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Case #51 "i Feel Cold"


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#21 onearmwonder

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Posted 03 March 2010 - 10:19 PM

Matt- You are kind of half right regarding RV infarct. You will see RV involvement in approx 30% of RCA MIs (can find this in the Critical Care Nursing Cert by Ahrens Et al). As the RCA supplies the SA node in the vast majority of the population, you will also see bradycardia as the rate is set by other cells (usually sub-junctional). When the RV fails it causes a back up into the venous circulation (resulting in peripheral edema). The poor RV output causes a low LV preload, low LV end diastolic volume and LV end diastolic pressure. In turn poor cardiac output and hypotension (similar to that seen in dehydration or other low preload states). These folks need preload, therefore titrated IVF. Actually shooting for a very high central venous pressure. This will help more than an inotrope. Dopamine has the potential to increase myocardial O2 demand and worsen the MI and should be used cautiously. Hope this helps. If you already knew it, then it was a good refresher for me.
-Regards


Hey with all do respect I'm still a new onlooker, but don't you mean that the RCA supplies the AV node in 90% of the population?

Matt
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#22 TexRNmedic

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Posted 03 March 2010 - 11:50 PM

Hey with all do respect I'm still a new onlooker, but don't you mean that the RCA supplies the AV node in 90% of the population?

Matt

and as I previously wrote "You will see RV involvement in approx 30% of RCA MIs (can find this in the Critical Care Nursing Cert by Ahrens Et al). As the RCA supplies the SA node in the vast majority of the population, you will also see bradycardia as the rate is set by other cells (usually sub-junctional)."


Matt, you are very correct. Thanks for pointing that out. I did mean AV. My bad for typing while getting sleepy. In the interest of education (and since our hosts have asked for references) I have the following review of coronary artery anatomy. Shows how unlikely an SA node infarct is versus an AV node infarct (since the AV is on much more distal circulation). I am just going to copy and paste most of my reply from emedicine.medscape.com from the heart anatomy page (Hyperlink included). When talking about left versus right dominance, we are talking about the origin of the posterior decending artery. In about 85% of the population this comes off of the distal RCA, termed a right dominance. In left dominance the blood is supplied to the PDA by a left coronary artery and most commonly the circumflex. In about 60% of the population the the SA branch comes off of the very proximal RCA as the first branch of the RCA.

Here is the copied bit-
The term dominance is used to refer to the origin of the posterior descending artery (PDA). When the PDA is formed from the terminal branch of the RCA (>85% of patients), it is termed a right-dominant heart. A left-dominant heart receives its PDA blood supply from a left coronary branch, usually the LCX. This is often referred to as a left posterolateral branch (LPL).

The RCA is a single large artery that courses along the right AV groove. The RCA supplies the right atrium, right ventricle, interventricular septum, and the SA and AV nodes. The RCA arises from the right aortic sinus and courses in the coronary (AV) groove between the right auricle and the right ventricle. In 60% of patients, the first branch of the RCA is the sinus node artery. As the RCA passes toward the inferior border of the heart, it gives off a right marginal branch that supplies the apex of the heart. After this branching, the RCA turns left to enter the posterior interventricular groove to give off the PDA, which supplies both ventricles.

The AV node artery arises from the "U-turn" of the RCA at the crux (ie, the junction of the AV septum with the AV groove). At this point, the PDA feeds the septal, right ventricular, and left ventricular branches. The PDA courses over the ventricular septum on the diaphragmatic surface of the heart. Unlike the septal branches off the LAD artery, the septal branches from the RCA typically are short (<1.5 cm). Terminal branches of the RCA supply the posteromedial papillary muscle of the left ventricle. (The LAD artery supplies the anterolateral papillary muscle of the right ventricle.) Near the apex, the PDA anastomoses with the anterior interventricular branch of the LCA.

-regards
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Wes Seale
Houston , TX

#23 STPEMTP

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Posted 04 March 2010 - 05:12 AM

First off, Welcome Ectopy and Trouble! We're new to the hosting case studies side, so no worries. Anyone who's "lurking" and following along, please feel free to chime in with your thoughts. Our goal is to facilitate learning and reviewing some key points.

Ok, here's the first update.

