Lady, fell and went boom?

[Canadian Caesar]

Barring RSI, a King LT could also work here :wink: Just an example of a challenging intubation where even a Medic might want to pull one out.

- So I bag her, and what are the Lung sounds? Any obvious Aspiration of Emesis?

- Any signs that she seized prior to us getting our eyes on her?

- Is there a patient in the room next to hers that can tell us anything about how the patient has been feeling or behaving lately? Unreliable info is better than none at all at this point I think.

But the answers I am most interested in at this point are:

- Did we have any Pill bottles present in her room? Possible overdose on meds?

- How is the rest of her body behaving? Does it seem appropriately limp? Or does the clenching of her Vocal Chords also extend to other muscle groups in her body?

[Mateo_1387]

BP : 180/110

RR : 8 - snoring, inadequate

HR : 64

SPO2: 80% on room air

Pupils : dilated, very sluggish to react

BGL - 72

Vomit : greenish yellow slime with chunks of what once resembled carrots in it

AVPU : unresponsive

GCS : 5 - (1 eyes, 1 verbal, 3 motor - appropriate flexion to painful stimuli)

what's going on with this patient?

Just a first impression, but it looks like the patient is herniating due to intercranial bleed. Maybe from a hemorrhagic stroke, or maybe due to trauma, since the door is off the hinges.

What other interventions you gonna do to benefit ?

RSI

IV

O2

keep the blood pressure above 110 systolic

Hyperventilate

Sit the patient up

Rapid transport to appropriate neurological facility.

[fireflymedic]

Nice work Mateo - you hit it on the head - had massive IC bleed. Only disagreement I have with your treatment plan is keeping systolic above 110 - I'll take 90-100 so as not to increase ICP any further. I did end up getting the tube - courtesy of drugs to loosen her up (got DAI not RSI due to no second medic being around), but I could imagine the nightmare if I hadn't had that luxury. Bleed wasn't due to trauma that we are aware of - doc's best guess was aneurysm. The general sickness was probably a headache leading to this that they dismissed. Pt coded in ER and they didn't get her back. The end. Good thoughts and playin gang. I'll ride with some of you all anyday

[Christopher.Collins]

Question the facility's name...

Question is lack of nursing staff and patients....

Question why you found a woman appearing to be the glutton from the movie Se7en...

Flee due to an "unsafe scene"

[Mateo_1387]

Nice work Mateo - you hit it on the head - had massive IC bleed. Only disagreement I have with your treatment plan is keeping systolic above 110 - I'll take 90-100 so as not to increase ICP any further.

Cool.

As for the blood pressure, I was taught that it is prudent to have the blood pressure about 110-120 to keep up cerebral perfusion pressure. My number may be too high, but that is what I remember from school.

Maybe someone can chime in and maybe give a small lesson on this subject.

(got DAI not RSI due to no second medic being around), but I could imagine the nightmare if I hadn't had that luxury.

I am familiar with RSI, but what is DAI?

[fireflymedic]

as long as you can keep a MAP of 60, I can live with a lower BP therefore, you're not needing such a high BP. You can have a lower BP and still be perfusing adequately. DAI is drug assisted intubation - give enough sedatives ie valium, versed, ativan whatever flavor of the month to knock 'em down and hopefully relax enough to get the tube - no paralytics given at any time. RSI involves use of paralytics. Basically with DAI you are not fully taking away their ability to breathe, just let meds wear off a bit and they'll pick back up, RSI you are taking that ability away. Nice job.

[Canadian Caesar]

DAI = Drug Assisted Intubation?

Just my best guess, I don't know for sure.

[Mateo_1387]

As far as DAI is concerned, I guess I have heard of it, I was not familiar with the lingo.

I was taught that for trauma, a MAP of 60 is fine, but for a head bleed, the MAP needs to be higher to maintain CPP, because with Hypotension, plus herniation, the CPP cannot maintain at a lower pressure. I was just talking more about it to see if maybe there is some literature/studies done on the subject.

[fireflymedic]

Mateo - good thinking, however remember that with increased perfusion pressure, you are also increasing the possibility of increased swelling. You have herniation going on already, the brain has no where to go but down. You increase that pressure, you are just killing the person faster. MAP of 60 will do you just fine. Any higher and you'll see the patient going downhill much faster. Remeber with an IC bleed you are just increasing the pressure already within the brain and if you push that CPP higher it's not a pleasant result. Keep enough flow to keep tissue alive until they reach definitive treatment (around 60 or so especially with the transport time we had) but not so high you push them over the edge (had we maintained as high as you stated our patient would have been long dead before reaching ER).

Keep learning though - you got good thoughts, I'll ride with ya anytime !

[Kaisu]

The other thing that is useful with a patient with increasing ICP is hyperventilation. Blowing off the CO[sub:6d6f6f1c85]2[/sub:6d6f6f1c85] is helpful to reduce swelling. This is another balancing act as the trick is to keep partial pressure of CO[sub:6d6f6f1c85]2[/sub:6d6f6f1c85] around 40 - too low and you risk hypoxia. With increased ICP, you are going to have a cushings response, where the BP rises in an attempt to maintain cerebral perfusion pressure. This is a late sign. This patient needs a neurosurgeon and effective prehospital treatment is limited. This is a beat feet situation for sure.