Bieber Posted May 27, 2012 Author Share Posted May 27, 2012 Heh, Kiwi, you'd be surprised how little a hospital may do if they know they have a DNR... Chris, temp is still 100 F, BGL is 100. Level of responsiveness is still difficult to determine because of the patient's dyspnea, but he responds when commanded by squeezing his hand. Still no crackles, Dwayne! Link to comment Share on other sites More sharing options...
Kiwiology Posted May 27, 2012 Share Posted May 27, 2012 Regarding the Os calculation, we use the standard US method: (2 * (Na) + (BUN / 2.8) + (glucose / 18) + (ethanol/4.6) My question was more how are you getting those values pre hospitally without a lab? I am not keen to intubate at this point. We are working hard to keep this patient's saturation at 90% and I am not sure he would tolerate an RSI procedure as well as we think. Intubation is potentially disasterous and I have to be backed into a corner before I do it. I do not feel that I am backed up enough to try a RSI at this time. Additionally, I am not going to base my current plan on what the receiving hospital might do. I share your concern but I'm not sure this guy will last the half hour transport to the hospital, he might, but he might not. I agree intubating him is not without risk and that he might severely desaturate during laryngoscopy however if we preoxygenate him well I don't think that will be a problem; local flavour here is to sit him up and tightly seal a bag mask over his face with a PEEP valve on it for 3-5 minutes. I don't think he would tolerate that awfully well so perhaps a little fentanyl premedication beforehand might settle him to allow it. Heh, Kiwi, you'd be surprised how little a hospital may do if they know they have a DNR... True, but at the moment I don't think he is at the acute end of his life i.e. actively dying so I think we should work on him; if he has a cardiac arrest or something then he has clearly described he doesn't want to be coded so that's the end of it then Link to comment Share on other sites More sharing options...
chbare Posted May 27, 2012 Share Posted May 27, 2012 What about the capnograph waveform. It's morphology may give us a significant amount of information. Particularly if we compare the initial printout to what we see now. Additionally, what do you guys say about giving fluids? The patient may actually benefit. We could give a conservative bolus, reassess and go from there. Link to comment Share on other sites More sharing options...
Kiwiology Posted May 27, 2012 Share Posted May 27, 2012 Not sure on the fluids personally if he has CHF it's probably not going to help but we have no evidence of that so we could try a small bolus Why do you say it's going to help? Are you thinking he might have had a right ventricular infarct? Link to comment Share on other sites More sharing options...
chbare Posted May 27, 2012 Share Posted May 27, 2012 He's been breathing like a big dog, he has a slightly elevated temperature and he is tachycardic. He very well may be dehydrated. 1 Link to comment Share on other sites More sharing options...
Kiwiology Posted May 27, 2012 Share Posted May 27, 2012 Good points, we could try some fluid I suppose Link to comment Share on other sites More sharing options...
Bieber Posted May 27, 2012 Author Share Posted May 27, 2012 Great call on the fluids, Chris. Capnograph shows a shark fin morphology. Link to comment Share on other sites More sharing options...
chbare Posted May 27, 2012 Share Posted May 27, 2012 Thanks. This definitely points toward obstructive pathology. While not a quick fix, are steroids still on the table? We could consider a bolus of solumedrol and a continuous albuterol or Xopenex treatment. Reassess after a conservative bolus and consider another if needed. Link to comment Share on other sites More sharing options...
Kiwiology Posted May 27, 2012 Share Posted May 27, 2012 I was told most steroids are immunosuppressants; I am unaware of specifics however if that is true, owing the high suspicion of a COPD exacerbation and a respiratory infection should we be giving them? Link to comment Share on other sites More sharing options...
systemet Posted May 27, 2012 Share Posted May 27, 2012 You get about fifteen seconds of this: After fifteen seconds or so, patient reverts to the initial rhythm, with the occasional PVC. Uggh... That looks a little suspicious for VT. There seem to be some retrograde P waves in there, too. Could be some sort of aberrant junctional tachycardia as well. Either way, don't like it. Glad it stopped quickly. Suggests that the myocardium doesn't like being hypoxic. Link to comment Share on other sites More sharing options...
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