Bieber Posted July 2, 2011 Share Posted July 2, 2011 Right now I'm highly suspicious for a neurological cause, given his history of a-fib and DVTs, I'd consider him at risk for coagulopathies, plus his abnormal flexion doesn't sit well with me either. But I want to know more about this guy. What about his chest infection? Do we have a diagnosis, treatment, if it's been clearing up, staying the same or getting worse? Also, what is this guy's normal blood sugar range? What kind of meds is his on? Link to comment Share on other sites More sharing options...
BushyFromOz Posted July 2, 2011 Author Share Posted July 2, 2011 Im getting smashed at work at the moment, ill try and answer some questions tomorrow. Link to comment Share on other sites More sharing options...
BushyFromOz Posted July 3, 2011 Author Share Posted July 3, 2011 Questions answered in order they were asked. Psych Meds are effexor, seroquel No other meds he is on would cause these symptoms Hospitals less than 10 minutes Weather outside is cool, about 14 degrees Initial assessment to findings would be less than 10 minutes Ate lunch around 1330 Chest infection was a productive cough and SOB on exertion, treated with antibiotics with good results, now has intermittent dry cough Patients normal BSL between 4 and 7.5mmol You backup crew arrives and together you lift the patient onto s tretcher and into the truck. once inside the patient becomes lucid for a few seconds and starts asking for his wife, is confused to place but mknows date and month. before you finish a complete GCS the patient returns to GCS 6 and starts drooling. You pull them over R lateral and pop in a 16G cannula and hang a bag of saline TKVO. You withold the narcan as the patient in an RSI candidate. Now that he is in bright light you notice his L pupil is blown. Anything else youd like to do? Whats the possibilities at the moment? Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted July 3, 2011 Share Posted July 3, 2011 He's got a bleed, stick a fork in him, he's done Sent from my SPH-D700 using Tapatalk Link to comment Share on other sites More sharing options...
BushyFromOz Posted July 3, 2011 Author Share Posted July 3, 2011 He's got a bleed, stick a fork in him, he's done Sent from my SPH-D700 using Tapatalk Could be.. Any other reason he could have a blown pupil? Link to comment Share on other sites More sharing options...
Richard B the EMT Posted July 3, 2011 Share Posted July 3, 2011 If he's in Australia any evidence of spider bite or snake/scorpion exposure? While already answered to an apparent negative, as I kind of speed-read through, here, insect or snake bite is not restricted to Austrailia and/or New Zealand. While I may not see any snake bites within NYC, I have friends and associates carrying personal Epi-pens in case of bee stings. Link to comment Share on other sites More sharing options...
DartmouthDave Posted July 3, 2011 Share Posted July 3, 2011 (edited) Hello, Effexor is a SNRI and is fairly well tolerated. I vaguely recall that Effexor toxicity may cause seizures. But, I am not sure of this. Like SSRI a SNRI may cause Serotonin Syndrome (agitation, hyperthermia, muscle rigidity). But, this is very rare and dose not quite fit the picture. Seroquil is a noval class anti-psychotic. It effects Dopamine, Anticholenergic, and Histamine receptors if I recall correctly. EPS and Tardive Dyskensia are potential side effects. Overdose tend to cause a decreased LOC (central ACH effects), low BP (Histamine I think) and possible prolonged QT or QRS. Here is what we know so far: BP: Slight HTN (Norepi effect from Effexor???) HR: NSR Temp: Hypothermia (Environmental??) LOC: Waxes and Wanes......all in all too low (ACh effects??) Pupils: In the 1st post they were 2mm and sluggish.....Are they blown now? Ach dilates. Ch will constrict pupils. Airway: Drooling.....Ch cause?? It could be an overdose. Still, a very quick drop in LOC considering he went out to close the gate. Maybe, he overdose early in the day and now the symptoms are now presenting. Or, it could be a CNS event happening. All I know is this fellow airway is at risk. Tube him now or later at the ED. Pop in an OG. If it is an OD supportive care until he wakes up. If a CT shows a bleed (et al...) NSx will take it from there. Anxious to see how it plays out. Cheers Edited July 3, 2011 by DartmouthDave Link to comment Share on other sites More sharing options...
zippyRN Posted July 5, 2011 Share Posted July 5, 2011 (edited) what what has been said so far, i'm thinking along the lines of some kind of CNS insult and/or something meds related , possibly compounded by a head or spinal injury from falling ( increased risk of spinal in jury given his age - has he got an 'old man ' kyphosed neck?) i'm not necessarily worried aobut his temp at the moment given the environmental factors - it's very much remove him from the 'cold' surface time i'd not be actively rewarming him even in theabsence of a cooling guideline ... Edited July 5, 2011 by zippyRN Link to comment Share on other sites More sharing options...
BushyFromOz Posted July 9, 2011 Author Share Posted July 9, 2011 Nice to see you guys hashing it out, seriously, cause the A&E physician and the guys up in CCU didn't get it either, but one of you i think was leaning the right way earlier on. L pupil blown, R pupil still sluggish Link to comment Share on other sites More sharing options...
DartmouthDave Posted July 9, 2011 Share Posted July 9, 2011 (edited) Hello, According to 'Pharmacology in Nursing Practice' (4th edition) noval or atypical class antipsychotic, "...do not appear to cause EPS, including tardive dyskinesia." So, I think we can rule that out. Also, I was thinking, were the tabs extended release (ER) or sustained release (SR)? I have seen a few cases in which there was a rapid decline once the mass or SR or XR tabs started to break down. For example, a fellow who took a load of Diltizem SR crashed fast. Or, a lady who took a pile of Lithium SR that suddenly crashed fast. It could be a central Ach (muscarnic blocking) effect going on here. Altered LOC, sluggish pupils, dilated pupils, and weakness. The only thing that dose not fit is the temperature. But, it could be environmental as noted above. But, I think he is too sick for some central Ach effects. Considering, these drugs are, '...characterized by a high therapeutic index with respects to morality.' (Pharm Text) This also hold true to what I have seen. I have seen many antipsychotic OD (by over zealous staff....and patients!!) and supportive care is all that is needed. However, all antipsychotic agents may cause Neuroleptic Malignant Syndrome (NMS). The FEVER mnemonic I have heard used for NMS. A mnemonic used to remember the features of NMS is FEVER.[7] F – Fever ---->Maybe E – Encephalopathy ---->Yes V – Vitals unstable ---->yes E – Elevated enzymes (elevated CPK) --->Unknown R – Rigidity of muscles ----> The posturing could be abnormal tone...so a maybe As for new treatment ideas....maybe Cogentin, or Benadryl I guess. Cheers Edited July 9, 2011 by DartmouthDave Link to comment Share on other sites More sharing options...
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