also know this can cause vision loss and fixed/dilated pupils.

This may help us reach a diagnosis.

Take care,

chbare.

Ridryder 911,

I completely agree with you. I think ETI is the gold standard for securing the airway and all of the various airway devices out there are backup/rescue devices, or devices that can be used in the OR by someone who has the ability to transition to ETI if required. I actually fear that some people who have pull in the medical community (and who live echelons above reality) will look at these devices as a replacement for ETI in the prehospital environment. I know you are pretty busy with your studies, but I could PM you with some of the data I have on the King LT.

Take care,

chbare.

Spock,

I think we are getting our King LT's form http://www.narescue.com. There is allot of info and even some research data about the King LT on this website as well. The King seems to be getting allot of good press, but I am always a little skeptical about the latest and greatest devices, so I am happy to hear that someone experienced in airway management gives the King LT two thumbs up. It looks like I will get to use the King LT on cadavers at SLAM next month, I am looking foreword to that experience.

Thanks again,

chbare.

Spock,

Thank you for the information on the King LT. My National Guard unit is looking at using the King LT over the Combitube. I have been prowling around the posts looking for someone that has first hand experience with the King LT. I have used the airway on a simulator and found that it was pretty easy insert and manage.

chbare

zippyRN,

I could not give you an exact number. Your best bet is to check out the NLNAC's (National League for Nursing Accrediting Commission) web page. The address is http://www.nlnac.org/. The Department of Education recognizes the NLNAC as the national accrediting body for nursing programs in the USA.

I hope this helps.

Take care,

chbare.

Ridryder 911, we use the LMA in our ER as a backup and I have had pretty good results with it. Disclosure statement, I have not used the LMA many times. I think dislodging would be even more of a problem in the back of an ambulance or helicopter. The LMA is pretty easy to insert and it's about as "Murse" proof as you can get. I know allot of people and the studies indicate that one of the most common problems with the LMA is the lip flipping back during insertion. The most common problem I have encountered is air leaking around the seal into the esophagus during ventilation, especially on very large people or people who require high ventilatory pressures. Otherwise I like the LMA and actually carry a size 4 and size 5 LMA unique in an airway crash bag in addition to my combitube while on duty with the National Guard.

PRPGfirerescuetech, thank you for the link. This should be some good information.

Take care everybody,

chbare.

Does anybody have first hand experience using this airway as a backup/rescue device. My National Guard unit is looking at using this airway. We currently use the combitube. I have used the King LT on an airway simulator and found the device easy to insert and use, however, this is not even close to a real person. I have googled and found research on this device, and it seems to work pretty well in the controlled OR environment. From what I have found it seems to provide a better seal than the LMA. The manufacturer boasts a seal of 30 cm of H2O verses a seal of about 20 cm of H2O with the LMA. However, you know how the maker of a product likes to brag about their product being the latest and greatest gizmo. It looks like I will get a chance to use the King LT on cadavers next month at SLAM, but I was just curious if any one had any first hand experience with this device. A web site with allot of info about the device is, http://www.narescue.com. However, this company is also selling the device, so I tend to be a little cautious regarding the info they put out.

Thank you and Take Care,

chbare.

I would like to thank every body for their posts. There are many people on this site who have extensive EMS experience, (and even a few who have been in EMS longer than I have been alive) and I value your comments.

I want to emphasize this is something that I am carefully considering, and may not even be an option if my employer does not get the 911 contract. I know there is a significant difference between the nursing education and Paramedic education, and I do not want to compromise prehospital patient care if my training is not considered adequate. I will not even consider working in the prehospital environment until I receive guidance from the state board of nursing, the state EMS board, and my malpractice insurance company. In addition, both my employer and physician medical director would have to develop specific protocols and competencies for prehospital nurses.

A possible route I may consider is applying for reciprocity and testing out at the state EMT-I level and working as an EMT-I. A few people have told me this is a bad idea because of possible role confusion. This is also something I would consider very carefully.

I do have prehospital military experience; ambulatory medicine, patient transport, tactical medicine, and evacuation experience, however, this is still quite different from civilian EMS.

If after I receive guidance I feel there are any doubts about the legalities and my abilities to provide prehospital care I will decline the offer and continue to support the company by strictly sticking to patient transfers.

As of now I am leaning toward holding off on any ambitions of working EMS until after paramedic school.

I would like to thank everybody again for their responses.

Take care,

Chbare.

I work for a private ambulance company on my days off providing ALS coverage for transfers. The company is looking at providing county 911 coverage. My boss recently asked me if I would like to start providing 911 coverage. My co-workers seem pretty excited to work with me. I would be working with experienced paramedic partners and would have very specific protocols regarding the skills I would perform. Both my boss and medical director state that they feel confident in my ability to be part of the pre-hospital team. Does any one have any experience with RN's working in the field? I have limited field experience, 2 years as an EMT -B and EMT -I training, and I do not want to compromise patient care. I jut wanted to know if any of you have had to work with RN's in the field and what experiences did you have?

Thank you,

chbare.

Excellent! The diagnosis is peritonsillar abscess. I believe it is the most commonly seen neck abscess. The abscess can cause an upper airway obstruction and should be regarded as a priority for treatment. The patient received humidified oxygen, was placed in a position of comfort, and tolerated IV therapy. His vital signs were monitored frequently as well as frequent airway assessments. Initial treatment included; 1000ml of NS over 60 minutes, 30 mg of Toradol IVP, and 1000mg of Ceftriaxone IVPB. Within the hour an EENT doc was consulted and the patient eventually received an I&D. It was well tolerated and he was discharged home a couple of days later. He eventually had an elective T&A. I am glad everybody liked the scenario. I am with you Dirt Devil on clinicians who hand out scripts for URI's without actually putting to work all of those years of assessment skills they should have learned in school, of course when the triage nurse handed me the chart on this patient she told me this was an in and out wimp call. So, I guess the shoe fits allot of people. Thanks for the warm welcome everybody, and take care.

chbare.

I will try to answer all of the questions.

Eydawn:

The pain was present when he saw his PCP and did get worse after starting ABO therapy. No unsusal exposure to substances or activities that would cause throat pain. No other medical problems or history. He has neved had throat pain like this.

Dust Devil:

You are correct about the exam, this was a once over my xray vision can see all kind of exam. No rash noted. Unknown if a rapid strep was performed, I believe not because the patient did not say anything about having a throat swab. I glad it did not take long for someont to ask about a detailed EENT exam. His oral mucosa is moist and intact however you note that his left tonsil appears pushed foreward and the patients uvula appears displaced from the unusual position of the tonsil. You do not note any exudate.

ERDoc:

His oral mucosa is moist and intact , however you note that his left tonsil appears pushed foreward and the patients uvula appears displaced from the unusual position of the tonsil. You do not note any exudate. No strider noted.

I hope the additional information helps.

Take care everybody,

chbare.

Interesting case

Twenty three year old male presents to the ER complaining of a very severe sore throat. He states he was seen by his family doctor about 2 days ago with a cough and sore throat. He was diagnosed with an upper respiratory infection and put on a course of Zithromax. He states his throat has become very sore and he states having difficulty swallowing since the onset of his symptoms. Vital signs are; Resp-22 non labored, Pulse- 110 strong at the radial, B/P-110/066, SAO2-97% on room air, Temp-101.3 tympanic, Pain-10/10 to his throat. His physical exam is unremarkable and his lung sounds are clear in all lobes posterior and anterior. He denies any other medical problems or past medical history. The patient has no allergies and denies taking any other medications. What else would you like to know?

Take care everybody,

chbare.

"Glory Hole"