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Case #51 "i Feel Cold"


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#41 TexRNmedic

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Posted 07 March 2010 - 06:37 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've seen benzos used for a while in shivering. Mostly associated with heat stroke cooling therapy and post-arrest hypothermia protocols-usually incombination with an opiate. I don't remember where I heard the exact mechanism. Doesn't directly address thermoregulation as much as blunt muscle movement by increasing the inhibitory effect of GABAa as well as the afferent messages from the peripheri to the hypothalamus. If I remember right, meds like dantrolene work more directly on thermoregulation.

AG- 24 mmol/L. Not so good. K and ICa are way off too. I'd like to the know albumin level and mag, but could easily start treating now. Calcium gluconate if I have it, or mix up a little Ca Cl drip as 2nd choice. Give 1 gram of mag over the 30 minutes. Second gram if improvement with first. Na is better than expected and I'll start this guy on a lidocaine gtt /c loading dose for the V arrythmia. I'll stick with my previous IVFs for about a liters worth. His temp is right on the threshold for shivering (35c) so a little active rewarming (turn the heater on-now I'll be sweating buckets) should get this guy to stop shivering. I'll try 0.5 mg of atropine, but I'd like to see what the electrolyte replacement does too. Looking at the VBG, RR is a little fast. Benzos will help him relax and slow down and hopfully PH correct. I'll let somebody else work on your list of 20 questions.
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Wes Seale
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#42 TexRNmedic

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Posted 07 March 2010 - 06:55 PM

By the way. The malaise,palor, sweating, anorexia, N/V sound alot like APAP OD. I think I can wait for an APAP level in the ER but something to think about. Anybody have 140mg/kg of mucomyst handy?
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Wes Seale
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#43 SerendepitySaki

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Posted 07 March 2010 - 06:59 PM

ding ding ding!!!!!! as always....you hit all the high points thoroughly and in style.... the majority of the 20 questions are for folks that honestly don't know or that feel like teaching.... i think you've got both bases covered! (you definitely know the answers to those questions and you've done more than your share of teaching in this scenario!!!! I wanna come ride w/ you!)

and guys, if you didn't catch it, the missing magic lab fairy lab that you can probably guess is low based on etOH hx and then presumptively tx is Mg....

love the active rewarming....totally down w/ the ativan and lytes.... do you guys agree on everything else...? no zebras or traps, just giving everyone a chance to chime in...

Would you like warm MIVFs w/ KCl? (throw em on the defrost vent if you don't have a fluid warmer)

AG- 24 mmol/L. Not so good. K and ICa are way off too. I'd like to the know albumin level and mag, but could easily start treating now. Calcium gluconate if I have it, or mix up a little Ca Cl drip as 2nd choice. Give 1 gram of mag over the 30 minutes. Second gram if improvement with first. Na is better than expected and I'll start this guy on a lidocaine gtt /c loading dose for the V arrythmia. I'll stick with my previous IVFs for about a liters worth. His temp is right on the threshold for shivering (35c) so a little active rewarming (turn the heater on-now I'll be sweating buckets) should get this guy to stop shivering. I'll try 0.5 mg of atropine, but I'd like to see what the electrolyte replacement does too. Looking at the VBG, RR is a little fast. Benzos will help him relax and slow down and hopfully PH correct. I'll let somebody else work on your list of 20 questions.


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Sean G. Smith, RN-Alphabet Soup

#44 SerendepitySaki

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Posted 07 March 2010 - 07:02 PM

ooooh .....GOOD CATCH!!!!! yes they do and that's an EXCELLENT differential that someone else beat you to.... buried in the 20 questions was one about how the info given to date relates to ruling that in or out.... not where we're going, but no, it can't be ruled out either .... and yes, you can certainly have mucomyst if you'd like.... other than smelling like hell, it's not going to hurt anything, even if the guy isn't an APAP OD....

By the way. The malaise,palor, sweating, anorexia, N/V sound alot like APAP OD. I think I can wait for an APAP level in the ER but something to think about. Anybody have 140mg/kg of mucomyst handy?


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Sean G. Smith, RN-Alphabet Soup

#45 SerendepitySaki

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Posted 07 March 2010 - 07:17 PM

short answer: dantrolene is a "weird" bird.... it acts on ryanodine receptors to control intracellular ionized calcium....
and yeah, I'm totally down with everything you're saying....it's absolutely correct in every way, including mechanism.... i just misunderstood your original post and went running down the wrong road....

Sean, I've seen benzos used for a while in shivering. Mostly associated with heat stroke cooling therapy and post-arrest hypothermia protocols-usually incombination with an opiate. I don't remember where I heard the exact mechanism. Doesn't directly address thermoregulation as much as blunt muscle movement by increasing the inhibitory effect of GABAa as well as the afferent messages from the peripheri to the hypothalamus. If I remember right, meds like dantrolene work more directly on thermoregulation.


