medic001918 Posted November 13, 2006 Share Posted November 13, 2006 Alrighty, the general concensus seems to be to try a fluid bolus prior to addressing the rate. So we administer 250cc over 5-10 min or so. Pt's BP is 78 systolic. Now what? If we can now obtain a BP, things are improving. Has his rate changed at all? As long as lungs are still clear, let's continue with fluid replacement. Shane NREMT-P Link to comment Share on other sites More sharing options...
Lithium Posted November 13, 2006 Share Posted November 13, 2006 Yay! So my BLS skills actually worked (see first post ... trendelenberg!)? And 250 mls over 10 mins? I don't think so ... but anyways. Now that he has a palpable BP (although it's still too low for my liking) how's his mentation? GCS? HR improved at all? Repeat focused exams (and you still didn't answer my questions about abd/flanks and skin temp). Continue with my other treatments previously mentioned (atropine, consider pacing but most likely leading to dopamine). peace Link to comment Share on other sites More sharing options...
Shelbmedic Posted November 13, 2006 Share Posted November 13, 2006 if the fluid bouls of 250 worked and gave us a B/P of 78 I give another bolus of 250cc if lungs remained clear. Then reassess pt vitals,GCS, 12lead again for changes. If no changes and the HR came up just transport and monitor vitals. But if his B/P remained low or none as before then give atropine0.5mg up to 1mg if needed. Then reassess and go from here. Link to comment Share on other sites More sharing options...
hammerpcp Posted November 13, 2006 Author Share Posted November 13, 2006 Yay! So my BLS skills actually worked (see first post ... trendelenberg!)? And 250 mls over 10 mins? I don't think so ... but anyways. Too long? You suck at IV's so it took you awhile to get the fluid in with a 22 gauge. Oh and you only put the Pt supine on the stretcher because you recently read somewhere that trandelenburg doesnt work. :wink: Now that he has a palpable BP (although it's still too low for my liking) how's his mentation? GCS? HR improved at all? Repeat focused exams (and you still didn't answer my questions about abd/flanks and skin temp). Continue with my other treatments previously mentioned (atropine, consider pacing but most likely leading to dopamine). peace Mentation is improved, pt is responding a little quicker then he was. Pt still appears pale cool and diaphoretic. Denies any pain of any kind. HR remains unchanged. Link to comment Share on other sites More sharing options...
Ridryder 911 Posted November 13, 2006 Share Posted November 13, 2006 Thanks Hammer for pointing out Trendelenburg myth... as well, if 250 ml does not change any outcome, you are pissing in the wind then about fluid challenge... Amazing, most are not recognizing basic hemodynamic physiology though... R/r 911 Link to comment Share on other sites More sharing options...
Lithium Posted November 14, 2006 Share Posted November 14, 2006 Obviously the trendelenberg helped somewhat if the pressure came up and his mentation is improving :wink: (heh, please note sarcasm) Now that he is improving, I'll be a little more reserved. How far out are we? Link to comment Share on other sites More sharing options...
bassnmedic Posted November 14, 2006 Share Posted November 14, 2006 Okay, I know this is slightly off topic, but I have seen trendelenburg improve a patient's hemodynamic status. I have heard both sides of the story about it not working and so forth, but from my experience it has worked on more than one of my patients, then again it hasn't on others. Sorry.....now back to our regularly scheduled program Take care, Todd Link to comment Share on other sites More sharing options...
hammerpcp Posted November 14, 2006 Author Share Posted November 14, 2006 So you've been with this pt for about twenty minutes and 400cc's of NS have infused. The pts BP is 136/54, HR is still just below 50 BPM, and the Pt is responding normally and looks quite a bit better. What do you think is going on with this pt? And why or why not did you decide to treat aggressively? Link to comment Share on other sites More sharing options...
Lithium Posted November 14, 2006 Share Posted November 14, 2006 Now that the patients BP is much better, we can down him to a 3/2 first and foremost. Secondly, I'll lay off the drugs, as I'm sticking with my original presumption of a synergistic effect of the alcohol plus meds. His BP is improved and this perfusion to the brain is better, he's in no imminent threat. No sense in adding more pharmaceuticals to his system if I don't have to. I believe his HR remains bradycardic however due to the beta blockers and once again the alcohol. I'm surprised it hasn't increased even slightly however, simply due to startlings law with the fluid. Oh and with that, once he's reached 500 ml, I'll be slowing it down TKVO. peace Link to comment Share on other sites More sharing options...
becksdad Posted November 14, 2006 Share Posted November 14, 2006 My instincts still tell me that this is very possibly a medication interaction (including the ETOH). Quick question - did the same physician prescribe all meds? If not, is one aware of what the other is doing? It almost seems like the Levodopa and the Levocarb together, along with Trihex might be overkill. Maybe the same with Amiodorone and Metoprolol. Not really sure, but it seems they could have synergistic effects greater than any one of them alone. Since the patient is very much improved, despite the refractory bradycardia and still kind of low diastolic, I would cut the fluid back to KVO, keep patient supine, and continue monitoring frequently. I also figure that the cardiac meds are prescribed for a reason that I don't want to mess with, especially since I do not have a complete understanding of cardiology. So as long as patient continues with normal mentation and V/S remain improved, I would just continue with supportive care. I hope nobody feels like I kind of hijacked this thread because I'm an EMT playing in an ALS forum, but this is good for me to learn from... Link to comment Share on other sites More sharing options...
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