Respiratory scenario

[DFIB]

Its a little blurry, I don't think there are any significant ST changes, the T waves in V2, V3, V4 seem to be slightly peaked, which could lead to the conculsion he may still be somewhat hyperkalemic

Thanks friend.

[mobey]

Well that blows my opportunity at a post on polycythaemia, or anemias that can lead too what we see in the 12 lead, or the real definition of cyanosis, or ventilatory vs respiratory failure, or the use of CPAP.

I think there is still going to be some great discussion here.

To be clear, I am not hiding any great mystery about this dude's cyanosis. I ran this call as if my SP02 was innacurate, although I am quite aware it may not have been.

He is Hypercarbic, confused, and cyanotic - yet no tachypnia and a Sp02 within normal limits. (Did I mention I was looking for a squint patch?).

Would love to hear what some others would do for treatment before I post mine.

To sum up

Cyanosis of face/hands/lwr legs. Hypercarbic. Sp02 normal. Resp rate 18. Little chest wall expansion. Slight wheezes in apex's but over all too quiet to hear much of anything. Confused/slight combative. borderline tachycardia,normotensive.

[DFIB]

Lets consider that thie transport unit is a BLS unit.

Would we consider this patient stable enough for a BLS unit to transport or would it be acceptable to deny transport and recuest a ALS unit?.

[flamingemt2011]

Unless the ALS unit is very close by, I would suggest that you not delay transport. Whatever this patient's problem is needs immediate intervention that is obviously not available where he is. Every minute the patient remains at this facility is another minute he is closer to death. Would I prefer ALS, certainly ! Would I refuse to transport and wait 15-20 minutes on an ALS unit, NO.

[DFIB]

Unless the ALS unit is very close by, I would suggest that you not delay transport. Whatever this patient's problem is needs immediate intervention that is obviously not available where he is. Every minute the patient remains at this facility is another minute he is closer to death. Would I prefer ALS, certainly ! Would I refuse to transport and wait 15-20 minutes on an ALS unit, NO.

I believe this is an inter facility transport and he is already at a clinic or hospital. So is the seriousness of his condition my responsibility or the attending facilities? I think they should call an ALS for this guy. A BLS unit would not be very useful to this guy if his condition goes south.

[flamingemt2011]

"Facility" can mean alot of different things. I have a hospital within 30 miles of my house that has a 3 bed ER, with no OR or ICU. Lab and xray techs have to be called in from home after 5pm. Since the patient is still cyanotic, and is being transferred out, it is apparant that they do not have the capabilities to fix this problem. It is also fairly apparent to me that a Paramedic, will probably not be able to fix his problem either, although having ALS there when he arrests might allow for ROSC, but I doubt it would be much more likely than a BLS crew with an AED. He needs rapid intervention, the sooner you get him to that intervention, the greater his chances are for survival. If the attending doctor could have fixed it he would, and in a perfect world they would use a helicopter for transport.

If the patient was at home and called 911, would you wait 20 minutes for ALS, or load and go ?

[systemet]

Possibility 1: The pulse ox is wrong, and the patient is acutely hypoxemic, and cyanosis is due to a unhealthy amount of deoxygenated hemoglobin. This would make so many of the people posting on recent threads ecstatic, but is probably unlikely in practice. Do we have a good pleth? Is there another pulseox we can use to verify our values? I realise that we have a venous gas, but is there the possibility to get an ABG and SaO2. How's the SvO2? Do these things support our pulse oximetry?

Possibility 2: The patient's hypercapnia is baseline, because they're one of those relatively rare CO2-retaining COPDers. The pH argues for an acute change, especially if the bicarb / BE is normal. Another process is causing altered mentation, e.g. a CVA. The cyanosis is due to another cause, e.g. methemoglobinemia. If we can get an ABG with MetHb% or use a co-oximeter (as inaccurate as they are) for an SpMet this might help. There is a single case report on methemoglobinemia with cephalexin in a mixed overdose on pubmed. It's also possible that there's been another exposure, e.g. well-water, home-preserved meats, etc.

http://www.ncbi.nlm....themoglobinemia

Possibility 3: The patient is in acute ventilatory failure and has CO2 narcosis (supported by pH, mentation, PvCO2, past hx). However, if his CO2 is baseline high, then 80 mmHg might not be that high for him, even if it's in the danger zone for CNS / cardiac effects for most of the rest of us. Is it possible that he received a large dose of benzos, opiates or neuroleptics, or some other CNS depressant from the hospital? I've seen small facilities do this sometimes. This still doesn't explain the cyanosis, unless methemoglobinemia is also present. But then, I'd expect the saturation to be lower if there's a significant amount of MetHb present. Concommitant CO poisoning seems unlikely here.

---------------------------------

I think that we have too little information here to make a dx.

We might want to try a NRB if he's moving any tidal volume first, just to see if the cyanosis resolves with a higher FiO2. If that fails, Given the patient's mentation and pH, I think we can probably look at intubating. We can then ventilate with a target PETCO2 of 60 mmHg, which should bring the pH up to about 7.37, give or take a bit. Hopefully we can check that with a serial PvO2 if they have any point-of-care.

This would be an excellent time to call an EM physician in the city for a little help / advice. EMS hates patching, but it's these situations where a physician's input can be really valuable.

I'm curious to see how this one works out.

Edit: punctuation

Edited December 15, 2011 by systemet

[DFIB]

"Facility" can mean alot of different things.

I agree he needs rapid intervention but should I risk my certificate and livelihood to take a patient off a facilities hands The facility has treated him with multiple meds for two days and now wants to turn him over to a BLS unit.

Don't they have to transfer care to an equal or higher level of care?

Wouldn't giving this patient to a BLS team constitute negligence?

If the patient was at home and called 911, would you wait 20 minutes for ALS, or load and go ?

He is not at home and it is not a 911 call. He is in a facility and under the care of a physician.

Is it appropriate to transfer this patient to a lower level of care?

Edited December 16, 2011 by DFIB

[DwayneEMTP]

Transfer of patient care to whatever level of provider would be the Doc's call I believe, though still the crew's as to whether or not to accept it.

My feeling would be though that the apparent pronounced cyanosis alone would likely be more than enough to rate an ALS transfer if we're talking about more than going across the parking lot.

Dwayne

[DFIB]

Transfer of patient care to whatever level of provider would be the Doc's call I believe, though still the crew's as to whether or not to accept it.

My feeling would be though that the apparent pronounced cyanosis alone would likely be more than enough to rate an ALS transfer if we're talking about more than going across the parking lot.

Dwayne

Luv ya man. You can take my patient with cyanosis of unknown etiology any day.