Bieber Posted May 27, 2012 Author Share Posted May 27, 2012 Your patient suffers one more short burst of the tachycardic rhythm, but after the magnesium sulfate, IO fluid bolus and continuous albuterol treatments and CPAP, his lung sounds are improving. There's definitely wheezes apically, still diminished basally but you can finally hear some airflow down there--if only a little. SpO2 is up to 94% and his work of breathing is slowly coming down. Steroids are still on the table, the question is, do we want to give them or not? Do we want to begin transport? Link to comment Share on other sites More sharing options...
Kiwiology Posted May 27, 2012 Share Posted May 27, 2012 I wouldn't give him steroids and I am worried about the possible immunosuppression Lets get some wheels under this guy He is lucky he has EMTCity EMS treating him, you have CPAP, we do not in NZ so he would have bought some ketamine dreams and a tube by now Link to comment Share on other sites More sharing options...
DwayneEMTP Posted May 27, 2012 Share Posted May 27, 2012 Edit: Anyone still believe that this guy was fine 20 minutes prior to EMS arrival? Yeah, I would have given the steroids following the Mag. Queering his immune system (though that wasn't on my radar until Kiwi mentioned it) at this time is secondary to getting him some air. We are providing some short term relief with our other interventions, but he's going to need something on board that will last a bit longer, at least if our goal is still to avoid intubation. Plus, won't the steroids work towards relieving the bronchconstriction via a different mechanism than the other interventions employed so far? I would also go ahead and run a 250cc bolus and see if there is any noticeable difference at all, though I'll almost certainly run at least another 250ccs after, depending on results. It's my limited experience that dry lungs get really unhappy (though I'm guessing that chbare might use different terminology) and get constricted pretty severely sometimes. If no significant contraindications exist, and at least a half assed belief that relative or true dehydration exists, I'll always try a fluid bolus along with the neb to see if it will create a change. It can be surprising (or at least so it appears so to me) the difference that a bit of fluid as the only treatment can make in some of these patients. Though, perhaps there is something else going on in connection with the fluids and I've incorrectly associated 'moister lungs' with at least a partial relief of symptoms. I don't know. It's my hope that getting him some more air will satisfy his ache breaky heart a bit and we'll stop seeing those transient pissed off rhythms. But, you know, hoping and all... It looks like, this time around maybe, that watching for zebras instead of horses was a prudent course of action? What an excellent scenario, run perfectly. With everyone participating in the true spirit of learning...Man, what a treat. Link to comment Share on other sites More sharing options...
Bieber Posted May 27, 2012 Author Share Posted May 27, 2012 You initiate transport per Kiwi and get headed toward the hospital! Patient's current vital signs are: HR: 130 RR: 22 labored but less so than before SpO2: 93% and holding BP: 192/104 Lung Sounds: Wheezes apically, still diminished with some slight wheezes basally. No crackles. EKG: Sinus tachycardia, no more acute episodes of the aforementioned tachycardic rhythm (consensus on that?). Ambient Music: Danger Zone by Kenny Loggins Link to comment Share on other sites More sharing options...
chbare Posted May 27, 2012 Share Posted May 27, 2012 He's on furosemide with no mention of Potassium supplementation. Additionally, we've thrown a fair amount of albuterol at him. I would be concerned about electrolyte issues, but cannot do anything but report my findings. Link to comment Share on other sites More sharing options...
Bieber Posted May 27, 2012 Author Share Posted May 27, 2012 Ack! Sorry Chris I forgot that one. Patient IS in fact on Klor-Con. Link to comment Share on other sites More sharing options...
Eydawn Posted May 27, 2012 Share Posted May 27, 2012 Edit: Anyone still believe that this guy was fine 20 minutes prior to EMS arrival? Yeah, I would have given the steroids following the Mag. Queering his immune system (though that wasn't on my radar until Kiwi mentioned it) at this time is secondary to getting him some air. We are providing some short term relief with our other interventions, but he's going to need something on board that will last a bit longer, at least if our goal is still to avoid intubation. Plus, won't the steroids work towards relieving the bronchconstriction via a different mechanism than the other interventions employed so far? I would also go ahead and run a 250cc bolus and see if there is any noticeable difference at all, though I'll almost certainly run at least another 250ccs after, depending on results. It's my limited experience that dry lungs get really unhappy (though I'm guessing that chbare might use different terminology) and get constricted pretty severely sometimes. If no significant contraindications exist, and at least a half assed belief that relative or true dehydration exists, I'll always try a fluid bolus along with the neb to see if it will create a change. It can be surprising (or at least so it appears so to me) the difference that a bit of fluid as the only treatment can make in some of these patients. Though, perhaps there is something else going on in connection with the fluids and I've incorrectly associated 'moister lungs' with at least a partial relief of symptoms. I don't know. It's my hope that getting him some more air will satisfy his ache breaky heart a bit and we'll stop seeing those transient pissed off rhythms. But, you know, hoping and all... It looks like, this time around maybe, that watching for zebras instead of horses was a prudent course of action? What an excellent scenario, run perfectly. With everyone participating in the true spirit of learning...Man, what a treat. No, but what is "fine" for