Case Study -- What would you do?

[146233]

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You are dispatched to a nursing home for shortness of breath. Nursing staff states the 44 y.o. patient has been short of breath for an unknown period of time ("I just got on shift, I don't know.") and that her BP is 112/60. Hx of Hepatitis C, HIV, anoxic encephalopathy, and cardiopulmonary arrest. NKDA. Only HIV meds. Pt. is a full-code.

You walk into the room to find her responsive to pain, GCS 9, laying supine, cachectic, lower extremities contracted, obviously dyspneic. Airway intact, but full of thrushy/crusty junk. Breathing very fast and gasping, radial pulse rapid and very thready. Skin moist/warm. While you are placing her on O2 15Lpm via NRB, your partner assesses vital signs: P 132, R 60/gasping/retractions, BP 54/P. Further, the cardiac monitor shows a sinus tachycardia with no ectopy and her SpO2 is 84% with the supplemental oxygen.

No JVD, trachea midline, equal chest rise, major rhonchi in all lung fields. Abdomen soft/non-tender/nondistended x4 with no pulsating mass. Extremities all have thready pulses, are cool to the touch, and she is not moving any of them.

What do you do? 🙂

 

[jbar]

start bagging, start 2 large bore IVs NS wide open. Clear airway as best possible by wipping out with a 4x4. I'd probably nasally tube her after preping with neo-synephrine. Capnography to confirm tube, with continuous monitoring. If I had CPEP she may be a good canidate for that. Do a 12 a lead enroute, rapid transport. If 12 lead clear, in line neb albuterol, becuase of the rhonci. Trendelenberg position, keep reassesing lungs and neck for signs pulmonary effusion, if neg keep pushing fluid.

and mentally yell at nurse/family/doc for making this patient full code.

 

[146233]

start bagging, start 2 large bore IVs NS wide open. Clear airway as best possible by wipping out with a 4x4. I'd probably nasally tube her after preping with neo-synephrine. Capnography to confirm tube, with continuous monitoring. If I had CPEP she may be a good canidate for that. Do a 12 a lead enroute, rapid transport. If 12 lead clear, in line neb albuterol, becuase of the rhonci. Trendelenberg position, keep reassesing lungs and neck for signs pulmonary effusion, if neg keep pushing fluid.

and mentally yell at nurse/family/doc for making this patient full code.

I neglected to mention that her right lung was all full of fluid. My bad. I sedated her with 22mg etomidate and intubated her, without complication. I went to hang dopamine, but for some reason the EMS Coordinator that inventories our drug boxes didn't feel the need to include microdrip tubing. We transported her to the closest hospital with her SpO2 at 100%, but she was still in a bad way. They hung dopamine and gave her a slow bolus in the ED. Not a great prognosis, though. Very sad.

 

[gotmeds?]

You walk into the room to find her responsive to pain, GCS 9, laying supine, cachectic, lower extremities contracted, obviously dyspneic. Airway intact, but full of thrushy/crusty junk. Breathing very fast and gasping, radial pulse rapid and very thready. Skin moist/warm. While you are placing her on O2 15Lpm via NRB, your partner assesses vital signs: P 132, R 60/gasping/retractions, BP 54/P. Further, the cardiac monitor shows a sinus tachycardia with no ectopy and her SpO2 is 84% with the supplemental oxygen.

Now why exactly am I placing her on a non-rebreather?


Just giving you a hard time. It sounds like you ran a good call (you guys have RSI??)

 

[146233]

Haha, we're putting her on an NRB because my partner is a new guy who seemed to forget about bagging. 🙂 No RSI, just conscious sedation with bezocaine spray and etomidate (or versed). Worked like a charm. 👍

 

[MedicFL]

DO you all carry CPAP?

 

[146233]

DO you all carry CPAP?

How I wish we did. Could have saved this woman a tube. I'm one of many Chicago medics pushing for CPAP (and orders for an NTG drip for decompensating CHF), but bureaucracy is slow.

 

[fiznat]

CPAP for rhonchi? You said one lung was full of fluid, but even still I'm not sure that CPAP would be indicated. Our protocols specifically rule out CPAP for this patient on a number of factors:

-Patient does not have bilateral rales (a requirement for us)
-Patient is hypotensive (another contraindication as positive pressure ventilation decreases cardiac return)
-Patient is not alert (or only partially so)

Even still though, sounds like you managed the patient well. I had a VERY similar case recently (same history/presentation/vitals/everything) and would have loved to RSI her. Sadly we don't have it yet. We were stuck with just BVM + OPA. I would have nasally tubed but didn't have the time, and to be honest I've had awful experiences with the procedure in the past.

Tough call though.

 

[suimedica]

and mentally yell at nurse/family/doc for making this patient full code.

Meds:- For HIV, Lung:-with fluid, wonder howze the care: with dry crutty stuff to be wiped off with a 4X4.

great call.

 

[chimichanga]

wonder why, yet more lame a$$ nursing home staff:

1) has her supine, and not sitting up
2) why no one is in the room w/ her
3) why wasn't her mouth kept moist
4) why the lame a$$ staff didn't start an IV

I ran on too many of these calls...embarassing to the nursing profession

regarding the microdrip tubing, don't you check off your rig before your shift, or have they completely gotten rid of them at the base?

if so...keep some in your own "trick bag" (snag one from the hot ER nurses that you flirt with)

I kept several things that my company didn't stock... (ballard suction for one, as "they were too expensive")

 

[146233]

regarding the microdrip tubing, don't you check off your rig before your shift, or have they completely gotten rid of them at the base?

No, they carry them. And yes, I check my rig out before going in service. The microdrip tubing, which we only use for dopamine, is on the inventory sheet for our drug box -- which is sealed. We keep track of the narcotic vial numbers and ensure that the seal number doesn't change from day to day. Essentially, we're putting our licenses in the hands of the guy that checks the drug boxes once a month. ...and this month, he let me down.

if so...keep some in your own "trick bag" (snag one from the hot ER nurses that you flirt with)

You'd better believe I do now! The nurses are all so nice, too. 😍

 

[chimichanga]

sorry, I meant, don't you check your drug box every shift? seems not...

interesting policy...

We all checked our drug box every shift, or everytime someone else was going to use it...The oncoming guy checked it...

And tubing was kept in the box, as well as in the rig...

forget pushing for the CPAP now...get the policy changed so everyone checks his own drug box every shift change...

 

[146233]

sorry, I meant, don't you check your drug box every shift? seems not...

Yep, it's a stupid policy. I'll probably start ignoring it.

And tubing was kept in the box, as well as in the rig...

My service is cheap.

forget pushing for the CPAP now...get the policy changed so everyone checks his own drug box every shift change...

Seriously, right? The company policy is that everyone has to arrive 15 minutes prior to their scheduled start time to check out the rig. I'm going to meet some serious resistance trying to get the drug box added to the list of things to check out. People never seem to appreciate efforts to protect their licenses. *sigh*

 

[chimichanga]

I arrived at least 30 min early...same w/ my p...

we were at the convenience store at start of shift, w/ drugs, rig, and engine checked out...

our worst prob was a low main oxygen, or the ever-pouplar low fuel...

damn last shift...

good for you...we should all check our own drug box...

 

[pmdc222]

I'm kind of confused. Our narc box has a seal on it but it is see-through. But our overall drug box isn't sealed - how could this only be checked once a month and sealed? I use something from it basically every shift...that would mean resealing it all the time...

We use a drug and then replace it from the supply cabinet, everyone checks the box in the morning and the first crew of the month checks the expiration dates.

I can't really imagine relying on someone else to make sure I have that important drug when I need it

 

[jwk]

Haha, we're putting her on an NRB because my partner is a new guy who seemed to forget about bagging. 🙂 No RSI, just conscious sedation with bezocaine spray and etomidate (or versed). Worked like a charm. 👍

22mg Etomidate in this patient is not conscious sedation.

 

[146233]

22mg Etomidate in this patient is not conscious sedation.

In our SMO's, it's labeled "conscious sedation," but I think you're right; "drug assisted intubation" is better. 🙂 It was actually a 0.3mg/kg dose repeated x1 for a total of 22mg.