Scene survey/ history:
Room temp is on the cool side
You note a roasting pan next to the patient with some saliva in it and dried emesis stains on the carpet near the patient.
Pt states he doesn't take any meds beyond the pain medication his surgeon prescribed. Vicodin
Pt denies renal problems or hypertension
Pt does admit to decreased urine output. Not sure if its concentrated or has a foul odor to it.
Pt had back surgery (lumbar) along with open fixation of tibia due to snowmobile accident. Moving all extremities with equal strength.
No known allergies

Exam:
No JVD noted
Pt is actively shivering, diaphoretic, and cold to the touch. Confirmed when applying EKG.
While cutting clothing to get at patient in search of elusive IV access you note 2 fentanyl patches on L arm. 25mcg/hr
Bilateral blood pressures are equal.
No audible wheeze/rales/rhonchi from across room (should have clarified earlier). Auscultation clear with good air movement.
No pedal edema noted.
Heart tones normal
Mucuos membranes are dry
Abd soft non distended. No pain with palp, no masses.
Pt does mention pain in back and leg at surgical sites.
Blood glucose level 173mg/dl
Pacing/Defib pads applied.

inital strip with 12 lead

Ok, 2 questions for the group.

1. EJ access or IO access? Which one do you want? please give some rationale as to choice (example: EJ--> allows for faster fluid flows)

2. Istat. You do have one. We'll give you one for the call. Cardiac enzymes and coags have already been requested and will be provided "free of charge". Please take a look at the link provided above and pick up to 2 cassettes to obtain the lab results you'll have for the case.

For the 2 questions, we'll going to go with the majority opinion on the access site and cassette choices. Looking at updating with lab work Thursday night or friday. May update sooner depending on volume of responses. If I missed a question or assessment finding, please re-post and I'll add it to the Lab work request.

*LEGAL DISCLAIMER: we are using the Istat machine just to showcase some of the equipment available to some teams. We are not endorsing or promoting any particular product. We are not receiving any financial compensation for mentioning their product*
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#24 SerendepitySaki

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Posted 04 March 2010 - 01:59 PM

I'm thinking STP got a couple of back to back late calls after we got off the phone last night .... if we don't hear from him by 1800, I'll post an update. In the meantime, two questions for y'all.

1. everyone seems to be leaning IO vs EJ... no worries... one of the "new guys" please specify which IO you'd like to and briefly describe contraindications and technique.... (unless someone prefers EJ)
2. pick yer poison. we'll give you an iStat... you can have co-ags, cardiac enzymes, and two other cartridges... I posted a link to the available products.... let us know what you'd like....

trouble, ectopy..... get your buds to come out and play! mike, wes, jlp... thank you for coming out and letting us learn from y'all! wes.... real nice layout of your thought process for teaching everyone...it will become a little more clear when we give y'all more basics to run with....



We're going to put our heads together tonight, edit a smooth, consolidated reply to the posts to date and get it out ASAP... I will check again @1700ish... anything posted by then will be included in our consolidated reply ...

remember basic rules of engagement.... no zebras... at least WE'RE not emphasizing any... you can have just about anything you want, as long as you ask for it.... please try and ref your posts where applicable...(if someone questions you, it's applicable, if you're "new", it's applicable...no, I don't think we expect you to ref ACLS guidelines, unless it's to point a questioning colleague in the correct direction...)

we will be posting more scene size up and basic assessment info in the next go round....

"new" guys come out and play! most of the stuff we plan to discuss here can be found in NAEMT, AHA, ACE-SAT, etc....


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#25 TexRNmedic

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Posted 04 March 2010 - 05:20 PM

I'm thinking STP got a couple of back to back late calls after we got off the phone last night .... if we don't hear from him by 1800, I'll post an update. In the meantime, two questions for y'all.

1. everyone seems to be leaning IO vs EJ... no worries... one of the "new guys" please specify which IO you'd like to and briefly describe contraindications and technique.... (unless someone prefers EJ)
2. pick yer poison. we'll give you an iStat... you can have co-ags, cardiac enzymes, and two other cartridges... I posted a link to the available products.... let us know what you'd like....

trouble, ectopy..... get your buds to come out and play! mike, wes, jlp... thank you for coming out and letting us learn from y'all! wes.... real nice layout of your thought process for teaching everyone...it will become a little more clear when we give y'all more basics to run with....


I've got a little bit more info to work with...
As far as labs go, I want to get in here early with what I want. By the way I will need some blood for these labs (hmm, maybe need to go with the EJ so I can get a little blood). I'll worry about the art stick later. Right now I'm more concerned about lytes (specifically K+, Na+ and Ca+) and renal function. The venous TCO2 will help too.

