OVeractiveBrain Posted January 21, 2008 Share Posted January 21, 2008 EMS is dispatched to a middle aged hispanic man for an unknown medical. Patient is a middle aged, 40 something hispanic male found in a hotel, where he works. Staff states they saw the man "drink something from his cart" and then "go unreponsive". The time course is not concrete, it sounds like earlier on (within the hour) was the drinking, now is altered mental. Medics interpreted "unresponsive" from the staff as "severely altered mental," since he is now a GCS of 6 and getting worse. Staff activated EMS immediately and phoned family who is present upon receipt of patient at the hospital. EMS arrival is within 10 nminutes of call, and to hospital in another 10. GCS: 6, Vitals are WNL (80, 120/70, good cap refill, sating 98%, breathing fine), lungs are clear, bowels are continent, sugar is 65. 12 Lead reveals no significant findings. at this point, the prehospital differential needs to be drawn. Deteriorating altered mental status moving towards 3, gag reflex intact. No hx, allergies of medications that anyone knows of. Possible toxic ingestion of an unknown fluid. What do you do? What do you think is wrong? Stop here and think about what you would do, what information you might like and where you would go with this. Your "trauma center/major med" hospital is 10 minutes away. The medics enroute administered narcan 0.8 IV, and have an amp of D50 (25g), 15LPM NRB. Differential was left at unknown altered mental secondary to toxic ingestion. In the ER assessment revealed a GCS of 3, one pupil may be enlarged (left 2.5, right 2), vital signs remained unchanged. No babinski. No other significant findings. Family is spanish speaking and small history is obtained. It seems that this man is middle-aged, works in the hotel, has no history, allergies, or medications. He has worked at this hotel (which is a fairly expensive one... its no motel 6, nor is it the W or the Ritz-Carlton) for some years, and it is his regular employment. Patient is induced and intubated, Chest X-ray reveals proper tube placement and clear lungs, no mediastinal shift, no abnormalities in lung fields or in axial skeleton. NG tube is placed and 20cc of fluid is removed. It appears to be gastric secretions of normal color. It is sent to pathology for analysis. A foley catheter is inserted and draws 250mL of urine, standard tox screen is negative. This all happens in 5 minutes. CT scan comes back with "diffuse edema, MRI ordered." I left my rotation prior to hearing what the path screen on the gastric contents was and no MRI was conducted on my way out. The doc on staff was pretty sure it was a CVA. I disagreed, but kept my mouth shut... she has the MD and about 10 years of experience in an ER on top of my 2.5 in a truck. So here is what I open for discussion: What do you do with an unknown altered mental that is rapidly deteriorating? Do you go for a "coma cocktail" or just perform monitoring of life signs. One doctor questioned the failure to intubate in the field (though they did have to induce the patient in the ER, so i can imagine it would have been challenging to tube in the field). This patient is as up in the air as can be. With the information given in teh field, what were your thoughts of a differential and treatment? Given the advanced techniques in the hospital, what are your thoughts on a differential and treatment? Does knowing what you know from the hospital encounter shift your differential from what you thought it could be in the field? Hopefully this will get you all thinking. Link to comment Share on other sites More sharing options...
Canadian Caesar Posted January 21, 2008 Share Posted January 21, 2008 I'll assume the BGL of 65 was a typo and not a dead give away as to the cause of the problem... Right? Link to comment Share on other sites More sharing options...
AZCEP Posted January 21, 2008 Share Posted January 21, 2008 That would be 65 mg/dL, and it is a bit low but not dangerously so. A little D50 would be a reasonable idea with this finding. More concerning would be the lack of improvement following the D50 administration. I'd like to know what was on his "cart" that he would be able to drink. What is his job at the hotel? What kind of things is he around while at work? I'm guessing he did not drink the standard mini-bar type solution. Link to comment Share on other sites More sharing options...
