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#52.... Much More Than Meets The Eye...


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#41 TexRNmedic

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Posted 22 April 2010 - 03:39 AM

Oh and Happy Birthday Tex!! :lol:


Thanks a bunch. Worked last night. Nap most of the day and dinner with the fam. Now a little Shiner Bock (great Texas beer) and a little Letterman before bed. Y'all keep up the great work!
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Wes Seale
Houston , TX

#42 TexRNmedic

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Posted 22 April 2010 - 03:42 AM

Can I request the SS Minnow A.S.A.P since all the birds are grounded.


I hear the US Coast Guard will fly in this kind of weather. May be time to get swift water rescue SWR101 toned out!
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Wes Seale
Houston , TX

#43 medic675

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Posted 22 April 2010 - 03:54 AM

I cant tell you all about the labs and meds, but I got a GCS of 2-3-4.
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Brian Nolan
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#44 TexRNmedic

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Posted 22 April 2010 - 03:57 AM

Can I request the SS Minnow A.S.A.P since all the birds are grounded.

BTW the way, what is the biggest difference between you on a CCT versus the helicopter? No pilot and room for more tools. Believe it or not, you have just about every tool you will need to care for this patient.
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Wes Seale
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#45 jjones1418

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Posted 22 April 2010 - 04:22 AM

Etomidate's not really contraindicated. It's still the best induction agent we have. I was worried about adrenal suppression, and I'd toss her a dose of Solu-Cortef along with it. :) Thing is, in our situation, etomidate causing issues 24h post-admission is, to quote someone from these forums, like worrying about the train whistle hurting the child's ears when he's tied to the train tracks. I was just saying that if I had access to propofol, it might be nice.

Succinylcholine is a bad choice for this patient. Succinylcholine causes a shift of K+ to the extracellular fluid, causing an increase in serum K+ levels. Everything I've ever read says the K+ increase is about 0.5, and of course there are instances of more or less. As I suspected, she's hyperkalemic along with her hypocalcemia. Rocuronium is my drug of choice for her.

Also, my treatment has changed a little for her. If I've got a nice, long transport, I've got time to get some of these treatments going. Her kidneys are screwed, by the way. She's already on dialysis.

Beat down an old man and steal his vodka. Give it to her via OGT after we drop one in post intubation. (haha) Seriously, she's a train wreck. She'll do good to survive this. Gonna start with airway management once in the ambulance. You said she barely gagged with suctioning. Fentanyl at 3 mcg/kg may be enough to get her intubated. She needs a 2nd IV line as well. Probably do an IJ or subclavian if there's nothing else peripherally.

1) Fentanyl, Solu-Cortef, Etomidate, Rocuronium, Tube. Ativan/Fentanyl for post-intubation management.
2) Calcium Chloride and NaHCO3
3) Albuterol 5mg via inline nebulizer
4) Insulin

Start with that. Pretty sure we're not stocking pharm-grade ethanol on our CCT unit. Something tells me that Tex's unit might be short one bottle of those for this evening. (Happy Birthday)
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Jason Jones, EMT-P

#46 Flightgypsy

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Posted 22 April 2010 - 04:35 AM

We definitely don't want to give her LR as it can exacerbate the hyperammonemia and probably isn't the best choice with the metabolic processes going on with the ethylene glycol poisoning either. I will need to find some more info on that for you though.
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#47 TexRNmedic

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Posted 22 April 2010 - 04:36 AM

Succinylcholine is a bad choice for this patient. Succinylcholine causes a shift of K+ to the extracellular fluid, causing an increase in serum K+ levels.

Beat down an old man and steal his vodka. Give it to her via OGT after we drop one in post intubation. (haha).

1) Fentanyl, Solu-Cortef, Etomidate, Rocuronium, Tube. Ativan/Fentanyl for post-intubation management.
2) Calcium Chloride and NaHCO3
3) Albuterol 5mg via inline nebulizer
4) Insulin

Start with that. Pretty sure we're not stocking pharm-grade ethanol on our CCT unit.