TX: Cardioversion/pace/defib setup. Take off the narc transdermals. Look around for any more. Maybe do a quick test for Trousseau sign if I really feel the need to kill a little time while waiting on us to decide EJ/IO. ;) I'm going start with NS at a pretty good clip (500cc/hr). If I can wait, I want to see my lytes before choosing an antiarrythmic drug. Reassess pupil size and confirm with the patient he hasn't taken anything else (prescribed, OTC, herbal or from the corner of 1st and Long St). 2mg of Ativan to attenuate the shivering, help the guy relax and maybe nudge his BP down (he may end getting some electricity soon). Try another 12-lead ECG.

CHEM8+
03M88-01
Sodium (Na)
Potassium (K)
Chloride (Cl)
Ionized Calcium (iCa)
TCO2
Glucose (Glu)
Urea Nitrogen (BUN)/Urea
Creatinine (Crea)
Hematocrit (Hct)
Hemoglobin* (Hgb)

&

i-STAT CG4+
07G02-01
pH
PCO2
PO2
TCO2*
HCO3*
BEecf*
sO2*
Lactate
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Wes Seale
Houston , TX

#26 Ectopy

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Posted 04 March 2010 - 09:35 PM

I completely agree with Wes' Chem8+

As for the EJ/IO debate - im pretty unorthodox about that. If the EJ is popping out to say hello, then clearly it's the faster route.

However, I've found that I've become pretty damn quick at getting an IO set up and in place. Im partial to the B.I.G (insertion site can be found here)

Now to the unorthodox part: To the question of blood, this guy needs large bore SOMETHING, but I dont need large bore to get blood, a butterfly will work. However, I'm also not opposed to going for an EJ after an IO has been placed. This way I have a nice second large (almost central) line and can draw bloods. If I do the EJ second, then if the shit really starts to hit the fan fast, you already have access through the IO.

For the labs, im particularly interested in seeing his serum potassium levels. After what sounds to be pretty intense trauma, this gent's kidney's might not have been able to keep up with the extra K load, failed, and now his system is flooded with potassium.

Initial presentation indicated a low heart rate which may be indicative of a block, a byproduct of high serum K. Secondly, vfib (as we saw a run of in the strip) is also a hallmark of a lot of K circulating.


If the patients K is high my treatment would be as follows:

Bicarb 0.75 mEq/kg IVP resulting in a temporary increase in extracellular pH pushing the K+ cation into the intracellular space. Also helps with general circulating pH which is also probably pretty high on this guy.
Calc-Choloride - 5ml of 10% - given AFTER the bicarb due to calciums higher interaction levels with an acidic environment.

Second line treatment:

D50 (2 amps) COMBO WITH INSULIN
Insuling (5 units, 10 units max) COMBO WITH D50
Albuterol treatment
All shift K+ into intracellular space


Wes, (once again for my own education)

Why 500ml/hr?
What about Versed or other sedatives besides Ativan?

I'm pretty liberal with electricity, and am known to shock early and often!

Matt
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Matthew George - NREMT-P, FP-C, CCP, Instructor

#27 SerendepitySaki

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Posted 04 March 2010 - 10:58 PM

weigh in here again brother...didn't mean to leave you out of the round up!

Hey with all do respect I'm still a new onlooker, but don't you mean that the RCA supplies the AV node in 90% of the population?

Matt


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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#28 Tmed725

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Posted 05 March 2010 - 01:02 AM

I'll put my hat in the ring...

1) My eyes are not good enough to read that 12 I actually got dizzy trying to read it, does it give you a QTC
2) Im old school, I can do the EJ faster and don't need to give lido with it, also its above the level of the surgery in case of some zebra clot (I know no zebras but perhaps a funny looking horse). I theoretically can also transduce it if I'm feeling saucy, special and its in a good spot.
3)labs CHEM8+ (03M88-01), CG4+ (07G02-01)
4)How much Vicodin has he taken and was he using other OTC with it (APAP overdose?)

Dave
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#29 Trouble

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Posted 05 March 2010 - 04:36 PM

I'll put my hat in the ring...

