chbare Posted June 20, 2006 Share Posted June 20, 2006 32 year old male presented to the er by ambulance combative and agitated. Primary Assessment ; RR-42 labored, hr 180 narrow complex tachycardia on the monitor, skin pale and mottled, b/p-85/40 Sao2-88%. LOC-awake but incoherent swinging at er staff and thrashing in his bed. HEENT: normocephalic, PERL Pupils at 4 bilat, nose and throat unremarkable, CX; lungs diminished without adventitious sound through all lobes, ABD, soft, EXT, full ROM noted nail beds cyanotic, no evidence of trauma. PMHX; unknown. HPI; EMS reports possible meth overdose. TX; given 10mg Haldol IM initially, the paramedic working ER identified that the patients was not ventilating and perfusing adequately and recommends immediate RSI to the ER doc. RSI performed (10 midazolam & 10 vecronium given) Intubated with 7.5 ETT placement verified. After RSI Pt's HR increased to 190 b/p 80/p, pt cardioverted at 100j no response noted, given 150mg of amiadarone IV and cardioverted at 200j without response, given 150mg codarone repeat dose without response, cardioversion at 300j without response, pt remains pale and mottled with b/p 80/p, immediate unsynchronized shock given at 360j without response. Pt placed in head down feet up position and bolused with 2000ml NS without response, given 40 mg diltiazem IV, HR decreased to 150-160, diltiazem drip started and titrated up to 45 mg /hour, HR decreased to 120's B/P stabilized in the 110 systolic range, the diltiazem drip was eventually titrated down to 20mg per hour. Labs; Ck-336, BUN and Creat were elevated, UDS + Cocaine and Meth, Tryponin negative, all other labs were negative. Disposition; pt remained intubated and was admitted to the ICU. Please note, this case was written by a paramedic in our er who wanted somebody to review the ed treatment and provide suggestions/feedback regarding the care that this patient recieved. I appreciate you responses and will try to clarify any questions the best I can. Take care, chbare. Link to comment Share on other sites More sharing options...
AZCEP Posted June 20, 2006 Share Posted June 20, 2006 Why no BZD? Other than the Versed for induction, seems they missed it. A blood glucose might have been a good idea as well. Might consider some IV fluids while we are doing things. Link to comment Share on other sites More sharing options...
chbare Posted June 20, 2006 Author Share Posted June 20, 2006 AZCEP, thank you for the questions, I checked with the medic to verify the answers. Two IV's were established upon arrival and the fluid bolus was started as soon as vascular access was established. The BGL was 110mg/dl. As far as the RSI, these were the meds that the ER doctor ordered. 10 mg of versed was given for sedation followed by 10 mg of vecronium. Thank you again for the questions and feedback. Take care, chbare. Link to comment Share on other sites More sharing options...
AZCEP Posted June 20, 2006 Share Posted June 20, 2006 Yep, I should have read the scenario a bit closer. You listed it right there. My "Uh-oh" flag would be raised using Cardizem with a blood pressure that low, but I guess it worked out. Flood these patients with benzo's and wait for the street corner pharaceutics to wear off. Link to comment Share on other sites More sharing options...
chbare Posted June 20, 2006 Author Share Posted June 20, 2006 AZCEP, he told me there was allot of pucker related to using cardizem, band he was shocked that cardioversion did nothing to slow the rate. He said as soon as the cardizem hit the rate slowed and the pressure went up. He just wanted to know how other people would have responded to this scenario and what other options could have been explored. Take care, chbare. Link to comment Share on other sites More sharing options...
ERDoc Posted June 20, 2006 Share Posted June 20, 2006 A couple of things I was thinking while reading the scenario (not being there, this is all Monday Morning Quarterbacking). I don't think I would have so quick to intubate. All of the bad things in this scenario could be rate related. I would try to get the rate down first. Had I needed to intubate, I would have chosen a different choice of meds (but this is more personal preference) and a bigger tube. Synchronized cardioversion was the way to go here, I would not have done an unsynchronized shock. I also would have given adenosine a try and not jumped to amiodarone first. I think the cardizem was a good idea, though the sphincter would have been tight. I think the BP was low due to the heart rate. Slow down the heart and allow a little more filling time and up your BP will come. Boluses were a good idea. NO beta blockers for this guy. Maybe some more haldol. In the end the guy survived, so I guess the ends justify the means, but it seems like this guy was committed to a tube a little early. Link to comment Share on other sites More sharing options...
chbare Posted June 20, 2006 Author Share Posted June 20, 2006 ERDoc, thank you for the input. I will pass this on. I was a little curious regarding the treatment as well. Take care, chbare. Link to comment Share on other sites More sharing options...
dgmedic Posted June 21, 2006 Share Posted June 21, 2006 I agree with the doc and AZ. Temp and EtCO2? Pale and mottled but how about super sweaty? This presentation without initial labs I would also be going down the road of E too - Due to the diminished lung sounds, I would have them listen again for some edema....my index would be pretty high for potential cocaine/amphet induced APE. I would have definately given some benzos.....lean more toward benzos rather than haldol even for calming them down if I was strongly thinking cocaine - potential for QTc prolongation.....probably doesn't matter though. I think benzos would have fixed a majority of issues. hhhmmmm, if I did RSI 'em I would go with the biggest tube possible....if 7.5 is adequate, go with it - and give a little bit o' fentanyl with it - just in case you pinch a lip, pop a tooth, or use a really long straight blade I would go with etomidate for induction just b/c of the pressure. After the labs, I would go with cocaine induce APE (have them listen to the lungs again or get a chest film)....with the labs you stated, I would go without rhabdo.... maybe wrong - but that is the first thing that came to mind.... -dg Link to comment Share on other sites More sharing options...
chbare Posted June 21, 2006 Author Share Posted June 21, 2006 Dgmedic, I do not have an initial etC02, I think they used an easy cap. The temp was normal. The chest x ray did not indicate pulmonary edema nor were any wet lung sounds noted. As soon as the HR came down, the patients vital signs stabilized. CK was not elevated, kind of a surprise to me! I agree with ERDoc that they could have considered adenosine. (I was not there, so it is just Monday morning quarterbacking.) I think most of this patients problems were rate related. I also like etomidate, but most of our er docs do not have allot of experience using it and tend to go for versed, unless they are on with a nurse that is very familiar with using etomidate. I also like to use fentanyl for sedation. Thank you for your input. Take care, chbare. Link to comment Share on other sites More sharing options...
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