medic25 Posted May 15, 2014 Author Share Posted May 15, 2014 I'm concerned about the increasing blood pressure, would you give mannitol or lopressor? If you have capnography available, titrate the respiratory rate to co2 of 35-40 Does neurosurgery determine it's operable? Monitor to ensure she stays sedated and no seizure activity Which drugs did you use for the RSI? Etomidate/sux for RSI, with a dose of fentanyl post-ET. Had propofol primed and ready if the patient became agitated, but neurology asked us to withhold sedation unless it became necessary to monitor the patients neurologic exam; unfortunately due to the nature of the pathology sedation was not necessary. We did use continuous waveform capnography, but with an initial ETCO2 goal of 30. With the evidence of increasing ICP we aimed for some relative hypocarbia. Mannitol was given, along with a bullet of hypertonic saline, and the HOB was raised to 30 degrees. This resulted in the patient regaining corneal reflexes and cessation of posturing. BP control is definitely an issue in a case like this. Lopressor is one option, but we started a nicardipine drip. This is easier to titrate than boluses of a beta blocker, and we achieved the target SBP of 160. Neurosurgery elected to do a ventriculostomy at bedside; the initial ICP's were in the 30's but were soon down to the 10-15 range. She remained relatively stable, and was admitted to the Neuro ICU. Not much of a zebra case here, but it does illustrate one big point for new PA's coming into EM. This patient was originally billed as "alcohol intoxication". It can be very easy to blow off this kind of patient, especially in a busy ED. With the wrong kind of triage nurse, this type of patient might get parked in a corner and put at the back of the chart rack. Especially for the patient who is too obtunded to give you the history, be sure to keep a broad differential for AMS; not everyone is "just a drunk". Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted May 15, 2014 Moderator Share Posted May 15, 2014 great case. thanks for posting. I had a similar one a while ago who was also on eliquis. I think I talked to you about it re: k-centra, etc. Link to comment Share on other sites More sharing options...
delco714 Posted May 16, 2014 Share Posted May 16, 2014 If she were THAT intoxicated, wouldn't she reek of etoh? She didn't have any signs of TCA od. Afebrile, vss. Narcan with no effect. All that keeps a hard press to primary brain/cns patho. Great case, thanks for sharing. I enjoyed the back and forth! Steve PA-C, Maine, urologic surgery Link to comment Share on other sites More sharing options...
Nonlegit Posted May 16, 2014 Share Posted May 16, 2014 Not much of a zebra case here, but it does illustrate one big point for new PA's coming into EM. This patient was originally billed as "alcohol intoxication". It can be very easy to blow off this kind of patient, especially in a busy ED. With the wrong kind of triage nurse, this type of patient might get parked in a corner and put at the back of the chart rack. Especially for the patient who is too obtunded to give you the history, be sure to keep a broad differential for AMS; not everyone is "just a drunk". I'll chip in and agree. I work in an ED that sees a ton of young, drunk, college kids, and they all begin to look the same. We had a 20's young lady that was brought in "code ETOH", but her drunk friend kept insisting that the patient had not drank very much. Fortunately because of gestalt or whatever you want to call it, our staff did not delay care; she had a large bleed ostensibly caused by a stressful event an hour previous and arrested in the room not 5 minutes after she was brought in. We barely had begun our workup. She lived out of the ED. Even if they are drunk, intoxicated people are a great source for occult pathology. Link to comment Share on other sites More sharing options...
gbrothers98 Posted May 16, 2014 Share Posted May 16, 2014 I'll chip in and agree. I work in an ED that sees a ton of young, drunk, college kids, and they all begin to look the same. We had a 20's young lady that was brought in "code ETOH", but her drunk friend kept insisting that the patient had not drank very much. Fortunately because of gestalt or whatever you want to call it, our staff did not delay care; she had a large bleed ostensibly caused by a stressful event an hour previous and arrested in the room not 5 minutes after she was brought in. We barely had begun our workup. She lived out of the ED. Even if they are drunk, intoxicated people are a great source for occult pathology. My experience was a sad case of middle aged female brought in 'drunk' per neighbor by EMS. She was aphasic and hemiparetic to go along with her severe thrombotic stroke. Got TPA at the 3 hr mark per neuro recommendation, bled that night and expired next day. In any altered mental state case, first priority is ABC. Then check glucose. Anyone under 60 gets narcan. Between heroin, fentanyl patches, oxycodone, et al, opiate od is rampantly making a comeback. G Brothers PA-C Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted May 16, 2014 Moderator Share Posted May 16, 2014 My experience was a sad case of middle aged female brought in 'drunk' per neighbor by EMS. She was aphasic and hemiparetic to go along with her severe thrombotic stroke. Got TPA at the 3 hr mark per neuro recommendation, bled that night and expired next day. In any altered mental state case, first priority is ABC. Then check glucose. Anyone under 60 gets narcan. Between heroin, fentanyl patches, oxycodone, et al, opiate od is rampantly making a comeback. G Brothers PA-C Making a comeback? It's a full force gale storm at this point. Thankfully we at least have a tried-and-true drug to treat it Link to comment Share on other sites More sharing options...
Dunedain Posted May 17, 2014 Share Posted May 17, 2014 I've triaged before and seen many ETOH/drug abuse patients presenting with similar symptoms but with that GCS and posturing I would have thrown up hemorrhage on the DDX rather quickly. I am sure some triage nurses might have put her down as a 3-4 but to me the presentation wasn't routine enough to tossthem in the waiting room. Even though the answers have already been stated I would have gotten: Vitals BG ABGs (possibly paged neuro/pulm for a heads up), gotten tube set ready Narcan I-STAT, EKG, Ammonia, lactate blah blah STAT CT w/o contrast BAC Straight cath for tox BC x2 Not exactly all in this order, anything glaring I miss? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted May 17, 2014 Moderator Share Posted May 17, 2014 lactate/procalcitonin if you think they might be septic Link to comment Share on other sites More sharing options...
skyblu Posted May 31, 2014 Share Posted May 31, 2014 Great case! Thanks for sharing! I had a "drunk" the other day. Finger stick of 22. EMS didn't do one because she's somewhat known to us, but she's usually not this out of it. Familiarity breeds contempt. And poor medical decisions! Link to comment Share on other sites More sharing options...
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