1) My eyes are not good enough to read that 12 I actually got dizzy trying to read it, does it give you a QTC
2) Im old school, I can do the EJ faster and don't need to give lido with it, also its above the level of the surgery in case of some zebra clot (I know no zebras but perhaps a funny looking horse). I theoretically can also transduce it if I'm feeling saucy, special and its in a good spot.
3)labs CHEM8+ (03M88-01), CG4+ (07G02-01)
4)How much Vicodin has he taken and was he using other OTC with it (APAP overdose?)

Dave


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#30 Trouble

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Posted 05 March 2010 - 05:26 PM

Wow! The 12 lead ekg is really ugly. It looks like I can see some PVCs in it however, not completely sure. As for the underlying rhythm it's hard to deciefer. This is probably due to the pt shivering so hard. Lets treat the pt not the monitor. Let check for central pulses do they correspond to our previous information given? As for IV access - I have the ez IO bone drill. So, I know that getting IV access would be quick and obtained immediately. However, this would also tie up my limited manpower priming the syringe for my syringe pump approx every few minutes. I like the idea of getting IV access by EJ. This would give us close to a central line as possible for now. I agree we the I-Stat cartridges here chem8+ and chem 4 is the only ones we carry.

As for other treatments I would like a temp from the pt as well an update set of vitals. Before giving him something(meds) to decrease his shivering , it would be nice why he is shivering? (like sepsis ??).He was obvious hot before hence why the window is open and his place feels like an ice box now. It would be really to easy to give a paralytic and intubate the pt just to see what the underlying ekg rhythm is. But unfortunately we would have to deal with the medical director. Based on the finding of emesis or lack of I would be considering this pt dehydrated - lets give him NS fluid boluses 500ml to start and try for a second iV site. Let also insert a urinary foley catheter. It might help with our DD- IT definitely appears that the kidneys could be shutting down. Ask the pt why he is taking fentanyl? underlying medical problem or is he abusing.

Still confused to the DD
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#31 Ectopy

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Posted 05 March 2010 - 06:10 PM

General Question to consider:

At what point (what markers, signs) do you guys use in making your decision to RSI? Our hands our pretty tied so it would be interesting to hear what other programs are doing....
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Matthew George - NREMT-P, FP-C, CCP, Instructor

#32 Tmed725

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Posted 05 March 2010 - 07:03 PM

General Question to consider:

At what point (what markers, signs) do you guys use in making your decision to RSI? Our hands our pretty tied so it would be interesting to hear what other programs are doing....

Continued failure to oxygenate
Failure to protect airway
Expected course (Burns, increasing airway edema, impending arrest)
Failure to keep his hands to himself
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#33 TexRNmedic

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Posted 06 March 2010 - 01:19 AM

Initial presentation indicated a low heart rate which may be indicative of a block, a byproduct of high serum K. Secondly, vfib (as we saw a run of in the strip) is also a hallmark of a lot of K circulating.

Why 500ml/hr?
What about Versed or other sedatives besides Ativan?


Matt


Sedation- I prefer ativan over versed for simple anxiolytic. I've noticed that it attenuates shivering better than versed (especially as part of hypothermia protocol. But we often end up paralyzing these folks too). The important thing here is this guy has inadequate cardiac output. What does shivering due? Increases O2 demand. The fact that I get a better look at his ecg is a bonus. I'm not putting him on an ativan drip, so I'm not to worry about renal clearance of only 2mg. I'm open to suggestions from of our pharmacology gurus around here (Sean!).

IVFs- The guy has no edema, no JVD, poor urine output and clear lung sounds. I would like to give him a little bolus or two or three. My personal preference is to run fluids at a rate (unless the patient really needs wide open) because I'll get busy and before I know it I've run a full liter in. I want to see how this guy responds to the fluids and I can titrate up or down on the rate. First BP was pretty hypertensive.

I'm more worried about hypokalemia and the associated disrrythmias VT/VF/malignant pvcs. Based on the ECG, I'm guessing this guy is spending more time in a maligant reentry arrythmia than not. The guy is sweating like crazy. Fast way to loose a lot of lytes. Hyperkalemia presentation in cardiac arrest usually skips over VT/VF and goes straight to PEA (hence the Hs&Ts for asystole/PEA from AHA).

The inflamation and dehydration can be enough to triger atherosclerotic plaque rupture and precipate an MI. Probably not his only problem right now.

By the way guys, how do the surgical wounds look.
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Wes Seale
Houston , TX

#34 jjones1418

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Posted 06 March 2010 - 06:55 PM

I'll take a CHEM8 and a CG4+.