this guy? Is he a multiple times/day neb tx type of COPD'r, or is he more a silent sufferer who just seems "fatigued" all the time and folks just chalk it up to him being old? Could be he had this brewing for a while, went to lay down because he didn't feel well, folks didn't bother him because he was "napping" and then someone picked up the oogly vibe that said "hey... something's wrong with grandpa... I'm gonna get my nurse to take a look." Who knows. Biebs? Got any info on this? Significant bronchoconstriction can occur in a fairly short time frame, especially if he had underlying inflammation... I'm surprised he was only being treated with Spiriva (tiotropium bromide), which is a long acting bronchodilator, without concurrent inhaled corticosteroid use. On that note, with the high BP's we're seeing, is he med compliant? Could be the BP is secondary to the respiratory distress, but could be grandpa decided not to take all his little pills today and refused that weird powdery inhaler thing that tastes like ass... so... maybe we're seeing an exacerbation due to non-compliant med use... Also, chronic dehydration is a serious problem in the elderly, and you are NOT misinterpreting that rehydration often leads to "happier" lungs... if your problem is not CHF and pulmonary edema, but rather acute-on-chronic bronchoconstriction, there's a very real possibility that those lung secretions are nice and thick and dry, and giving some moisture will definitely help with lung compliance and decrease work of breathing. Hydrated oxygen wouldn't be a bad idea (if you get the chance in between nebs... or you could pop a saline neb in there too). Just my thoughts. Wendy CO EMT-B 1 Link to comment Share on other sites More sharing options...
TicTok Posted May 27, 2012 Share Posted May 27, 2012 Hi all. I am from South Africa so this senario would have gone a little different for me. For one thing in our country, well DNRs donot really exist and nore do living wills. So no fighting for me. It is the patients decition and not the daughters and well we now have implied consent. Who is to say that she does not want the trust fund. This patient can be treated. I have had this pateint more than once (really is an old age thing). The problem is patients donot read text books and make our lives easy. Vital signs often over lap between lung cardiac/ respiratory pathology. So is this a bronchospasm with air trapping or cardiac asthma?. mmmmm. I was always taught that which ever one you pick must be hit hard. I am moving toward LUNG pathology. What is the ambiant temperature there, also what season is it. Being male he is more likely too have a rapid progresion of a life threatening brochospasm. I also agree that pneumonia must always be concidered. I would not have tubed this patient. I agree that a Sulbutmal neb is good but i say it should be combined with Ipatropium Bromide for the first dose (COAD/ COPD patients often responed better to the anticholernergic for relaxation of the bronchial smooh muscle). We donot use CPAP on the road here as other than intubated patients so I am not going to comment. On the iv access side of things. The patient has large Juguler veins. Why not try there. I find awake patient tolerate it well and you have large bore access if needed. It is quick. Mag sulph is a good Idea. I would maybe hold of on the solumedral though. I like fluid in any brochospasm who is dehydrated - small boluses. I probably woud not have waited on scene to long with this patient. Neb, monitors, load high semifowlers. IV access if posible and get going while waiting for the first neb is being finnished. Pull out the adreniline, intubation equipment and iv salbutamal and put them next to you - my good luck charm.This is only my 2cents worth. What monitor were you using there. Stay safe all 1 Link to comment Share on other sites More sharing options...
Bieber Posted May 28, 2012 Author Share Posted May 28, 2012 Great response, TicTok! The ambient temperature is around 75 F inside the nursing home; outside it is around 78 F and it is spring. Sticking an IV into the EJ is a good idea, but are you at all concerned about the patient's anticoagulated status with regards to that? We've also got a Lifepak 12 that we're using with full capabilities available to you. Wendy, unfortunately we've got no more info on the details surrounding the events leading up to his dyspnea other than those that have already been mentioned. Sorry! So for another quick recap, we're starting to make some headway with this patient. We've got some CPAP and nebulized albuterol going, we've gotten some magnesium sulfate down, and we've got a couple of folks in favor of steroids and a couple against. We're transporting now. Do we want to go lights and sirens or regular traffic? Also, how many folks do you want in the back with you if any? Any more interventions we want to try or do we want to continue as is and see how it goes for the rest of the trip? Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted May 28, 2012 Share Posted May 28, 2012 NO LIGHTS AND SIRENS. NO NO NO I got in late on this one from my last post and of course the best of the best were treating him. Continue as is, keep on trucking, drive methodically to the er and treat as you have been. Don't screw up what has been working. Oh yeah, does he have a foley? If so, you might want to empty the foley to gauge what his urine output is from when you begin treatment to arrival at the hospital. A full bag on arrival at the hospital doesn't help the nurses but if you empty the bag when you start to treat the guy and then bring a guy with a bag that has 200cc or 0cc into the er and tell them that you emptied the bag when you started treatment, that can tell the nurses some good info, especially if you decided to go with lasix at any time in the treatment regimen, which I don't believe we did. But sounds like the EMT City EMS Service is well on it's way to saving another one. Rock on. Link to comment Share on other sites More sharing options...
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