hammerpcp Posted November 12, 2006 Share Posted November 12, 2006 Called to a residence code 4 (highest priority) for elderly male confused. On scene you are told by the Pt's wife that she and the pt - and elderly male - had just returned from the cemetery for the Remembrance Day celebration. Pt took his Levodopa and then had a glass of wine. A few minutes later pt became "incoherent" according to pts wife---> EMS activated. Pt found sitting erect in chair, very pale, cool and diaphoretic, Alert and responding to questions slowly but appropriately. Meds: Lipitor; Amiodarone; Levodopa; Pariet; NTG; Altace; Metoprolol; Levocarb; ASA; Trihex (sp?) MedHx: Parkinson’s; MIx2 5yrs ago NKDA VS: HR 48 sinus bradycardia in lead two, no radial pulses, no obtainable BP, Sat 87 ORA ->98 on 100% O2, CBG 9.7mmol How would you treat this pt? Link to comment Share on other sites More sharing options...
Shelbmedic Posted November 12, 2006 Share Posted November 12, 2006 Well I think I would want know few more details what are his respriations like? Depth/Volume? A/E is it equal and bilat? what do you hear?Any chest discomfort? Hand grips/ Pupils are the E/R if so what size? any JVD?? any edema noted. Treatmeant including what you have done so far would be o2 via nrb@ 10l/min, Iv x 2 large bore. a fluid chalenge of 250cc if his lungs are clear and a 12lead? Link to comment Share on other sites More sharing options...
medic5587 Posted November 12, 2006 Share Posted November 12, 2006 Pt found sitting erect in chair, very pale, cool and diaphoretic, Alert and responding to questions slowly but appropriately. Sounds like too much Viagra! Link to comment Share on other sites More sharing options...
hammerpcp Posted November 12, 2006 Author Share Posted November 12, 2006 Well I think I would want know few more details what are his respriations like? Depth/Volume? A/E is it equal and bilat? what do you hear?Any chest discomfort? Hand grips/ Pupils are the E/R if so what size? any JVD?? any edema noted. Treatmeant including what you have done so far would be o2 via nrb@ 10l/min, Iv x 2 large bore. a fluid chalenge of 250cc if his lungs are clear and a 12lead? Resp rate 10 bpm, eupneic no distress, lung sounds clear in all fields, no adventitiouls sounds, equal chest rise bilt. no chest pain or discomfort. 12 lead unremarkable. Equal grip strength bilat. pupils 7mm equal and reacitve to light. No peripheral edema, no pulmonary edema audible. No JVD. Link to comment Share on other sites More sharing options...
paramedicmike Posted November 12, 2006 Share Posted November 12, 2006 Started the parkinson's meds when? How compliant with the meds has be been? Taking too many? Not enough? Food with the glass of wine? Stomach pain from the ulcers? All this and his sugar's pretty high, too. Start a line and bolus some fluid. High flow oxygen. Reassess. How's he change? -be safe. Link to comment Share on other sites More sharing options...
Lithium Posted November 12, 2006 Share Posted November 12, 2006 I concur with everyone so far, but if I'm unable to get a BP, I don't think he'll be able to answer my questions much longer. At this time, consider moving him to the stretcher prior to any major interventions (including IV). This gentleman will receive a full cardiac workup, and for further physical, how's his belly and flanks? Any distiention/rigidity? After all primary interventions (O2 100% via NRB at 15 lpm, continuous cardiac monitoring and repeat 12-lead in 5 to 10 minutes) he will be placed trendelenberg based on respiratory rate and patient comfort abilities. Ask his wife if they have a typical hospital where he's been treated for his MI. How was ambient temperature? I'd really like to make sure he isn't mildly hypothermic prior to initiating cardiac care below ... I'll place an 18 or even a 16 gauge right AC and follow through with a minimum 250 cc bolus and reassess while beginning transport code 4 CTAS 1. I'll be querying him regarding cardiac history and how he's feeling now (ie. OPQRST etc.) During transport if he deteriorates further or atleast shows no sign of improvement, I'd like to give him 0.5 mg of Atropine and perhaps another dose of 0.5 mg in 3 to 5 minutes. If no improvement with this drug, I'll be patching to my base hospital MD for orders for dopamine. Asking the doc to start at 10 mcg/kg. Skp pacing due to the fact I believe this really is more of a pressure problem then a rate, and he's not going to be able to receive sedation immediately. Hopefully we're only 5 minutes out tho ... :wink: Link to comment Share on other sites More sharing options...
hammerpcp Posted November 12, 2006 Author Share Posted November 12, 2006 I believe this really is more of a pressure problem then a rate,:wink: Why? BBT Link to comment Share on other sites More sharing options...
Lithium Posted November 12, 2006 Share Posted November 12, 2006 BBT? Two reasons ... if the atropine couldn't help bring his rate up, then there's something funky with his ANS. Secondly, alcohol has really weird interactions with a vide variety of medications, especially those affecting the CNS. Was it red or white wine? How much, over how long of a period? Any food with it as well? Is he a regular drinker or none at all? Levodopa has been known to cause orthostatic hypotension itself, add in some alcohol, and the pressure can drop. Not to mention if he's also taken his beta blockers and maybe even a squirt of nitro. Link to comment Share on other sites More sharing options...
EMS49393 Posted November 12, 2006 Share Posted November 12, 2006 I would think the rate is causing the hypotension. Cardiac output is probably compromised if his heart rate is in the 40's. If not responding to a fluid bolus, Atropine, and his 12/15 lead is unremarkable, I'd be inclined to pace. If he becomes more alert with better perfusion I'd sedate him and continue pacing. You stated you didn't feel as though he would answer your questions for much longer. So you could pace or mess around with dopamine until he loses consciousness completely, and then you'll still end up pacing. I'm not a fan of jerking around with dopamine in this type of situation. Pacing would be quicker to up this patients perfusion status. Technically speaking, he's quite hemodynamically unstable and warrants some Edison Medicine. Link to comment Share on other sites More sharing options...
medic001918 Posted November 12, 2006 Share Posted November 12, 2006 I'd treat this patient with supportive care (IV, O2, Monitor) and prompt transport to the hospital. We already know the 12 lead is unremarkable. Let's not forget that his beta blockers may be holding his rate down and causing the inability for the nervous system to compensate for any kind of fluid/cardiac deficity with a rate correction. Although a rate of 48 is a little lower than what is commonly seen with beta blockers, I can't say that I'd jump right into treating the rate. For a benchmark, I'm 27 and my last EKG (done this summer) was sinus brady at 48; and I have no cardiac history. It doesn't mean that it's not a rate issue, but I'm guessing that's not the major issue with this patient. Fluid replacement would be first up followed by possibly an attempt at pacing. Is it possible that he got his meds confused and has taken too much of his beta blockers as well? At which point Glucagon IV would be indicated. There are a number of possible causes for the change in mental status. Shane NREMT-P Link to comment Share on other sites More sharing options...
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