He's very sick and he's going to need interventions quickly. If I'm unable to get a peripheral IV, he's getting an EJ. If that's unavailable, he needs a central line or an IO, whichever is available. I'd be cautious with the IO in his legs with his accident/surgeries/fractures. So, just to be different, throw in an IJ.

1) O2 via NRB
2) Venous Access - Fluids at 500 cc/hr
3) Ativan / Versed for shivering
4) iStat - CHEM8 & CG4+ (I know you said cardiac enzymes, but are we getting a plain ol' CK?)

Is his pressure still 180/100? That ECG is worrisome. It's got some ventricular ectopy, and the few QRS complexes that are actually visible have a HUGE, peaked T-wave. I hope he doesn't arrest. Pads on is a great idea. Get your airway stuff out. All of this can be done en route.

I'm going to wait on the labs and an update before I throw the drug box at him. I've got an idea where this is headed, just need some clarification.

1) BP still 180/100?
2) Any update on urine color or apperance?
3) He still awake and alert?
4) What IV access do we have?
5) Any iStat results?
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#35 Ectopy

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Posted 07 March 2010 - 01:10 AM

I'm more worried about hypokalemia and the associated disrrythmias VT/VF/malignant pvcs. Based on the ECG, I'm guessing this guy is spending more time in a maligant reentry arrythmia than not. The guy is sweating like crazy. Fast way to loose a lot of lytes. Hyperkalemia presentation in cardiac arrest usually skips over VT/VF and goes straight to PEA (hence the Hs&Ts for asystole/PEA from AHA)..


Completely agree in most cases, BUT if you pick through the EKG the discernible complexes have pretty impressively peaked T-waves, not the biphasic T of a hypo-k patient.

Just waiting for an update! Bolus, ativan for shivering, I'd love to see some labs before I pick what I'm going to use to control the ventricular ectopy (hey, thats me). Also, once this guy calms down a bit a clear 12 would be great.
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#36 SerendepitySaki

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Posted 07 March 2010 - 01:28 AM

talking to STP as we "speak" ..... update tomorrow (Sunday)
surgical wounds look good.


Completely agree in most cases, BUT if you pick through the EKG the discernible complexes have pretty impressively peaked T-waves, not the biphasic T of a hypo-k patient.

Just waiting for an update! Bolus, ativan for shivering, I'd love to see some labs before I pick what I'm going to use to control the ventricular ectopy (hey, thats me). Also, once this guy calms down a bit a clear 12 would be great.


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LET THE WILD RUMPUS BEGIN !!!!!!
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#37 SerendepitySaki

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Posted 07 March 2010 - 03:21 AM

while y'all are waiting for the "real update" , I thought I'd throw in the towel on this one....the shivering, that is.....

no question about myocardial oxygen consumption...remember, that's one of the things i promised we'd talk about....we'll go into that more later....

obviously, no question about the renal part either...

as for using one over the other preferentially for shivering that's something new for me...not having any luck finding a ref or even extrapolating a guess out from the each one's chemical structure or how benzos act on the CNS...I'll keep digging......wes, if you've got anything i'd love to see it.... in the unit, if we want to add something extra on top of sedation (ativan or versed) for shivering, it's usually demerol....

I'm more of a versed kind of guy, [unless you're talking liver whack, in which case... ativan is kinder, gentler due to how it's metabolized] I like versed primarily because it's quicker on/quicker off IV and IM, (don't know anything about intranasally) works better on seizures, is kinder/gentler on the veins and possibly, hypotension (water based vs PEG/PPG) can't find a definitive ref for that last (increased hypotension)....

here's a nice backgrounder on prehospital IM versed vs IV ativan (http://www.nett.umic...mary_format.pdf ) you can look up Rapid Anticonvulsant Medications Prior to Arrival Trial (RAMPART) trial for more info..


Sedation- I prefer ativan over versed for simple anxiolytic. I've noticed that it attenuates shivering better than versed (especially as part of hypothermia protocol. But we often end up paralyzing these folks too). The important thing here is this guy has inadequate cardiac output. What does shivering due? Increases O2 demand. The fact that I get a better look at his ecg is a bonus. I'm not putting him on an ativan drip, so I'm not to worry about renal clearance of only 2mg. I'm open to suggestions from of our pharmacology gurus around here (Sean!).