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#46 SerendepitySaki

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Posted 07 March 2010 - 07:28 PM

AG- 24 mmol/L.


AG = Anion Gap.... everyone know where Wes got this? questions as to how it's used and its applicability here? (hate to be cheesy, but there's a good hint in the Wiki article on Anion Gap....)


AG = ( [Na+]+[K+] ) − ( [Cl]+[HCO3] ) here's the formula... day to day use, sometime we'll leave K+ out, which is where Wes got 24....
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#47 Ectopy

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Posted 07 March 2010 - 08:32 PM

Sean, I've seen benzos used for a while in shivering. Mostly associated with heat stroke cooling therapy and post-arrest hypothermia protocols-usually incombination with an opiate. I don't remember where I heard the exact mechanism. Doesn't directly address thermoregulation as much as blunt muscle movement by increasing the inhibitory effect of GABAa as well as the afferent messages from the peripheri to the hypothalamus. If I remember right, meds like dantrolene work more directly on thermoregulation.

AG- 24 mmol/L. Not so good. K and ICa are way off too. I'd like to the know albumin level and mag, but could easily start treating now. Calcium gluconate if I have it, or mix up a little Ca Cl drip as 2nd choice. Give 1 gram of mag over the 30 minutes. Second gram if improvement with first. Na is better than expected and I'll start this guy on a lidocaine gtt /c loading dose for the V arrythmia. I'll stick with my previous IVFs for about a liters worth. His temp is right on the threshold for shivering (35c) so a little active rewarming (turn the heater on-now I'll be sweating buckets) should get this guy to stop shivering. I'll try 0.5 mg of atropine, but I'd like to see what the electrolyte replacement does too. Looking at the VBG, RR is a little fast. Benzos will help him relax and slow down and hopfully PH correct. I'll let somebody else work on your list of 20 questions.


Wes,

Sorry to ask so many questions again, but just wanting to get a little better handle on things. If you get a minute, could you explain the Calc Gluconate vs. CaCl as first/second choice? Secondly, I'm a little fuzzy on the rationale behind the mag? What are the Na+ values that would have changed your lido choice to something else, and what would that be?

I'm currently neck deep in my thesis and trying to meet a deadline by tonight so I'll try to answer the 20 questions (and learn some of them!) once I bang this section out.

This has been SUCH a great case especially with all the experienced providers teaching the newer guys to crit care like myself.


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

#48 TexRNmedic

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Posted 07 March 2010 - 08:35 PM

ding ding ding!!!!!! as always....you hit all the high points thoroughly and in style.... the majority of the 20 questions are for folks that honestly don't know or that feel like teaching.... i think you've got both bases covered! (you definitely know the answers to those questions and you've done more than your share of teaching in this scenario!!!! I wanna come ride w/ you!)

and guys, if you didn't catch it, the missing magic lab fairy lab that you can probably guess is low based on etOH hx and then presumptively tx is Mg....

love the active rewarming....totally down w/ the ativan and lytes.... do you guys agree on everything else...? no zebras or traps, just giving everyone a chance to chime in...

Would you like warm MIVFs w/ KCl? (throw em on the defrost vent if you don't have a fluid warmer)


I'd love to make his first liter be NS+20 meq KCl but not really a prehospital IVF. Don't think I'd want it more than room temp. Mag + Ca plus active rewarming and this guy is going to vasodilate. I don't feel like dealing with rebound hypotension on top of everything else. Just need to nudge him up a couple degrees C. If this guy was in the unit I would want him on D5NS, an insulin gtt and just replace his K 50/50% oral and IVPB. Help bring his gap back down. I'd make a phone call and ask before treating APAP OD in this guy. A hot ambulance, mucomyst straight, a 50 YOM, who has been sweating like crazy and probably not showered in a week. Not a good combo. I'll be treating this guy chewing Big Red gum and an N95 mask on. By the way how far are we from the hospital now? Let me guess, flat tire and waiting on the ferry boat?

There has to be more than 5 people reading this case study. Come on out and play!
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Wes Seale
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#49 Gila

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Posted 07 March 2010 - 08:48 PM

A couple points to ponder:

In the absence of an ABG, the anion gap can be misleading. In addition, alterations in albumin (albumin being a major unmeasured anion) can skew the anion gap calculation. While it is a good tool to help validate our suspicions, we need to be aware of its pitfalls.