Beautifully said. Glad you caught my gentle hint dropping. I was hoping it would turn on a light bulb for somebody. Why would you make a intoxicated person drunker with ETOH? Why the albuterol? And other than to drop the glucose level why the insulin? Good plan. Of course you know we aren't going to let y'all off that easy! Good night folks!
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Wes Seale
Houston , TX

#48 onearmwonder

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Posted 22 April 2010 - 04:43 AM

Well damnit I guess my night is shot! Gotta break out the bottle of ethynol(I'm a high end tequilla guy myself), and find some way to spike it. It's just not fair, this bottle was a gift from my ex mother inlaw. Yeah I'll stop...

Anyways if this is ethylene glycol OD then we have to block the ADH and maybe even get to dialysis. We can do it the expenseive way or the poor mans way. I vote the expensive way because I'm gonna need a drink after this one and they both block ADH. So lets get 2 IVs of LR going due to possible acidosis, so don't want to give too much chloride. Suction! RSI and intubate using 1mg/kg of ROC. .3mg/kg of Etomidate with post intubation management of versed and fentanyl depending on vitals and being careful with possible renal and liver failure with the last two drugs. Try to promote as much renal clearance with fluids as possible. If we have Fomepizole(competitive inhibitor of ADH) and are very sure she has ingested Enthylene Glycol then we will give a loading dose at 15mg/kg followed by 10mg/kg every 12 hours. After 48 hours fomepizole induces it's own metabolism, so the dose must be increased to 15mg/kg every 12 hours. Any PT with a reasonable hx. of methanol or ethylene glycol ingestion should be treated emperically until the definitive dx. is established. Definitive tx. is dialysis for significant ingestions. I'm not a vent expert by any means, but it seems the best mode will be SIMV with a pressure support of 10. Tidal volume based off of ideal body weight(45.5+2.3 x every inch above 5') at 6-8ml/kg. RR should be kept close to what she was breathing prior to RSI so she can compensate for acidosis on her own. We don't want to screw her up anymore than she already is. Backup RR is set at 16. Peep at 5-8. FIO2 at 1.0. I:E ratio at 1 to 3. My service does not have an I-STAT so we're going off judgment. And I'm sure someone can blast me on the vent settings.

So once we start shifting the Ph eventually towards an alkalotic state, then that should take care of the possible elevated potassium. No Succs due to an automatic shifting of potassium of .5mls/dL. Give albuterol if you don't have insulin to act as a key to allow the influx of potassium out of the vasculature and into the cells decreasing hyperkalemia somewhat. Like I said earlier I'm new so I'm sure there is much more to take care of than I have mentioned here. Should have put together the uremic frost with possible EG ingestion. Oh well... So what else is there? Oh and Goldfrank's Toxicology was my reference again.

Matt
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#49 onearmwonder

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Posted 22 April 2010 - 04:54 AM

Sorry didn't see jjones post before I wrote my novel. Just thought I'd give him backup...

Matt
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#50 Flightgypsy

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Posted 22 April 2010 - 04:56 AM

Looking a little more into it LR is the fluid of choice for ethylene glycol poisoning but contraindicated with liver problems. Since she is in kidney failure and has a good BP I would probably opt to have NS @ TKO and use some bicarb for the acidosis. We also don't want to overload her already stressed heart and put her in CHF on top of everything else. Just a thought here.
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#51 onearmwonder

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Posted 22 April 2010 - 05:22 AM

Looking a little more into it LR is the fluid of choice for ethylene glycol poisoning but contraindicated with liver problems. Since she is in kidney failure and has a good BP I would probably opt to have NS @ TKO and use some bicarb for the acidosis. We also don't want to overload her already stressed heart and put her in CHF on top of everything else. Just a thought here.


Good thinking about the work of the heart FG! But her mucosa is pale and we don't know if she is in total renal failure. Still needs fluids don't you think? What if we threw out the I-STAT? I'd like to know how we would treat this patient different in the field. I think it can be very dangerous to play with a patients Ph with bicarb. Just my thought. Probably not as comfortable as you are FG. Will probably learn something from you by the end anyways. Man she is a train wreck!

Matt
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#52 TexRNmedic

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Posted 22 April 2010 - 05:34 AM

Well damnit I guess my night is shot! Gotta break out the bottle of ethanol(I'm a high end tequila guy myself), and find some way to spike it. It's just not fair, this bottle was a gift from my ex mother inlaw. Yeah I'll stop...

Anyways if this is ethylene glycol OD then we have to block the ADH and maybe even get to dialysis. We can do it the expensive way or the poor mans way. I vote the expensive way because I'm gonna need a drink after this one. So lets get 2 IVs of LR going due to possible acidosis, so don't want to give too much chloride. Suction! RSI and intubate using 1mg/kg of ROC. .3mg/kg of Etomidate with post intubation management of versed and fentanyl depending on vitals and being careful with possible renal and liver failure with the last two drugs. Try to promote as much renal clearance with fluids as possible. If we have Fomepizole(competitive inhibitor of ADH) and are very sure she has ingested Enthylene Glycol then we will give a loading dose at 15mg/kg followed by 10mg/kg every 12 hours. After 48 hours fomepizole induces it's own metabolism, so the dose must be increased to 15mg/kg every 12 hours. Any PT with a reasonable hx. of methanol or ethylene glycol ingestion should be treated empirically until the definitive dx. is established. Definitive tx. is dialysis for significant ingestions. I'm not a vent expert by any means, but it seems the best mode will be SIMV with a pressure support of 10. Tidal volume based off of ideal body weight(45.5+2.3 x every inch above 5') at 6-8ml/kg. RR should be kept close to what she was breathing prior to RSI so she can compensate for acidosis on her own. We don't want to screw her up anymore than she already is. Backup RR is set at 16. Peep at 5-8. FIO2 at 1.0. I:E ratio at 1 to 3. My service does not have an I-STAT so we're going off judgment. And I'm sure someone can blast me on the vent settings.

So once we start shifting the Ph eventually towards an alkalotic state, then that should take care of the possible elevated potassium. Like I said earlier I'm new so I'm sure there is much more to take care of than I have mentioned here. Should have put together the uremic frost with possible EG ingestion. Oh well... So what else is there?

Matt


Dang email via smartphone. Working nights means it will be awhile before getting sleepy. Few things to bring up. I've asked enough questions and thrown enough at you today, I'll just do a quick run down. What is in LR? If I remember right H2O, NaCl, Ca, K and Lactate. If the kidneys and liver are working right we get an alkalizing effect (lactate metabolism in liver->bicarb->increased CO2). What happens if they are not working right? Increased acidosis!

ADH= Matt means alcohol dehydrogenase instead of the usual antidiuretic hormone. Somebody do me a favor and tell us a little about the 3 phases of EG tox. Especially the timeline. Timeline will make a huge difference on what is going on with the patient.

No Antizol on board the rig tonight.

Vent settings- We have some outstanding RRTs around here but I'll give it a nurse/EMT-P go at it. SIMV can allow for potential hypoventilation and inconsistent rate and volumes secondary to spontaneous respirations. It has its place for sure. We really need to have some pretty tight control on her minute volumes. AC-vol will give us much better control on her rate and volume. We already have the ETCO2 hooked up to this patient. Lets setup a rate and volume and adjust for a compensatory low CO2. Add PEEP as needed. Start at fio2 of 1. Watch your plateau pressure to keep an eye on whats going on in the alveoli. What do you guys think?

Anybody have any thoughts about empirically treating lytes and PH based off of presentation with out labs? Bet y'all are feeling a little like this right nowPosted Image
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Wes Seale
Houston , TX

#53 RoadieRN

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Posted 22 April 2010 - 05:46 AM

As far as the use of RSI, you are doing induction with adequate preoxygenation followed by adequate sedation prior to paralysis. A patient like this could possible do ok with DAI, especially with minimal to no gag. I've seen this work on COPD guy in the ED. He was DL'd by one of our residents and then we paralyzed immediately after confirmation of the tube. As far as the onset of Rocc, it takes 45-60 seconds with a duration of 30-45 minutes. I've seen it appear to last longer with a pt not appearing to overbreathe the vent. Insulin pushes the K back into the intracellular from the extracellular. Endpoint of Ca administration would be the EKG changes and absence of the the tetany noted. Perhaps, bolusing her with 1L of IVF would be a good start to see where we are with her BS. I hesitate giving her too much fluid. She already has BLE swelling, hinting at some CHF. Could be a part of the bisferiens pulse noted in the earlier assessment. Lasix may or may not work, depending on the function of her kidneys.

A thought about the use of Albuterol in hyper K. It takes 20mg/hr to make any dent in reducing the K. I'd stick to NaHCO3, D50, regular Insulin 10 units IV, and Kayexlate 30 mg OGT.
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Nick Crusius RN, BSN

Keep the rubber(or skid, if it applies) side down!

#54 RoadieRN

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Posted 22 April 2010 - 05:52 AM

I"d be very leery at treating what I think is hyper K without labs. Maybe the nurse in me, but numbers definitely help guide treatment. It would be difficult to defend that with your medical director, let alone in court.
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Nick Crusius RN, BSN

Keep the rubber(or skid, if it applies) side down!

#55 Flightgypsy

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Posted 22 April 2010 - 08:48 AM

Well now, I actually planned to treat after obtaining my I-Stat results (thanks to my well supplied CCT rig)!!!

But for arguments sake I would probably be more comfortable treating with Calcium based on her s/s and EKG (for both the hypocalcemia and the possible hyperkalemia) than I would be giving her fluids.
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#56 SerendepitySaki

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Posted 22 April 2010 - 11:15 AM

checking in before my exam... Tex is "meaner" than i am.....! told you it was an honor to copilot with him! between him and y'all, y'all pretty much got a lot covered....
one niggling key teaching point tho...
anyone else have thoughts on this?

We also don't want to overload her already stressed heart and put her in CHF on top of everything else. Just a thought here.


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

#57 Flightgypsy

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Posted 22 April 2010 - 02:31 PM

Worse CHF? ;)
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#58 jjones1418

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Posted 22 April 2010 - 02:58 PM

Beautifully said. Glad you caught my gentle hint dropping. I was hoping it would turn on a light bulb for somebody. Why would you make a intoxicated person drunker with ETOH? Why the albuterol? And other than to drop the glucose level why the insulin? Good plan. Of course you know we aren't going to let y'all off that easy! Good night folks!


The reason ethylene glycol is so nasty is because of the metabolites it forms. It binds to alcohol dehydrogenase and ends up creating an acid compound. Ethanol is given because of alcohol dehydrogenase's affinity for it. Ethanol competes with the ethylene glycol for ADH. The ADH enzyme breaks down the ethanol rather than the ethylene glycol, basically buying you time to get the unmetabolized ethylene gylcol out of the patient via dialysis.

The albuterol is for the Beta-2 selective stimulation. Increased Beta-2 stimulation promotes cellular reuptake of K+ via the Na/K+ pump. Nick's correct about the 20mg/hr per hour on the albuterol dose. Just use continuous in-line nebulized treatments.

Insulin works the same way, well, has the same targeted result. It causes an intracellular shift of K+ via the Na/K+ pump which is stimulated by the the insulin.

And I don't mind treating the hyperkalemia with the medications I chose without labs. I'm also comfortable in saying that she's probably hyperkalemic with that ECG. We don't have i-stat's on my ambulance, but a renal failure / dialysis patient that probably hasn't been dialyzed recently & that ECG is good enough for me.

The patient has several signs and symptoms associated with hypocalcemia, for which Ca++ would be beneficial. Ethylene glycol poisoning creates a nasty metabolic acidosis, which her body is already trying to compensate for with the RR of 28 and EtCO2 of 48 mmHg. That being my reasoning for the NaHCO3. The insulin not only helps with the hyperkalemia, but her blood glucose is through the roof. Albuterol would be the only one I'd possibly hold off on. She's got some weird cardiac pathophysiology going on, and tachycardia may not be her friend.

In regards to vent settings, I'd be very comfortable with SIMV in this patient. Sadly, I've given her Rocuronium to intubate... The intubation was more to protect her airway than it was to control her respirations. If I could have done it with just the Fentanyl or an induction agent that didn't require a paralytic, that would probably be more appropriate. The body tries to take care of itself, and leaving her breathing may not be a bad idea. Killing her minute volume with a paralytic and shitty vent management, however, is a bad idea.
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Jason Jones, EMT-P

#59 SerendepitySaki

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Posted 22 April 2010 - 03:22 PM

rvw HOCM w/ PB... off to my exam~!


Worse CHF? ;)


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

#60 TexRNmedic

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Posted 22 April 2010 - 03:38 PM

rvw HOCM w/ PB... off to my exam~!


We are getting there Sean. Good luck on your test. I'm only going to throw 6 things at a time at 'em.
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Wes Seale
Houston , TX