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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#38 TexRNmedic

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Posted 07 March 2010 - 07:06 AM

while y'all are waiting for the "real update" , I thought I'd throw in the towel on this one....the shivering, that is.....

no question about myocardial oxygen consumption...remember, that's one of the things i promised we'd talk about....we'll go into that more later....

obviously, no question about the renal part either...

as for using one over the other preferentially for shivering that's something new for me...not having any luck finding a ref or even extrapolating a guess out from the each one's chemical structure or how benzos act on the CNS...I'll keep digging......wes, if you've got anything i'd love to see it.... in the unit, if we want to add something extra on top of sedation (ativan or versed) for shivering, it's usually demerol....

I'm more of a versed kind of guy, [unless you're talking liver whack, in which case... ativan is kinder, gentler due to how it's metabolized] I like versed primarily because it's quicker on/quicker off IV and IM, (don't know anything about intranasally) works better on seizures, is kinder/gentler on the veins and possibly, hypotension (water based vs PEG/PPG) can't find a definitive ref for that last (increased hypotension)....

here's a nice backgrounder on prehospital IM versed vs IV ativan (http://www.nett.umic...mary_format.pdf ) you can look up Rapid Anticonvulsant Medications Prior to Arrival Trial (RAMPART) trial for more info..


Sean, I just got in from a 16 hour day in the ED and an hour on the road, so bear with me. Benzos- think of skeletal muscle relaxation. Increased inhibitory fuction of the GABAa receptor. Muscle relaxation plus afferent neuronal inhibition. Diazepam typically has the best effect. Versed has been getting lots of recognition lately with a bit of research out there. A lot of the reasons you don't like lorazepam are the reasons I like them for this guy. Mostly personal preference and familiarity in this kind of situation. I want the anxiolytic effect to stick around a bit and I'm hoping it might nudge his BP down, even only transiently. I want this guy to be calm but still be "with it" enough to maintain his airway and participate in his care. The doses required to slow his shivering might be a little too sedating with versed. Shoot, probably ativan too. I actually like ativan in seizures. With the electrolyte issues this guy is having, hyponatremic seizures may be in his future as well as more benzos. I'm willing to give Versed a fair shake.
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Wes Seale
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#39 SerendepitySaki

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Posted 07 March 2010 - 04:08 PM

oh no wes...please don't misunderstand me... it appears we agree 110% on EVERYTHING but shivering.... and unless I'm severely mistaken, the mechanisms /pathways by which benzos attenuate seizures don't impact thermoregulation.... I wasn't even disagreeing, I was just saying I didn't know how that would work.... bear in mind, my desk is covered w/ texts, I've spent a couple of hours on the internet, poring over journals, shouting out to my CRNA mentors, etc etc..... (they don't know either) I did find a paper that said versed had minimal effect on thermoregulation, but nothing that said ativan had any effect.

Kurz, A., Sessler, D.I., Annadata, R., et. al., Midazolam Minimally Impairs Thermoregulatory Control. Anesth. Analg. 81:1995, Pgs. 393-398.

you've made an excellent argument FOR ativan on the basis of this gentleman's presumptive substance abuse....
which was the point I was getting at once you brought it up..... if i'm going to use a benzo at all on this guy, i'd grab ATIVAN over versed, both because of how it's metabolized in the liver and that he probably stay "with it" longer with ativan vs versed....

(I'm greatful to you for introducing the teaching point... it was not one STP and I had originally planned on....it's something I teach in the unit in the context of "why grab ativan vs versed for DTs?" but I honestly never thought of it in the context of the field...)

stand by for update....


Sean, I just got in from a 16 hour day in the ED and an hour on the road, so bear with me. Benzos- think of skeletal muscle relaxation. Increased inhibitory fuction of the GABAa receptor. Muscle relaxation plus afferent neuronal inhibition. Diazepam typically has the best effect. Versed has been getting lots of recognition lately with a bit of research out there. A lot of the reasons you don't like lorazepam are the reasons I like them for this guy. Mostly personal preference and familiarity in this kind of situation. I want the anxiolytic effect to stick around a bit and I'm hoping it might nudge his BP down, even only transiently. I want this guy to be calm but still be "with it" enough to maintain his airway and participate in his care. The doses required to slow his shivering might be a little too sedating with versed. Shoot, probably ativan too. I actually like ativan in seizures. With the electrolyte issues this guy is having, hyponatremic seizures may be in his future as well as more benzos. I'm willing to give Versed a fair shake.


