Engineer's Special

[Kiwiology]

The treatment of choice for me is some midaz to stop the seizure, wait a minute to see if he loosens up and look at tubing him.

This is a tricky one because we are giving midaz for the seizure but we would also give it (probably in a bit lower dose for RSI in neurogenic coma) however for RSI we can also give ketamine over midaz and should also be giving 1mcg/kg fentanyl.

So I am unsure as whether to give fentanyl and sux ontop of the midaz (which we gave for the seizure but also will have some amnestic properties) or just give him some midaz and sux.

Either way, intubate, add PEEP of 10 and go to the hospital lickedly split.

[armymedic571]

The treatment of choice for me is some midaz to stop the seizure, wait a minute to see if he loosens up and look at tubing him.

This is a tricky one because we are giving midaz for the seizure but we would also give it (probably in a bit lower dose for RSI in neurogenic coma) however for RSI we can also give ketamine over midaz and should also be giving 1mcg/kg fentanyl.

So I am unsure as whether to give fentanyl and sux ontop of the midaz (which we gave for the seizure but also will have some amnestic properties) or just give him some midaz and sux.

Either way, intubate, add PEEP of 10 and go to the hospital lickedly split.

Kiwi..

Question that is slightly off topic. Do you prefer Midaz over Ativan and diazepam as its onset time is slower than the other two?........OR

is that all you have in your pharm kit?

[Kiwiology]

We only have midazolam

[DartmouthDave]

Hello,

Fellow pulls over (no erratic driving...crashing into stuff, ect...)his car and suddenly becomes unresponsive (if I am following this correctly so far).

So, a sudden onset of neurological decline with very high blood pressure and pinpoint pupils. I am thinking a Pontine SAH. Add to this a seizure and crackles in the patient's lungs (Neurogenic Pulmonary Edema). Yep, could be a SAH.

Kiwi stated:

"12 lead shows anterolateral infarct (couldn't be buggered searching for a copy we know what it looks like)"

Now, do you mean ST elevations? If so, sometimes SAH cause ST elevations in various leads. Also, sometimes pump failure rapidly ensues from a 'stunned myocardium' in SAH patients. Sorry, no references, but I worked in a Neurosurgical ICU and these were fairly frequently complications of a SAH. Too late to go digging for a reference.

As a DDx:

1. Hypoglycemia

2. Effexor OD

A BGL of 4 mmol isn't so low. I agree with ArmyMedic that giving glucose to a possible CVA isn't a wonderful idea. However, I would give 1/2 and amp of D50W as soon as the IV was in (while getting airway and other stuff set up).

I have seen many people try to OD on SSRI. Nothing much ever happens. With Effexor being a SNRI I have seen lots of troubles. But, in general, I haven't seen seizures or pinpoint pupils. Seizures seem to be much more of an issue with Effexor OD from my experience.

Key right now I think is treating the seizures and securing the airway.

Cheers...

PS... Give Narcan?

[Kiwiology]

I don't thin naloxone would do anything, it wasn't really indicated ....

[AT-Medic]

AT ,

I couldn't help but note that you stated Wikipedia as a sourece of factual information...........Sorry dude. FAIL.

I still disagree.....

OMG - did I fail, LMAO!

You sir are hilarious.....

I would personally use our Medication Assisted Intubation (as we are not allowed to use Sux in our system). This is basically drowning our patient with etomidate. So, 0.3 mg/kg of etomidate please. Boujie tube if necessary.

If the patient is still clencked, re-oxygenate and nasal intubation.

When we get the tube in Fent and versed for continued sedation......

Hello,

Fellow pulls over (no erratic driving...crashing into stuff, ect...)his car and suddenly becomes unresponsive (if I am following this correctly so far).

So, a sudden onset of neurological decline with very high blood pressure and pinpoint pupils. I am thinking a Pontine SAH. Add to this a seizure and crackles in the patient's lungs (Neurogenic Pulmonary Edema). Yep, could be a SAH.

Kiwi stated:

"12 lead shows anterolateral infarct (couldn't be buggered searching for a copy we know what it looks like)"

Now, do you mean ST elevations? If so, sometimes SAH cause ST elevations in various leads. Also, sometimes pump failure rapidly ensues from a 'stunned myocardium' in SAH patients. Sorry, no references, but I worked in a Neurosurgical ICU and these were fairly frequently complications of a SAH. Too late to go digging for a reference.

As a DDx:

1. Hypoglycemia

2. Effexor OD

A BGL of 4 mmol isn't so low. I agree with ArmyMedic that giving glucose to a possible CVA isn't a wonderful idea. However, I would give 1/2 and amp of D50W as soon as the IV was in (while getting airway and other stuff set up).

I have seen many people try to OD on SSRI. Nothing much ever happens. With Effexor being a SNRI I have seen lots of troubles. But, in general, I haven't seen seizures or pinpoint pupils. Seizures seem to be much more of an issue with Effexor OD from my experience.

Key right now I think is treating the seizures and securing the airway.

Cheers...

PS... Give Narcan?

Excellent post. You are working the same approach as I think I would be. Treat for seizures due to possible OD, rule out CVA, work with the good airway we have, and secure it via ET time permitting. Depending on what station I’m working at, I could be just a block from the hospital, or be 45 plus minutes away. So it changes how you do things completely.

[DartmouthDave]

Hello,

Don't you just give Narcan to every altered LOC?

Cheers

[jonas salk]

Just throwing it out there, the guy is a diabetic, there stands a chance that his normal BGL is pretty high and that 4 mmol/L is hypoglycemic for him.