Engineer's Special

[Kiwiology]

Please participate on only one forum

After a day of dragging people strapped to a gurney into your van with tinted windows and giving them drugs (what? ... you make it sound like something bad) you are sent to a guy passed out in his car on the side of the road.

When you arrive there are two cops and seven firefighters standing round doing nothing as well as the Engineer who is leaning on the truck looking at the chalkboard menu of the diner he has parked the outside of.

Single male patient in his fifties on the drivers side, slumped down over the seat and passenger seat.

- Unresponsive, GCS 3

- RR 24 PR 90 HR 130 BP 230/120 SpO2 96 BGL 90 (~4 mmol/l)

- Sinus rhythm on 3 leads

- Clear and equal lung sounds

- Constricted pupils

- Medic alert bracelet says diabetic

There are two bottles of medication in the centre console; one of Effexor and the other is Captopril.

So while the fireys sit round eyeing up the daily specials what are you gonna do?

Edited May 13, 2010 by kiwimedic

[medicKristina]

Ummmmm. B*tch slap them? That is seriously not ok. This is looking like possibly a stroke, which they might have been able to ascertain had they done something as simple as take basic vital signs. Yeah. That slap is being warmed up right now...

Edited May 13, 2010 by medicKristina

[Kiwiology]

Ok, so having had basic vital signs taken ... what would you like to do with them? (numbers above)

Mocachino and slice of chocolate cake to go are not acceptable answers .... *taps foot

[AT-Medic]

I don't want to go into treatment as that can be as different as night and day depending on location. So I'll take a shoot as to what I think might be the problem. Effexor is a very popular drug for depressive disorders in general. Effexor also comes with a nearly never ending list of side effects. I would highly suspect a toxic response to the Effexor as a result of OD or hypersensitivity. The pill bottle will yeld information as to when this Rx or refill was started, dose, and by counting - the number of pills left, assuming that there are no pills in a plastic pill box at home. So based on the current vitals, I woulld guess that the pt is in a postictal state from a seizure caused by the Effexor, as well as the fact that the pt is hypertensive and tachycardic which are both side effects of Effexor. Whats burning in the back of my mind? Is this an intentional or unintentional OD? Although decreased in this pt's age group, the risk of suicidality is high on Effexor.

Local tx for this pt would be; support ABC's as needed, monitor for change in status, moniotr heart rhythm, IV-kvo or saline loc, transport to hosp. I would like to address the HTN, but there is no HTN tx in Maryland.

[Just Plain Ruff]

I don't want to go into treatment as that can be as different as night and day depending on location. So I'll take a shoot as to what I think might be the problem. Effexor is a very popular drug for depressive disorders in general. Effexor also comes with a nearly never ending list of side effects. I would highly suspect a toxic response to the Effexor as a result of OD or hypersensitivity. The pill bottle will yeld information as to when this Rx or refill was started, dose, and by counting - the number of pills left, assuming that there are no pills in a plastic pill box at home. So based on the current vitals, I woulld guess that the pt is in a postictal state from a seizure caused by the Effexor, as well as the fact that the pt is hypertensive and tachycardic which are both side effects of Effexor. Whats burning in the back of my mind? Is this an intentional or unintentional OD? Although decreased in this pt's age group, the risk of suicidality is high on Effexor.

Local tx for this pt would be; support ABC's as needed, monitor for change in status, moniotr heart rhythm, IV-kvo or saline loc, transport to hosp. I would like to address the HTN, but there is no HTN tx in Maryland.

Ok we've got the basic vitals. What is critically important for this guy is airway control. Get him intubated with that GCS. Once that is done we can get the IV and all that jazz. You could bag the guy until you get the IV in case you need to RSI him. He might not tolerate the intubation so we can RSI him.

Do a repeat Dstick with the IV needle blood.

Check pupils and then load and go.

[Lone Star]

Please participate on only one forum

After a day of dragging people strapped to a gurney into your van with tinted windows and giving them drugs (what? ... you make it sound like something bad) you are sent to a guy passed out in his car on the side of the road.

When you arrive there are two cops and seven firefighters standing round doing nothing as well as the Engineer who is leaning on the truck looking at the chalkboard menu of the diner he has parked the outside of.

Single male patient in his fifties on the drivers side, slumped down over the seat and passenger seat.

- Unresponsive, GCS 3

- RR 24 PR 90 HR 130 BP 230/120 SpO2 96 BGL 90 (~4 mmol/l)

- Sinus rhythm on 3 leads

- Clear and equal lung sounds

- Constricted pupils

- Medic alert bracelet says diabetic

There are two bottles of medication in the centre console; one of Effexor and the other is Captopril.

So while the fireys sit round eyeing up the daily specials what are you gonna do?

Your overt attempt at fire bashing aside...

Isn't HR (Heart Rate) and PR (Pulse Rate) the same thing? If so, how can you have two different readings at the same time? Presuming that the vx were assessed at the same time...

[AT-Medic]

Ok we've got the basic vitals. What is critically important for this guy is airway control. Get him intubated with that GCS. Once that is done we can get the IV and all that jazz. You could bag the guy until you get the IV in case you need to RSI him. He might not tolerate the intubation so we can RSI him.

Do a repeat Dstick with the IV needle blood.

Check pupils and then load and go.

Wow, that whole below 8 - must intubate mind set. Hence the reason for all the studies out there wanting to take intubation away from us. Its not your first tool in this case, or in about 99% of all cases. In reviewing my post, I could have added to my Local tx statment, the fact that I would have used an NPA, and placed the pt on 02 at 15-lpm. This pt automatically buys a 12 lead, which was something else I left out. I would also monitor his EtCO2, which would have some bearing on intubation. Unless there was a staus change with the airway, bagging would have been the most I would have done. The ED would most likely place this person on Bi-Pap, not intubate, but then again, you sometimes can't guess what the Doc is going to do.

[Just Plain Ruff]

Wow, that whole below 8 - must intubate mind set. Hence the reason for all the studies out there wanting to take intubation away from us. Its not your first tool in this case, or in about 99% of all cases. In reviewing my post, I could have added to my Local tx statment, the fact that I would have used an NPA, and placed the pt on 02 at 15-lpm. This pt automatically buys a 12 lead, which was something else I left out. I would also monitor his EtCO2, which would have some bearing on intubation. Unless there was a staus change with the airway, bagging would have been the most I would have done. The ED would most likely place this person on Bi-Pap, not intubate, but then again, you sometimes can't guess what the Doc is going to do.

Well AT, It's really good that you have bipap but for those of us who do not have bipap, cpap, epap and whatever brand spanking shiny things that your service seems to have Intubation is my only tool. RSI I do have.

I've been involved in Effexor overdoses before and they can get bad really quick.

I did not go on his Glasgow, I went on the thought that he overdosed as well as was unconscious. I did mention bagging him, perhaps I should have said, let's see how bagging works but I have one hospital to send a patient to and the physicians want them intubated. If I were to fly him, the flight crew would have immediately intubated him if he remained in that state.

So to bash me was not a good thing. You have more tricks in your arsenal and I have less. So be it.

We have cpap but it's in a freakin closet because they haven't written the protocol for it. How's that for backwards.

Before you slam other providers with their treatment you might want to get some clarification as to what we have to work with before you go off and make yourself look like a A***

So KIWI how many pills are missing or do they seem to be all there

What are the pupils? Be it a overdose or a Stroke, unresponsive means BAD MOJO

Edited May 13, 2010 by Ruffems

[Kiwiology]

Isn't HR (Heart Rate) and PR (Pulse Rate) the same thing?

Yes my mistake, the HR is 130

So KIWI how many pills are missing or do they seem to be all there

What are the pupils? Be it a overdose or a Stroke, unresponsive means BAD MOJO

There is no apparent discrepancy between the date of filling and instructions on the bottle vs how many are left in the bottle

The pupils were constricted upon arrival but when moved to the ambulnace you note one is now dialated

Patient poos all over your nice, clean stretcher

IV NS KVO

Lung sounds are now crackles

[aussiephil]

Pt is a prime candidate for a CVA, however we only have a 3 lead ECG to look at & the patient is diabetic. With numbers like this, he could be poly presenting with a hypo, CVA & silent infarct.

BGL, 10% Glucose slow IV, it isnt that bad really, lets bring it up slowly. Airway managment, urgent transport. This patent needs a hospital, not an ambulance, no matter how qualified you think you are.