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Sean G. Smith, RN-Alphabet Soup

#40 SerendepitySaki

SerendepitySaki

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Posted 07 March 2010 - 06:20 PM

so here we go guys.... (edited to change RR from 16 to 24)

#1: This is a REALLY busy, information dense post.... read and read again

#2: and please remember, this is a "suspend your disbelief" type scenario for teaching purposes.... yeah in real life, we'd get Os, IVs, monitors, and load and go w/ ongoing tx as dictated by time, etc....and you might not have anything but a BG.... we're trying to emphasize solid basic stuff that you may see again either on a cert exam or the exam of real life, hence the "20 questions" routine....

Clarification on injuries:
it was a tib/fib fx, approx 1 month ago and the cast was on the right leg.
spine was transverse processes(sp?) at L2-4

Fentanyl patches off.
NRB on.
LP12 (or machine o’ choice) on w/ leads and pads.
Temp: slightly cold ....95F /35 C
Foley in unless someone says no. 30mL slightly concentrated, dark yellow nonodorous urine out.

Vicodin – he takes 10/325 q 4-6 hrs. states he has taken 2 today per scrip for both chronic and post op pain. Denies current herbals, OTCs, or recreational. Aside from slight global weakness and predictive course of preexisting injury Appears Neuro Intact. Pupils: PERRLA GCS 15 MMSE: WNL somewhat less than excellent historian.

What was the significance of being told no JVD? Please discuss how this test should be done. In other words, almost everyone can display JVD under the “right” conditions. What increases your index of suspicion to pathology?

What was the significance of being told no pedal edema?

What was the significance of being told you had equal, bilateral BPs?

You have equal, somewhat erratic distal pulses (40-50bpm) X 4. Central pulses (brachial and fem x2) present. rate and regularity as per distal. What does this tell you with regards to hemodynamics?

Given that pt denies other OTCs and you don't have access to LFTs, etc, how would you rule in/out APAP OD on the basis of physical assessment/info given thus far?

Negative Trousseau’s. If you don’t know what this test is, please read on..... Trousseau's is a way of getting a feel for serum Ca++ levels in the field w/out labs... gotta have Ca++ for coordinated muscular contraction....use a bp cuff obliterate pulse downstream of brachial artery 2-3 minutes... spasming (sp?) is + for hypocalcemia http://www.turner-wh...r00_hypocal.pdf (ANOTHER hat tip to Wes for introducing a great teaching point!)

You may have both an EJ an IO. Some one please take point, verbalize contraindications for each and state where you are placing them.

EJ whizzes: if needed, what can we do to get the EJ to “pop out and say hello” in a profoundly dehydrated pt? (you guys have no trouble visualizing and cannulating in this guy, but what if?)

Please calculate Anion Gap and discuss Anion Gap and Base Excess and their relationship to what has been presented thus far.

If the magic lab fairy was going to bless you with one more #, what would you pick and why? Do you actually need this # or can you safely treat empirically?

Bonus Points: discuss the oxyhemoglobin dissociation curve in light of the current labs, etc. right or left shift?

Now that you have labs, what is the consensus on MIVF, medications and your rationale?

Run through the labs and hx to date....thoughts?

As for second set of vitals, : BP 110/60 palpable HR of 40 (monitor varies but tachycardic) RR 24 SPo2 97

iSTAT Labs: Coags slightly elevated but WNL Cardiac Enzymes slightly elevated but WNL

CHEM8+ 03M88-01
Sodium (Na) 138
Potassium (K)2.9
Chloride (Cl) 95
Ionized Calcium (iCa) 1.16 mmol/L
TCO2 21
Glucose (Glu) 170
Urea Nitrogen (BUN)/Urea slightly elevated but WNL
Creatinine (Crea) slightly elevated but WNL
Hematocrit (Hct) 45 (extra extra bonus points: is the "true" H&H [and BUN/Crea or other labs for that matter] higher or lower and why?)
Hemoglobin* (Hgb) 14.4

i-STAT CG4+ 07G02-01 (venous #s)
pH 7.57
PCO2 22
PO2 28
TCO2* 21
HCO3* 19
BEecf* -2.3
sO2* 70
Lactate 6.2

I think we got everything....it was my turn to update, so any screw-ups or inadvertent omissions are on me.... post or send send a pm and i will clarify/correct asap....
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup