My wife feels cold

[Thunderchild145]

I'm not saying that's the correct thing to do, but I do think that's how I, being a brand new medic student, would try and manage this patient.

EDIT: Actually, seeing as how the temp is only 90 I'd probably skip the active rewarming and run it to the ER. But I'd go after the hypotension/bradycardia fairly aggressivly. I might even consider TCP.

[vs-eh?]

As far as the hypothermia I'd probably just take hot packs and place them over carotid and femoral arteries. I'd consider a few drugs for the hypotension/bradycardia, mainly epinepherine 1mg IVP, Atropine 0.5mg IVP, or dopamine 2-10 mcg/kg/min IV infusion. I'd definately keep ventilating with BVM and ETT.

I'd probably check lung sounds but even if she did have fluid on her lungs her pressure is too low for nitrates, diuretics or vasodilators.

Oh yea, and the low amplitude EKG makes me think about electrolytes. I'd probably hand some Ringers and see if it helps any.

You'd probably wanna skip that...

Ok, drinky time.

PS - NOBODY on the road would have made a diagnosis of Myxedema coma. Nobody.

[akroeze]

You'd probably wanna skip that...

Ok, drinky time.

PS - NOBODY on the road would have made a diagnosis of Myxedema coma. Nobody.

Exactly... that's the problem with these scenarios sometimes. You have time to sit down and think about it, look at all the S/S, look up the relevant literature and then post. In the field you don't have that luxury. Most people would treat the symptoms and report it simply as "Altered LOC"

[Lithium]

And (no offense here Vs or akroeze), this is exactly what is wrong with EMS. People feel they don't have the luxury to sit down and think. I feel bad for those patients, their families, but not so much for their lawyers. But that is beside the point ... it just struck a nerve with me.

Back to the scenario, as soon as her airway was secured I would have considered TCP much sooner then what it seems everyone else was thinking. Let's get some perfusion going before I concern myself with rewarming.

peace

PS, why wouldn't ANYONE make a field impression (or diagnosis, as you wish) of myxedema coma?

[mediccjh]

You'd probably wanna skip that...

Ok, drinky time.

PS - NOBODY on the road would have made a diagnosis of Myxedema coma. Nobody.

Au contraire. I have before, my medic preceptor looked at me like I was nuts, and ended up buying me lunch.

[JCicco345]

Unstable, bradycardic, wouldn't it be a good opition to atleast consider pacing ??? Just curious.

thanks in advance.

[hammerpcp]

I am going to go ahead and take a little credit for that diagnoses. Although I was not familiar with the exact process it took all of about three seconds to get to the diagnoses since I already recognized the chronic symptoms. And VS, with todays technology it isn't too hard to carry multiple reference guides in your pockets. Obvioulsly there is alot more that we don't know then that we do know what with the length of schooling we have and all........

Thanks for enabling the expanse of my brain with this scenario.

And thanks to google:

TCP does sound like a good idea, along with some blankets, fluid replacement (and electrolyte-hyponatremia is common), possibly glucose replacement (depending on results of BG reading, but hypoglycemia would be expected), and continue to assist with ventilations. This is awesome. Thanks for the reminder aobut TCP, I didn't even condsider that as an option.

Lithium can you precept me?

[Lithium]

Hammer, I would love to have a student like you ... to be able to come up with something so 'off the wall' as myxedema coma is great. To be honest, I've noticed a change in how you post lately since you've started your ALS classes, more like you're not afraid to actually talk about medical things... haha

Continuing with the pacing however, what would you consider for sedation for this patient? If any?

And remember, ALS is still about the ABCs, we just have more tools to support them.

[Thunderchild145]

The pt seems to have decresed LOC already, also the BP is way, way too low. Skip the sedation.

[brock8024]

I will have to dissagree that you could not make this DX out in the field. We are covering this in our paramedic class right now. In our book there are S/S and how to treat this and many other conditions. It is tue that we are not robots and can not remember everything that we are tought but it is our duty to our patients to read up on our down time and make sure we are up on this stuff esp. the things we do not see everyday. Hell doctors have to do that to keep up on things and I would hope that even nurses do.

By the way active re warming in the hyopthermic myxedema coma is contraindicated. It can cause cardiac dysrhythmias and cardiovascular collapse secondary to vasodilation. Or at least that is what is in my book.

Brock