Canadian Caesar Posted January 21, 2008 Share Posted January 21, 2008 Ah I see. A different measuring scale than I am used to alltogether. Perhaps he decided to finish a bottle of liquor that was left in a room after checkout rather than let it go to waste. And perhaps that bottle was laced with somthing. I'm just an EMT so I dont know, but would Narcan counteract the effects of some date-rape type drug like Rohypnol? Link to comment Share on other sites More sharing options...
fiznat Posted January 21, 2008 Share Posted January 21, 2008 I hate unknown AMS. The differential is pretty much: 1) Neurogenic (seizures, cva, psych) 2) Metabolic (sugar, hyper/hypo 'lytes) 3) Tox (considering what was available for injestion/inhalation/etc) 4. Hemodynamics (cardiac, bleeds, trauma, etc) The H's and T's work as well... Often times besides the obvious (BGL readings, obvious OD signs, history of similar conditions) there is little we can do to isolate the cause of an unknown AMS. As far as prehospital care, I would focus on things that would be important to me: -Seizures? Check for incontinence, history, meds --> be prepared for another seizure -CVA? Check pupils, BP, history --> routine ALS, expedite transport if appropriate -Tox? Consider scene safety, find out what patient had access to. -Psych? Extra hard sternal rub, brush the eyelashes. Find out about history. -Imbalances? 12 lead ECG, routine ALS -Hemodynamics? Treat VS as indicated, consider traumatic history... All in all not much we do besides the real basics. If there was a gag reflex and the providers don't have protocol for sedated intubation or RSI there really isn't much to do besides supportive care. The resources of the ED really shine in cases like these, while at the same time the limitations of EMS are made painfully clear. Link to comment Share on other sites More sharing options...
Asysin2leads Posted January 21, 2008 Share Posted January 21, 2008 What this almost definitely probably is: A guy who is drunk, and as mentioned before, took his last swig and then took a nap. However, given the absence of other mitigating factors, like nice volunteer bystanders who are showing us its a bottle of liquor, if the man is laying apparently unconscious on the floor with the bottle of the unknown substance laying next to him, the scene can and should be approached as a hazardous materials response. First, we self evacuate and all for appropriate resources. If we are appropriately trained we should approach with at least Level D protection and SCBA's, i.e. full turnout gear. If the substance is easily identifiable, we can proceed from there. Otherwise, decon, treat, notify, etc. Link to comment Share on other sites More sharing options...
zzyzx Posted January 24, 2008 Share Posted January 24, 2008 Good scenario, but I don't have much to add here. If I had this guy in the field and he didn't respond to Narcan and had a normal blood glucose, I would think that he most likely had a CVA, probably a bleed. Of course I would also try to investigate what it was that he could've drunk off the cart. My treatment would just be standard ABC's. I don't have RSI where I work, so I couldn't intubate if he still had a gag. Link to comment Share on other sites More sharing options...
Fluffpaw38 Posted January 24, 2008 Share Posted January 24, 2008 As an EMT-B. Get ALS on the way Vitals every 5 minutes (high priority) Radio medical control/direction, give them info, as if there are any specific interventions they would like us to do till ALS arrives. Oxygen 15L via non-rebreather Keep suction ready Keep AED ready Re-assess initial assessment Detailed physical exam maybe And i love hearing what the medics have to say. It just motivates me more to go back to class =] thanks super duper EMTcity medics! Link to comment Share on other sites More sharing options...
firemedic37 Posted January 25, 2008 Share Posted January 25, 2008 Consider C-Spine. With a GCS of 6 consider intubation, Trauma Center 10 away and gag reflex intact, I would do a nasal airway and bag the guy. Establish IV of LR, 12-Lead, monitor vitals, administer Nalozone and Thianamie, if no response then consider D50. Link to comment Share on other sites More sharing options...
Medic26 Posted January 25, 2008 Share Posted January 25, 2008 As far as the airway go's, a nasal intubation could have been in order. So many people people forget this great technique and cop out with....we don't have RSI. :roll: If the patient was that unresponsive he certianly needed his airway protected. As far as treatments with ALOC, not much else we can do but supportive measures once we rule out low blood glucose and give narcan. A good history helps but you aren't always blessed with good information. Link to comment Share on other sites More sharing options...
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