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Respiratory scenario


mobey

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OK, before we get too advanced, I'd like to hear from some of our newer BLS/ILS providers..... then chbare/Squint can come school us all ;)

Called for interfacility transfer

66 y/o male longstanding history of COPD, persistant smoker, CHF, non-med compliant.

Meds: Dosen't matter.... He has not filled prescriptions in years. (ventolin/spiriva/Prednisone/Metorolol/Lasix few others I can't remember but all related to CHF and COPD)

HxCC: Pt presented to ER 2 days ago with shortness of breath. Worked up for pulmonary embilism with spiral CT - Negative

WBC count slightly elevated at 15. No other abnormal blood values

ECG normal, no chest pains.

Over the last 12 hrs pt has turned quite cyanotic, he is becoming disoriented and combative at times.

On arrival: you find him semifowlers in no obvious distress. He is blue as a smurf. There is a simple mask at 4lt on his obeise belly. He tracks you as you enter the room, but is disoriented.

There is a 22G in his right hand and a hydrocortisone infusion just finishing.

He has also had Cephalexin about an hour ago.

Vitals: HR96 BP 148/90 Respitory rate 18 non-laboured, Sp02 96%, Temp 35.9C,

What else would you like?

BTW this is from memory, so there may be a few thing I forget.

1800th Post!!!!

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OK, before we get too advanced, I'd like to hear from some of our newer BLS/ILS providers..... then chbare/Squint can come school us all ;)

Called for interfacility transfer

66 y/o male longstanding history of COPD, persistant smoker, CHF, non-med compliant.

Meds: Dosen't matter.... He has not filled prescriptions in years. (ventolin/spiriva/Prednisone/Metorolol/Lasix few others I can't remember but all related to CHF and COPD)

HxCC: Pt presented to ER 2 days ago with shortness of breath. Worked up for pulmonary embilism with spiral CT - Negative

WBC count slightly elevated at 15. No other abnormal blood values

ECG normal, no chest pains.

Over the last 12 hrs pt has turned quite cyanotic, he is becoming disoriented and combative at times.

On arrival: you find him semifowlers in no obvious distress. He is blue as a smurf. There is a simple mask at 4lt on his obeise belly. He tracks you as you enter the room, but is disoriented.

There is a 22G in his right hand and a hydrocortisone infusion just finishing.

He has also had Cephalexin about an hour ago.

Vitals: HR96 BP 148/90 Respitory rate 18 non-laboured, Sp02 96%, Temp 35.9C,

What else would you like?

BTW this is from memory, so there may be a few thing I forget.

1800th Post!!!!

Understood, I'll keep it zipped.

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OK, before we get too advanced, I'd like to hear from some of our newer BLS/ILS providers..... then chbare/Squint can come school us all ;)

Called for interfacility transfer

66 y/o male longstanding history of COPD, persistant smoker, CHF, non-med compliant.

Meds: Dosen't matter.... He has not filled prescriptions in years. (ventolin/spiriva/Prednisone/Metorolol/Lasix few others I can't remember but all related to CHF and COPD)

HxCC: Pt presented to ER 2 days ago with shortness of breath. Worked up for pulmonary embilism with spiral CT - Negative

WBC count slightly elevated at 15. No other abnormal blood values

ECG normal, no chest pains.

Over the last 12 hrs pt has turned quite cyanotic, he is becoming disoriented and combative at times.

On arrival: you find him semifowlers in no obvious distress. He is blue as a smurf. There is a simple mask at 4lt on his obeise belly. He tracks you as you enter the room, but is disoriented.

There is a 22G in his right hand and a hydrocortisone infusion just finishing.

He has also had Cephalexin about an hour ago.

Vitals: HR96 BP 148/90 Respitory rate 18 non-laboured, Sp02 96%, Temp 35.9C,

What else would you like?

BTW this is from memory, so there may be a few thing I forget.

1800th Post!!!!

Well lets start from the beginning,

Airway- Open patient? Audible sounds (stridor, gurlging, wheezing)?

Breathing- Respiraton rate? Breath Sounds? capnography?

Circulation- Pulse quality (strong, weak, irregular, thready, regular?)

Labs showing any imbalances of electrolytes anything?

Any other history of heart problems except for CHF?

If they did an echo did they find anything?

Has he been this cyanotic the whole time?

Is this mental status normal for him? Has it deteriorated since his arrival?

Any trauma or other medical history?

Any food or drug allergies?

Is he on oxygen now? if so how much and by which device?

What is his blood sugar (strange yes, but I like to cover all bases especially with a severly cyanotic patient)

Is the amount of cyanosis normal for him?

Congrats on the 1800th post!

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Are you able to obtain any info from him? Headache? Erectile Dysfunction?

Perhaps a cortisol level is in the lab report?

Has he been given any other meds at the hospital?

How much hydrocortisone did he receive and has he had that med before? If so, did he have any reactions?

Good post! You have me thinking. I am eager to see if I am on the right track....

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Hello,

I am not sure why he is blue. I will think about this.

However, what I do know:

1) I do not like his temp (35.9). Hypothermia (non-environmental) is always worrysome.

2) An elevated WBC and he is on steriods.

3) He got Cephalexin. Abx for a CAP (community aquired pneumonia)

1+2+3 = septic/pneumonia as opposed COPDE?

Mobey is lost in rural Alberta. So, I assume a long transport time. I wouldn't be keen on a confused blue man for a long haul without a ABG to see what his Pa0, PaCo2 and lactate are. Then think about a tube.

And, a better IV than one #22.

If it was a shrot transport (30-45 minutes) I would be less cautious.

Cheers

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Wait, I'm confused.

He's in a skilled facility, but he's non-med compliant on all the controllers? You get booted home if you don't play nice where I'm from.

Was the cephalexin IV as well? How does the IV site look? Last oral intake? Breath and ABD sounds?

Hm. Odd. Did he start the cephalexin and steroid upon d/c from the ED for PE workup? What was the indicator that sent him that way in the first place?

Wendy

CO EMT-B

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Well lets start from the beginning,

Airway- Open patient? Audible sounds (stridor, gurlging, wheezing)?

Patent

Breathing- Respiraton rate? Breath Sounds? capnography?

As above. EtC02 79 on sidestream

Circulation- Pulse quality (strong, weak, irregular, thready, regular?)

Weak, regular at the radial

Labs showing any imbalances of electrolytes anything?

Blood labs are normal except a venous PC02 of 82

Any other history of heart problems except for CHF?

No

If they did an echo did they find anything?

No echo

Has he been this cyanotic the whole time?

As in OP

Is this mental status normal for him? Has it deteriorated since his arrival?

As in OP

Any trauma or other medical history?

Nope

Any food or drug allergies?

Nope

Is he on oxygen now? if so how much and by which device?

Again see OP

What is his blood sugar (strange yes, but I like to cover all bases especially with a severly cyanotic patient)

Not to mention altered pt's! 8.3mmol

Is the amount of cyanosis normal for him?

Dude you gotta read the entire original post before asking questions.....

Congrats on the 1800th post!

Thank you! I'll prepare a speach

Are you able to obtain any info from him? Headache? Erectile Dysfunction?

He becomes more orientated at times... so somewhat trustworthy periodically. No headache. Don't know ED

Perhaps a cortisol level is in the lab report?

Nope

Has he been given any other meds at the hospital?

2.5mg Salbutamol 2 hrs ago. Had ativan SL for CT yesterday. unknown dose.

How much hydrocortisone did he receive and has he had that med before? If so, did he have any reactions?

100mg iv, this is his 3rd dose in 2 days

Good post! You have me thinking. I am eager to see if I am on the right track....

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