medic53226 Posted July 19, 2006 Share Posted July 19, 2006 Dispatch: Medic 2 respond to a rural residence for a pt with ALOC and decreased resp, fever recent liver surgery. Upon arrival you find a 75 y/o female in bed supine with local FD, pt is combative, and it is everything they can do to keep her under control. Pt is having snoring respirations, and hot to the touch. BP 142/68, Resp 30 snoring. Decorticate Posture. What do you want else to know. Link to comment Share on other sites More sharing options...
chbare Posted July 19, 2006 Share Posted July 19, 2006 Medic53226, sounds like this patient is very ill. No hazards noted during our assessment of the scene? What are our resources? (BLS,ILS,ALS, nearest hospital and what facilities, helo) Need to get her on high flow O2 and do a respiratory assessment. (effort, accessory muscle use, lung sounds, obstruction-->snoring could be the tongue ) Are we able to manage her airway with BLS? We may need to intubate her for airway management based on our assessment. What exactly is her mental status? What is her pulse rate and quality in addition to temp? Need to quickly find out if she is allergic to any meds and her medical/surgical history in addition, we need a medication list. Further interventions will be based on our assessment of her ABC's. Take care, chbare. Link to comment Share on other sites More sharing options...
MrSpykes Posted July 19, 2006 Share Posted July 19, 2006 I would like to know what kind of surgery the patient had on their liver, was it for CA, or a transplant, or infection. Try to verbally calm her down. Get a SAMPLE history from a family member or caretaker. I would like to assess the area of the liver surgery looking for any redness, heat, discharge. Also note any evisceration of ABD organs. Find out when exactly the pt had surgery, PN rating on a scale of 1-10. Definitely put them on high flow O2. What is the general appearance of the skin. Link to comment Share on other sites More sharing options...
medic53226 Posted July 19, 2006 Author Share Posted July 19, 2006 Scene safe, PT is on NRB by FD and is 98% SPO2, PT is very warm to the touch and ashen in color, pt had a stent put in a artery in the liver to help with cirrhosis of the liver, pt is diabetic, pt is also givin NP, pt still snoring, and very combative, Nearest hospital 20-30 miles no helicopter, bad weather T storms. GCS 8 E4/V2/M2. Lungs are clear and no recent falls, no new meds, just liver stent placed 2 weeks ago. Has eaten as far as family knows, and has been checking her own BGL. What else Link to comment Share on other sites More sharing options...
kristo Posted July 20, 2006 Share Posted July 20, 2006 I'd check her blood glucose levels myself - I wouldn't trust a patient with an altered mental status to do that themselves. This patient is showing some symptoms of low glucose levels. The recent surgery (or any implications with it, such as an infection) might be affecting the diabetes. Check the glucose, be prepared to do ALS on her airway (just in case) and get en route to the hospital ASAP - don't need to run hot, but at least get moving. Link to comment Share on other sites More sharing options...
rocket Posted July 20, 2006 Share Posted July 20, 2006 pt is also givin NP Is that short for nasopharyngeal airway? if not I'd like to try to get one inserted. And let's get her sat up if possible. No new meds eh? What meds is she currently taking? Let's see the bottles and do some some counting. And some detective work about the PMHx. Per the family, has this type of behaviour (incl posturing) happened before? -Trevor Link to comment Share on other sites More sharing options...
rocket Posted July 20, 2006 Share Posted July 20, 2006 Forgot to add: As BLS provider I'd want to get going now(barring any jaw-dropping info from the family). Let's take a fireman with us (help in the back), call for ALS intercept if possible en-route and go. Hot. I have an idea as to what is going on. If I'm right then I know there isn't much else I can do (BLS) other than to maintain or improve her level of stability and get her to definitive care ASAP. I have a feeling some blood tests are in order. Something that doesn't mix well with bleach.... -Trevor Link to comment Share on other sites More sharing options...
AZCEP Posted July 20, 2006 Share Posted July 20, 2006 Move to the transport unit, continue with above mentioned suggestions. Bilateral IV's, blood glucose, cardiac monitor, capnography, and pulse oximetry. Any pain meds in the shoe box? Could be pain reliever following the surgery. Untoward response to a narcotic can present like this. I'll agree this sounds like an infection, but there is the possibility of other causes. If she remains combative, we might consider sedation chemically. No reason to fight if we don't have to. Link to comment Share on other sites More sharing options...
brock8024 Posted July 20, 2006 Share Posted July 20, 2006 http://www.clevelandclinicmeded.com/diseas...ph/henceph.htmt This sounds like ammonia toxicity which is a side effect of hepatic encephalopathy from what I understand. One of the drugs of choice for the ammonia is lactulose. Lactulose prevents the absorption of ammonia in the colon and increases water in the stool. It is used in Pt's with hepatic disease with portal systemic encephalopathy. I would treat the patient with supportive care. Drop a tube if needed and what ever else she needs. Brock Link to comment Share on other sites More sharing options...
chbare Posted July 20, 2006 Share Posted July 20, 2006 Lets check a temp as well. I would hold on lactulose until we can get labs and a NH3 level. (elevated NH3 can defiantly cause altered LOC) I agree that we are potentially looking at sepsis. Any body remember the 5 W's of infection after a surgical procedure? Also agree that we need a BGL. We need to do a more detailed head to toe physical assessment and pay special attention to her ABD. In addition, we need to look for S/S of internal and external bleeding. Take care, chbare. Link to comment Share on other sites More sharing options...
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