Ectopy:

Some people prefer calcium gluconate because the incidence of tissue necrosis is lower if extravasation were to occur. Another clinically relavent difference is calcium chloride has about three times the amount of ionized calcium per gram when compared to gluconate. However, I believe when equal-molar amounts are given, the amount of ionized calcium delivered to the plasma is pretty similar. At the end of the day, I have not found any smoking gun evidence that says one agent is decisively better than the other; however, my medical directors prefer that we use gluconate. Hope that helps.
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Christopher Bare
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#50 SerendepitySaki

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Posted 07 March 2010 - 09:04 PM

dude! you are the ULTIMATE straight man! it's o.k....... we've still got a wee bit more to play with.... (Take heed! Wes' sentence below important consideration!)


Don't think I'd want it more than room temp. Mag + Ca plus active rewarming and this guy is going to vasodilate. I don't feel like dealing with rebound hypotension on top of everything else. Just need to nudge him up a couple degrees C.



By the way how far are we from the hospital now? Let me guess, flat tire and waiting on the ferry boat?
Yep. and your spare's flat too... ;-) [ just kidding guys.... not really.... STP'll determine how far he wants to take you guys....we've worked out several routes and there are still a few good things to emphasize....i'm just tech support....]

There has to be more than 5 people reading this case study. Come on out and play!
Yep! No zebras! safe environment! just the basics!
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Sean G. Smith, RN-Alphabet Soup

#51 SerendepitySaki

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Posted 07 March 2010 - 09:06 PM

A couple points to ponder:....... the anion gap calculation. While it is a good tool to help validate our suspicions, we need to be aware of its pitfalls.


good call Chris. there's definitely something in the presentation that is skewing the relevance of the AG.... again, it's cheesy, but wiki did a good job on this one...
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#52 SerendepitySaki

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Posted 07 March 2010 - 09:13 PM

Matt... school first.... kick a*s on that thesis! here's a couple of nudges for you, when you get time.... what MAY be depleted in chronic etOHers, especially those who present with recent hx of dehydration and vomiting? How does Lido work?

and yeah, Wes rules...makes me want to drop out of grad school and move back west....

the rationale behind the mag? What are the Na+ values that would have changed your lido choice to something else, and what would that be?

I'm currently neck deep in my thesis and trying to meet a deadline by tonight so I'll try to answer the 20 questions (and learn some of them!) once I bang this section out. This has been SUCH a great case especially with all the experienced providers teaching the newer guys to crit care like myself.


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

#53 TexRNmedic

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Posted 07 March 2010 - 10:53 PM

Sorry to ask so many questions again, but just wanting to get a little better handle on things. If you get a minute, could you explain the Calc Gluconate vs. CaCl as first/second choice? Secondly, I'm a little fuzzy on the rationale behind the mag? What are the Na+ values that would have changed your lido choice to something else, and what would that be?

Matt-
Glu vs Cl- Biggest two reasons Glu preferred. 1. It is a lot easier on the veins. 2. CaCl can sometimes have some funky hemodynamic effects if given too quickly. The gluconate molecule is signficantly larger than elemental Cl. (Hence the reason you get 27mg/ml of Ca in CaCl vs 9mg/ml of CaGlu.

Mag- Electrolytes tend to trend in predictable ways in association to each other as the body attempts to maintain homeostasis. Sometime they move together and sometimes in an inverse relationship. As you start to see changes in some electrolytes you can hypothesis what others will do (especially if you have a hunch on what is going on with the patient). In this patient the same mechanism that has caused the low K, Ca (and even lowish Na)will nudge the Mag down. Example- Mag regulates potassium channels. Low mag and the cells loose K. Then the kidneys(if they work right) will get rid of the extra K. Low mag ends up with low K. Then we go back and look at the patient for signs of hypomagnesemia- weakness, muscle cramps, cardiac arrhythmia, hyperactive DTRs, hypertension.

Albumin- If I remember the numbers right about 60% of calcium and about 30% of mag is bound to plasma proteins. If this guy is malnurished, has hepatic dz, or some other metabolic issue using up proteins or inhibiting their manufacture, you'll have a decreased albumin level. Low albumin means low protein bound serum lytes. That is where ionized Ca comes in to play. Use it to correlate low serum and low ionized Ca. Both low, need to give a little Ca. Kind of an over simplified view, but it will work.

Speaking of things bound to albumin-One more billable for our employer- 100mg thiamine IM. Not really going to help right now but will make a difference down the road.

Anion Gap is kind of like a balance scale for anions versus cations (- vs +). Can't be used in isolation but a good tool to predict metabolic acidosis. Since AG doesn't take into consideration things like lactic acid and albumin levels, it can be a little inaccurate. But if you know the lactate level (6.2- assuming mmol/l vs mg/dl) and can guess this guys albumin level is low you can have a good idea of whats going on.

Lido vs amiodarone- This one I'm going to leave to you to look up. How does lidocaine work in relationship with Na? If Na level is low and you give the standard dose of lido and block Na channels what might happen? How well will lido work? What are some of the nasty things that amio can do? What is the half-life of each med? How long do you think this guy will need anti-arrythmic therapy? Until his lytes are corrected or for the rest of his life? Rhetorical questions. I don't need an answer here.

This guy has issues that can't be fixed on the way to the hospital. He is going to need a couple of days in the MICU to SLOWLY even out the PH and electrolyte problems as well as figure out what caused it. We just need to get things rolling, address hemodynamic issues, prevent arrythmias and start getting him normothermic....and address anything else our hosts throw at us.

Sean, you are more than welcome to ride with me or I'll head east and ride with you. Let you teach me a few things I'm sure. I'm not flying yet, so you'll just have to deal with the smell of diesel fumes.
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Wes Seale
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#54 SerendepitySaki

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Posted 07 March 2010 - 11:59 PM

this is all essentially correct, but you guys are also overlooking a something big and basic.....honestly, not some obscure stump the chump reindeer game.... right out there in the open....

Wes, i have absolutely no issues w/ groundpounding! ;-) you ever headed out research triangle way, you've got a crash pad.....
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Sean G. Smith, RN-Alphabet Soup

#55 STPEMTP

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Posted 08 March 2010 - 06:09 PM

One thing left out of update (my fault here).

closest facilities: (normal road conditions)
hospital with cardiac cath capabilities: 20 mins
Level 1 trauma center: 30mins
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#56 GravyMedic

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Posted 08 March 2010 - 06:52 PM

One thing left out of update (my fault here).

closest facilities: (normal road conditions)
hospital with cardiac cath capabilities: 20 mins
Level 1 trauma center: 30mins


Thanks for stepping up and keeping the case scenarios going. You guys have big shoes to fill and you're doing a great job.

Leading my differential dx is cold sepsis. Given his surgeries, met. acidosis, temp and lactate levels, he seems septic. Fluid resucitation is a must for him. Septic or not, he's clamped down severely, urine output of 30cc and concentrated, if i remember correctly. I will start with a litre bolus and give a second if needed. Also, electrolyte replacement has to happen. His EKG looks horrible. They were a little hard to make out, but one of them looked like he was having a run of Torsades. Im not too concerned about the potential for vasodilation and subsequent drop in BP r/t replacement, b/c he has a life threatening problem that has to be addressed now. I'd give 40K and 1g mag to start. If BP drops, then I'd give then 1g Ca++. Lets get him warm somehow. Someone is going to go and throw a few blankets in the dryer while we're getting him ready to go. Fluid warmers if we have them. Im not opposed to the benzo's for shivering, but I dont really want to slow his RR down, its compensatory and helping us right now. Drop an NGT. If his BP does drop to a mean <70, I'd hang some Levo. If arrythmias continue, I'd give a 2nd gram of Mag. FSBS a little high, receiving can deal with that. Thats it for now.
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#57 Smoorhe

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Posted 08 March 2010 - 11:13 PM

Thiamine?
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#58 ST RN/PM

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Posted 09 March 2010 - 12:32 PM

Thiamine?

Thiamine.....Wernicke's encephalopathy..... ETOH abuse.....would explain Hepatic insufficiency, nutritional deficiencies and subsequent electrolyte abnormalities. Definitely Cold sepsis lookin......Lactate of 6 shows anaerobic metabolism and inadequate tissue perfusion, as does the urine.
Sean, the wild rumpus has definitely begun! Great case study!!!!!! Waitin to see..... Steve
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Steve T. RN, PM

#59 SerendepitySaki

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Posted 09 March 2010 - 04:39 PM

It's all on Jim man....he deserves all the credit...... I'm just the tech support.... but send me some of your ideas and we can bounce 'im back and forth for the NEXT one....

Sean, the wild rumpus has definitely begun! Great case study!!!!!! Waitin to see..... Steve


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Sean G. Smith, RN-Alphabet Soup

#60 SerendepitySaki

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Posted 09 March 2010 - 04:57 PM

Secondly, I'm a little fuzzy on the rationale behind the mag? Thanks, Matt


Matt, a quick, but in depth review of Torsades should answer your question. Feel free to repost if not....

also, why are this pt's lytes hosed? it's NOT quite the usual suspects, and it's not hard, but it's right out there and no one has addressed it thus far (NB: Wes e-mailed me, but he's givng you a chance to play...) my anion gap question directly relates....


and when you're thinking about stuff like electrolyte imbalances, don't forget to think Hydrogen ion (H+) and Bicarb (HCO3-)
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup