Guest guest Posted April 15, 2008 Report Share Posted April 15, 2008 It has been a while since I have posted a scenario, so here goes: This one is primarily for the medics and the medic students who are suffering the woes of pharmacology, although nurses and physicians are welcome to chime in, but please give the medics a chance to be heard before you jump in with the answers. Thankya vurry mush. At 1930 hours you are called to a small rural hospital where a 10 year old boy was taken after sustaining a mid-shaft fracture of the femur when kicked by a horse. The hospital opted to attempt external fixation of the femur before transport to a tertiary center, and the patient was given 30 mL of 2% lidocaine for a femoral block and another 10 mL injected subcutaneously for insertion of a tibial pin. The patient weighed 30 kg. Within a half-hour the patient began to have clonic-tonic seizures. epam 5 mg was given IV, without effect, and lorazepam 5 mg was then administered IV, also without controlling the seizures. The patient was then paralyzed with 60 mg of succinylcholine and intubated, and you are called to transport him to the tertiary center 40 miles away. The foregoing procedures happened approximately 30 minutes prior to your being called. On your arrival at the hospital you find the patient unresponsive, intubated, with the following vital signs: BP 146/96, HR 122, respirations 12 by vent. He has one IV established in the right cephalic vein with an 18 gauge cath, NS running TKO. You insist upon a 12-lead EKG prior to accepting the patient, and one is done, revealing a sinus tachycardia at 120 without ectopy or significant ST/T wave changes. You accept your patient and begin transport. Shortly after you leave, his BP drops to 82/56. Please answer the following questions: 1. What are the possible causes of his seizure activity? 2. What are the probable causes of his abnormal vital signs? 3. What should you do for him enroute? 4. What, if any, problems do you see with his treatment prior to your arrival? If you desire more information, history, et cetera, please ask and you will receive. The prize for winning is (take your choice) shots and beer with Hillary Clinton, bowling with Barak Obama, or going flying with McCain. Gene Gandy ************** It's Tax Time! Get tips, forms and advice on AOL Money & amp; Finance. (http://money.aol.com/tax?NCID=aolcmp00300000002850) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 15, 2008 Report Share Posted April 15, 2008 It sounds like the subcutaneous lidocaine ended up getting administered intravenously, causing seizure activity. To prevent Lidocaine from being absorbed by the vascular system, many physicians administer Lidocaine with epinephrine, with the resulting vasoconstriction making it less likely that the Lidocaine will be absorbed into the vasculature. I'd get orders for a barbiturate instead of a benzodiazepine to stop the seizures. -Wes Ogilvie, MPA, JD, LP -Attorney/Licensed Paramedic -Austin, TX In a message dated 4/15/2008 10:57:56 P.M. Central Daylight Time, wegandy1938@... writes: It has been a while since I have posted a scenario, so here goes: This one is primarily for the medics and the medic students who are suffering the woes of pharmacology, although nurses and physicians are welcome to chime in, but please give the medics a chance to be heard before you jump in with the answers. Thankya vurry mush. At 1930 hours you are called to a small rural hospital where a 10 year old boy was taken after sustaining a mid-shaft fracture of the femur when kicked by a horse. The hospital opted to attempt external fixation of the femur before transport to a tertiary center, and the patient was given 30 mL of 2% lidocaine for a femoral block and another 10 mL injected subcutaneously for insertion of a tibial pin. The patient weighed 30 kg. Within a half-hour the patient began to have clonic-tonic seizures. epam 5 mg was given IV, without effect, and lorazepam 5 mg was then administered IV, also without controlling the seizures. The patient was then paralyzed with 60 mg of succinylcholine and intubated, and you are called to transport him to the tertiary center 40 miles away. The foregoing procedures happened approximately 30 minutes prior to your being called. On your arrival at the hospital you find the patient unresponsive, intubated, with the following vital signs: BP 146/96, HR 122, respirations 12 by vent. He has one IV established in the right cephalic vein with an 18 gauge cath, NS running TKO. You insist upon a 12-lead EKG prior to accepting the patient, and one is done, revealing a sinus tachycardia at 120 without ectopy or significant ST/T wave changes. You accept your patient and begin transport. Shortly after you leave, his BP drops to 82/56. Please answer the following questions: 1. What are the possible causes of his seizure activity? 2. What are the probable causes of his abnormal vital signs? 3. What should you do for him enroute? 4. What, if any, problems do you see with his treatment prior to your arrival? If you desire more information, history, et cetera, please ask and you will receive. The prize for winning is (take your choice) shots and beer with Hillary Clinton, bowling with Barak Obama, or going flying with McCain. Gene Gandy ************** It's Tax Time! Get tips, forms and advice on AOL Money & amp; Finance. (_http://money.http://moneyhttp://money.<WBhttp://mo_ (http://money.aol.com/tax?NCID=aolcmp00300000002850) ) [Non-text portions of this message have been removed] **************It's Tax Time! Get tips, forms and advice on AOL Money & Finance. (http://money.aol.com/tax?NCID=aolcmp00300000002850) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 16, 2008 Report Share Posted April 16, 2008 Gene, What happened to the all expense paid trip to beautiful Ladonia, Texas??? Shiplet, LP, AASP EMS Education Coordinator Collin County Community College <>< " Tomorrow's Pre-Hospital Health Care Team...Learning Together Today " Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 16, 2008 Report Share Posted April 16, 2008 I'd concur with Wes on this one... Did the hospital happen to draw a blood gas upon intubating the patient? What about a head CT to r/o any bleeds or masses? I recognize this is a pharmo review, but should always rule out other things too. SX of lidocaine toxicity are seizures, apnea, unconsciousness, and CV collapse... Our patient has experienced them all, albiet two of them were as a result of RSI. I'd recommend aggressively treating this kids CV collapse. Start with fluids... PALS fluid challenges are 20ml/kg. Infuse 600 ml of NS and reevaluate the pressure. If that doesn't work, start with some Dopamine 5 mcg/kg/min and titrate up to maintain SBP of 100. That's 150 mcg/min of Dopamine. Mix up 400mg of Dopamine in a 500ml bag of NS or D5 and that gives you a concentration of 800mcg/ml... From there, using a 60gtt set you should infuse it in at around 10-12 gtts / min. Though if this is an interfacility transport -- Bum a pump and take it with you Go easy, I'm still green. Joe Percer, LP It sounds like the subcutaneous lidocaine ended up getting administered > intravenously, causing seizure activity. > > To prevent Lidocaine from being absorbed by the vascular system, many > physicians administer Lidocaine with epinephrine, with the resulting > vasoconstriction making it less likely that the Lidocaine will be absorbed > into the > vasculature. > > I'd get orders for a barbiturate instead of a benzodiazepine to stop the > seizures. > > -Wes Ogilvie, MPA, JD, LP > -Attorney/Licensed Paramedic > -Austin, TX > > > In a message dated 4/15/2008 10:57:56 P.M. Central Daylight Time, > wegandy1938@... <wegandy1938%40aol.com> writes: > > It has been a while since I have posted a scenario, so here goes: This one > > is primarily for the medics and the medic students who are suffering the > woes > of pharmacology, although nurses and physicians are welcome to chime in, > but > please give the medics a chance to be heard before you jump in with the > answers. Thankya vurry mush. > > At 1930 hours you are called to a small rural hospital where a 10 year old > > boy was taken after sustaining a mid-shaft fracture of the femur when > kicked > by > a horse. > > The hospital opted to attempt external fixation of the femur before > transport > to a tertiary center, and the patient was given 30 mL of 2% lidocaine for > a > femoral block and another 10 mL injected subcutaneously for insertion of a > > tibial pin. > > The patient weighed 30 kg. Within a half-hour the patient began to have > clonic-tonic seizures. epam 5 mg was given IV, without effect, and > lorazepam 5 mg was then administered IV, also without controlling the > seizures. > > The patient was then paralyzed with 60 mg of succinylcholine and > intubated, > and you are called to transport him to the tertiary center 40 miles away. > The > foregoing procedures happened approximately 30 minutes prior to your being > > called. > > On your arrival at the hospital you find the patient unresponsive, > intubated, > with the following vital signs: BP 146/96, HR 122, respirations 12 by > vent. > He has one IV established in the right cephalic vein with an 18 gauge > cath, > NS running TKO. > > You insist upon a 12-lead EKG prior to accepting the patient, and one is > done, revealing a sinus tachycardia at 120 without ectopy or significant > ST/T wave > changes. > > You accept your patient and begin transport. Shortly after you leave, his > BP drops to 82/56. > > Please answer the following questions: > > 1. What are the possible causes of his seizure activity? > 2. What are the probable causes of his abnormal vital signs? > 3. What should you do for him enroute? > 4. What, if any, problems do you see with his treatment prior to your > arrival? > > If you desire more information, history, et cetera, please ask and you > will > receive. > > The prize for winning is (take your choice) shots and beer with Hillary > Clinton, bowling with Barak Obama, or going flying with McCain. > > Gene Gandy > > ************** > It's Tax Time! Get tips, forms and advice on AOL Money & amp; > Finance. > (_http://money.http://moneyhttp://money.<WBhttp://mo_ > (http://money.aol.com/tax?NCID=aolcmp00300000002850) ) > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 16, 2008 Report Share Posted April 16, 2008 The Inn At Ladonia has been booked solid now for quite sometime. But they may be building a motel in Honey Grove soon. GG > > Gene, > > What happened to the all expense paid trip to beautiful Ladonia, Texas??? > > Shiplet, LP, AASP > EMS Education Coordinator > Collin County Community College > <>< > > " Tomorrow's Pre-Hospital Health Care Team...Learning Together Today " > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 16, 2008 Report Share Posted April 16, 2008 A bolus of 250 ml of NS brought the blood pressure back to normal limits. Now, here's another hint. Does anybody have a question about the amount of sux given? GG > > I'd concur with Wes on this one... Did the hospital happen to draw a blood > gas upon intubating the patient? What about a head CT to r/o any bleeds or > masses? I recognize this is a pharmo review, but should always rule out > other things too. > > SX of lidocaine toxicity are seizures, apnea, unconsciousness, and CV > collapse... Our patient has experienced them all, albiet two of them were as > a result of RSI. I'd recommend aggressively treating this kids CV collapse. > Start with fluids... PALS fluid challenges are 20ml/kg. Infuse 600 ml of NS > and reevaluate the pressure. If that doesn't work, start with some Dopamine > 5 mcg/kg/min and titrate up to maintain SBP of 100. That's 150 mcg/min of > Dopamine. Mix up 400mg of Dopamine in a 500ml bag of NS or D5 and that gives > you a concentration of 800mcg/ml... From there, using a 60gtt set you should > infuse it in at around 10-12 gtts / min. Though if this is an interfacility > transport -- Bum a pump and take it with you > > Go easy, I'm still green. > > Joe Percer, LP > > It sounds like the subcutaneous lidocaine ended up getting administered > > intravenously, causing seizure activity. > > > > To prevent Lidocaine from being absorbed by the vascular system, many > > physicians administer Lidocaine with epinephrine, with the resulting > > vasoconstriction making it less likely that the Lidocaine will be absorbed > > into the > > vasculature. > > > > I'd get orders for a barbiturate instead of a benzodiazepine to stop the > > seizures. > > > > -Wes Ogilvie, MPA, JD, LP > > -Attorney/Licensed Paramedic > > -Austin, TX > > > > > > In a message dated 4/15/2008 10:57:56 P.M. Central Daylight Time, > > wegandy1938@wegandy <wegandy1938%wegandy19> writes: > > > > It has been a while since I have posted a scenario, so here goes: This one > > > > is primarily for the medics and the medic students who are suffering the > > woes > > of pharmacology, although nurses and physicians are welcome to chime in, > > but > > please give the medics a chance to be heard before you jump in with the > > answers. Thankya vurry mush. > > > > At 1930 hours you are called to a small rural hospital where a 10 year old > > > > boy was taken after sustaining a mid-shaft fracture of the femur when > > kicked > > by > > a horse. > > > > The hospital opted to attempt external fixation of the femur before > > transport > > to a tertiary center, and the patient was given 30 mL of 2% lidocaine for > > a > > femoral block and another 10 mL injected subcutaneously for insertion of a > > > > tibial pin. > > > > The patient weighed 30 kg. Within a half-hour the patient began to have > > clonic-tonic seizures. epam 5 mg was given IV, without effect, and > > lorazepam 5 mg was then administered IV, also without controlling the > > seizures. > > > > The patient was then paralyzed with 60 mg of succinylcholine and > > intubated, > > and you are called to transport him to the tertiary center 40 miles away. > > The > > foregoing procedures happened approximately 30 minutes prior to your being > > > > called. > > > > On your arrival at the hospital you find the patient unresponsive, > > intubated, > > with the following vital signs: BP 146/96, HR 122, respirations 12 by > > vent. > > He has one IV established in the right cephalic vein with an 18 gauge > > cath, > > NS running TKO. > > > > You insist upon a 12-lead EKG prior to accepting the patient, and one is > > done, revealing a sinus tachycardia at 120 without ectopy or significant > > ST/T wave > > changes. > > > > You accept your patient and begin transport. Shortly after you leave, his > > BP drops to 82/56. > > > > Please answer the following questions: > > > > 1. What are the possible causes of his seizure activity? > > 2. What are the probable causes of his abnormal vital signs? > > 3. What should you do for him enroute? > > 4. What, if any, problems do you see with his treatment prior to your > > arrival? > > > > If you desire more information, history, et cetera, please ask and you > > will > > receive. > > > > The prize for winning is (take your choice) shots and beer with Hillary > > Clinton, bowling with Barak Obama, or going flying with McCain. > > > > Gene Gandy > > > > ************ * > > It's Tax Time! Get tips, forms and advice on AOL Money & amp; > > Finance. > > (_http://money.http://money.<wbhttp://mo<WBhttp://mo_ > > (http://money.http://moneyhttp://money.<wbhttp://mo) ) > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 17, 2008 Report Share Posted April 17, 2008 OK yes I am coming in late on this and from what I am reading all seem to be great responses Gene your question about the amount of sux...First I am not a huge fan on sux as a pedi treatment BUT to play along it is appropriate to double the dose for a pedi patient is it not???? am I tapping the right tease in your question there Terrell wegandy1938@... wrote: A bolus of 250 ml of NS brought the blood pressure back to normal limits. Now, here's another hint. Does anybody have a question about the amount of sux given? GG > > I'd concur with Wes on this one... Did the hospital happen to draw a blood > gas upon intubating the patient? What about a head CT to r/o any bleeds or > masses? I recognize this is a pharmo review, but should always rule out > other things too. > > SX of lidocaine toxicity are seizures, apnea, unconsciousness, and CV > collapse... Our patient has experienced them all, albiet two of them were as > a result of RSI. I'd recommend aggressively treating this kids CV collapse. > Start with fluids... PALS fluid challenges are 20ml/kg. Infuse 600 ml of NS > and reevaluate the pressure. If that doesn't work, start with some Dopamine > 5 mcg/kg/min and titrate up to maintain SBP of 100. That's 150 mcg/min of > Dopamine. Mix up 400mg of Dopamine in a 500ml bag of NS or D5 and that gives > you a concentration of 800mcg/ml... From there, using a 60gtt set you should > infuse it in at around 10-12 gtts / min. Though if this is an interfacility > transport -- Bum a pump and take it with you > > Go easy, I'm still green. > > Joe Percer, LP > > It sounds like the subcutaneous lidocaine ended up getting administered > > intravenously, causing seizure activity. > > > > To prevent Lidocaine from being absorbed by the vascular system, many > > physicians administer Lidocaine with epinephrine, with the resulting > > vasoconstriction making it less likely that the Lidocaine will be absorbed > > into the > > vasculature. > > > > I'd get orders for a barbiturate instead of a benzodiazepine to stop the > > seizures. > > > > -Wes Ogilvie, MPA, JD, LP > > -Attorney/Licensed Paramedic > > -Austin, TX > > > > > > In a message dated 4/15/2008 10:57:56 P.M. Central Daylight Time, > > wegandy1938@wegandy <wegandy1938%wegandy19> writes: > > > > It has been a while since I have posted a scenario, so here goes: This one > > > > is primarily for the medics and the medic students who are suffering the > > woes > > of pharmacology, although nurses and physicians are welcome to chime in, > > but > > please give the medics a chance to be heard before you jump in with the > > answers. Thankya vurry mush. > > > > At 1930 hours you are called to a small rural hospital where a 10 year old > > > > boy was taken after sustaining a mid-shaft fracture of the femur when > > kicked > > by > > a horse. > > > > The hospital opted to attempt external fixation of the femur before > > transport > > to a tertiary center, and the patient was given 30 mL of 2% lidocaine for > > a > > femoral block and another 10 mL injected subcutaneously for insertion of a > > > > tibial pin. > > > > The patient weighed 30 kg. Within a half-hour the patient began to have > > clonic-tonic seizures. epam 5 mg was given IV, without effect, and > > lorazepam 5 mg was then administered IV, also without controlling the > > seizures. > > > > The patient was then paralyzed with 60 mg of succinylcholine and > > intubated, > > and you are called to transport him to the tertiary center 40 miles away. > > The > > foregoing procedures happened approximately 30 minutes prior to your being > > > > called. > > > > On your arrival at the hospital you find the patient unresponsive, > > intubated, > > with the following vital signs: BP 146/96, HR 122, respirations 12 by > > vent. > > He has one IV established in the right cephalic vein with an 18 gauge > > cath, > > NS running TKO. > > > > You insist upon a 12-lead EKG prior to accepting the patient, and one is > > done, revealing a sinus tachycardia at 120 without ectopy or significant > > ST/T wave > > changes. > > > > You accept your patient and begin transport. Shortly after you leave, his > > BP drops to 82/56. > > > > Please answer the following questions: > > > > 1. What are the possible causes of his seizure activity? > > 2. What are the probable causes of his abnormal vital signs? > > 3. What should you do for him enroute? > > 4. What, if any, problems do you see with his treatment prior to your > > arrival? > > > > If you desire more information, history, et cetera, please ask and you > > will > > receive. > > > > The prize for winning is (take your choice) shots and beer with Hillary > > Clinton, bowling with Barak Obama, or going flying with McCain. > > > > Gene Gandy > > > > ************ * > > It's Tax Time! Get tips, forms and advice on AOL Money & amp; > > Finance. > > (_http://money.http://money.<wbhttp://mo<WBhttp://mo_ > > (http://money.http://moneyhttp://money.<wbhttp://mo) ) > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 19, 2008 Report Share Posted April 19, 2008 Tube placement is fine. Chest X-ray unknown. Sat and ETCO2 are fine. Skin is cool and somewhat pale but dry. The key to the scenario is in figuring out how much lidocaine he received. Here's one of the things you have to know to solve it; How does one figure a " percent " solution. For example, he received a total of 40 ml of a 2% lidocane solution. How much lidocaine did he receive? Is it within normal range for administration or too much? If too much, could that cause his problems? How much sux did he receive? For his weight is it too much, just right, or too little? And does he have enough benzos onboard to keep him " snowed " while he's paralyzed? What's the problem with paralyzing a patient but allowing him to remain conscious? (That's not necessarily what happened, but just asking). Over the years I have experienced several occasions where PHYSICIANS did not know that. GG > > How's his tube placement? If it somehow got misplaced, that would > cause his vs to drop or maybe he has a tension pneumo whether from the > ET tube or being thrown from a horse. Did they do a chest xray after > the intubation and what is his spo2 and etco2 if it is available. > Also what is his skin color, moisture, and temp? Or maybe he had a > reaction to the medications. Regardless, this is a good scenrio. > > -- > > > > > > OK yes I am coming in late on this and from what I am reading all > seem to be great responses Gene your question about the amount of > sux...First I am not a huge fan on sux as a pedi treatment BUT to play > along it is appropriate to double the dose for a pedi patient is it > not???? > > am I tapping the right tease in your question there > > > > Terrell > > > > wegandy1938@ wegandy19 > > A bolus of 250 ml of NS brought the blood pressure back to > normal limits. > > Now, here's another hint. Does anybody have a question about the > amount of > > sux given? > > > > GG > > > > > > > > > > I'd concur with Wes on this one... Did the hospital happen to draw > a blood > > > gas upon intubating the patient? What about a head CT to r/o any > bleeds or > > > masses? I recognize this is a pharmo review, but should always > rule out > > > other things too. > > > > > > SX of lidocaine toxicity are seizures, apnea, unconsciousness, and CV > > > collapse... Our patient has experienced them all, albiet two of > them were as > > > a result of RSI. I'd recommend aggressively treating this kids CV > collapse. > > > Start with fluids... PALS fluid challenges are 20ml/kg. Infuse 600 > ml of NS > > > and reevaluate the pressure. If that doesn't work, start with some > Dopamine > > > 5 mcg/kg/min and titrate up to maintain SBP of 100. That's 150 > mcg/min of > > > Dopamine. Mix up 400mg of Dopamine in a 500ml bag of NS or D5 and > that gives > > > you a concentration of 800mcg/ml... From there, using a 60gtt set > you should > > > infuse it in at around 10-12 gtts / min. Though if this is an > interfacility > > > transport -- Bum a pump and take it with you > > > > > > Go easy, I'm still green. > > > > > > Joe Percer, LP > > > > > > It sounds like the subcutaneous lidocaine ended up getting > administered > > > > intravenously, causing seizure activity. > > > > > > > > To prevent Lidocaine from being absorbed by the vascular system, > many > > > > physicians administer Lidocaine with epinephrine, with the resulting > > > > vasoconstriction making it less likely that the Lidocaine will > be absorbed > > > > into the > > > > vasculature. > > > > > > > > I'd get orders for a barbiturate instead of a benzodiazepine to > stop the > > > > seizures. > > > > > > > > -Wes Ogilvie, MPA, JD, LP > > > > -Attorney/Licensed Paramedic > > > > -Austin, TX > > > > > > > > > > > > In a message dated 4/15/2008 10:57:56 P.M. Central Daylight Time, > > > > wegandy1938@ wegandy<wegandy1938%wegandy19> writes: > > > > > > > > It has been a while since I have posted a scenario, so here > goes: This one > > > > > > > > is primarily for the medics and the medic students who are > suffering the > > > > woes > > > > of pharmacology, although nurses and physicians are welcome to > chime in, > > > > but > > > > please give the medics a chance to be heard before you jump in > with the > > > > answers. Thankya vurry mush. > > > > > > > > At 1930 hours you are called to a small rural hospital where a > 10 year old > > > > > > > > boy was taken after sustaining a mid-shaft fracture of the femur > when > > > > kicked > > > > by > > > > a horse. > > > > > > > > The hospital opted to attempt external fixation of the femur before > > > > transport > > > > to a tertiary center, and the patient was given 30 mL of 2% > lidocaine for > > > > a > > > > femoral block and another 10 mL injected subcutaneously for > insertion of a > > > > > > > > tibial pin. > > > > > > > > The patient weighed 30 kg. Within a half-hour the patient began > to have > > > > clonic-tonic seizures. epam 5 mg was given IV, without > effect, and > > > > lorazepam 5 mg was then administered IV, also without > controlling the > > > > seizures. > > > > > > > > The patient was then paralyzed with 60 mg of succinylcholine and > > > > intubated, > > > > and you are called to transport him to the tertiary center 40 > miles away. > > > > The > > > > foregoing procedures happened approximately 30 minutes prior to > your being > > > > > > > > called. > > > > > > > > On your arrival at the hospital you find the patient unresponsive, > > > > intubated, > > > > with the following vital signs: BP 146/96, HR 122, respirations > 12 by > > > > vent. > > > > He has one IV established in the right cephalic vein with an 18 > gauge > > > > cath, > > > > NS running TKO. > > > > > > > > You insist upon a 12-lead EKG prior to accepting the patient, > and one is > > > > done, revealing a sinus tachycardia at 120 without ectopy or > significant > > > > ST/T wave > > > > changes. > > > > > > > > You accept your patient and begin transport. Shortly after you > leave, his > > > > BP drops to 82/56. > > > > > > > > Please answer the following questions: > > > > > > > > 1. What are the possible causes of his seizure activity? > > > > 2. What are the probable causes of his abnormal vital signs? > > > > 3. What should you do for him enroute? > > > > 4. What, if any, problems do you see with his treatment prior to > your > > > > arrival? > > > > > > > > If you desire more information, history, et cetera, please ask > and you > > > > will > > > > receive. > > > > > > > > The prize for winning is (take your choice) shots and beer with > Hillary > > > > Clinton, bowling with Barak Obama, or going flying with McCain. > > > > > > > > Gene Gandy > > > > > > > > ************ * > > > > It's Tax Time! Get tips, forms and advice on AOL Money & amp; > > > > Finance. > > > > (_http://money.http://money.<wbhttp://mo<WBhttp://mo_ > > > > (http://money.http://money.<wbhttp://mo<wbhttp://mo) ) > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 19, 2008 Report Share Posted April 19, 2008 How's his tube placement? If it somehow got misplaced, that would cause his vs to drop or maybe he has a tension pneumo whether from the ET tube or being thrown from a horse. Did they do a chest xray after the intubation and what is his spo2 and etco2 if it is available. Also what is his skin color, moisture, and temp? Or maybe he had a reaction to the medications. Regardless, this is a good scenrio. -- > A bolus of 250 ml of NS brought the blood pressure back to normal limits. > Now, here's another hint. Does anybody have a question about the amount of > sux given? > > GG > > > > > > I'd concur with Wes on this one... Did the hospital happen to draw a blood > > gas upon intubating the patient? What about a head CT to r/o any bleeds or > > masses? I recognize this is a pharmo review, but should always rule out > > other things too. > > > > SX of lidocaine toxicity are seizures, apnea, unconsciousness, and CV > > collapse... Our patient has experienced them all, albiet two of them were as > > a result of RSI. I'd recommend aggressively treating this kids CV collapse. > > Start with fluids... PALS fluid challenges are 20ml/kg. Infuse 600 ml of NS > > and reevaluate the pressure. If that doesn't work, start with some Dopamine > > 5 mcg/kg/min and titrate up to maintain SBP of 100. That's 150 mcg/min of > > Dopamine. Mix up 400mg of Dopamine in a 500ml bag of NS or D5 and that gives > > you a concentration of 800mcg/ml... From there, using a 60gtt set you should > > infuse it in at around 10-12 gtts / min. Though if this is an interfacility > > transport -- Bum a pump and take it with you > > > > Go easy, I'm still green. > > > > Joe Percer, LP > > > > It sounds like the subcutaneous lidocaine ended up getting administered > > > intravenously, causing seizure activity. > > > > > > To prevent Lidocaine from being absorbed by the vascular system, many > > > physicians administer Lidocaine with epinephrine, with the resulting > > > vasoconstriction making it less likely that the Lidocaine will be absorbed > > > into the > > > vasculature. > > > > > > I'd get orders for a barbiturate instead of a benzodiazepine to stop the > > > seizures. > > > > > > -Wes Ogilvie, MPA, JD, LP > > > -Attorney/Licensed Paramedic > > > -Austin, TX > > > > > > > > > In a message dated 4/15/2008 10:57:56 P.M. Central Daylight Time, > > > wegandy1938@wegandy <wegandy1938%wegandy19> writes: > > > > > > It has been a while since I have posted a scenario, so here goes: This one > > > > > > is primarily for the medics and the medic students who are suffering the > > > woes > > > of pharmacology, although nurses and physicians are welcome to chime in, > > > but > > > please give the medics a chance to be heard before you jump in with the > > > answers. Thankya vurry mush. > > > > > > At 1930 hours you are called to a small rural hospital where a 10 year old > > > > > > boy was taken after sustaining a mid-shaft fracture of the femur when > > > kicked > > > by > > > a horse. > > > > > > The hospital opted to attempt external fixation of the femur before > > > transport > > > to a tertiary center, and the patient was given 30 mL of 2% lidocaine for > > > a > > > femoral block and another 10 mL injected subcutaneously for insertion of a > > > > > > tibial pin. > > > > > > The patient weighed 30 kg. Within a half-hour the patient began to have > > > clonic-tonic seizures. epam 5 mg was given IV, without effect, and > > > lorazepam 5 mg was then administered IV, also without controlling the > > > seizures. > > > > > > The patient was then paralyzed with 60 mg of succinylcholine and > > > intubated, > > > and you are called to transport him to the tertiary center 40 miles away. > > > The > > > foregoing procedures happened approximately 30 minutes prior to your being > > > > > > called. > > > > > > On your arrival at the hospital you find the patient unresponsive, > > > intubated, > > > with the following vital signs: BP 146/96, HR 122, respirations 12 by > > > vent. > > > He has one IV established in the right cephalic vein with an 18 gauge > > > cath, > > > NS running TKO. > > > > > > You insist upon a 12-lead EKG prior to accepting the patient, and one is > > > done, revealing a sinus tachycardia at 120 without ectopy or significant > > > ST/T wave > > > changes. > > > > > > You accept your patient and begin transport. Shortly after you leave, his > > > BP drops to 82/56. > > > > > > Please answer the following questions: > > > > > > 1. What are the possible causes of his seizure activity? > > > 2. What are the probable causes of his abnormal vital signs? > > > 3. What should you do for him enroute? > > > 4. What, if any, problems do you see with his treatment prior to your > > > arrival? > > > > > > If you desire more information, history, et cetera, please ask and you > > > will > > > receive. > > > > > > The prize for winning is (take your choice) shots and beer with Hillary > > > Clinton, bowling with Barak Obama, or going flying with McCain. > > > > > > Gene Gandy > > > > > > ************ * > > > It's Tax Time! Get tips, forms and advice on AOL Money & amp; > > > Finance. > > > (_http://money.http://money.<wbhttp://mo<WBhttp://mo_ > > > (http://money.http://moneyhttp://money.<wbhttp://mo) ) > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 19, 2008 Report Share Posted April 19, 2008 Okay percent solutions are based on 1 gram of medicine in fluid... In this case, 50 mL of a 2% solution would contain 1 gram total of Lidocaine (This part I know is right, because we carry 50 ml 2% vials in our drug box for mixing lido gtts)... So that's 20mg / mL which means if he's gotten a total of 40 mL of solution, then he's received a whopping 800mg total of Lidocaine... A quick google which doesn't suffice as I intend to go look it up in a moment in a book shows a typical femoral nerve block is initially dosed with 30-40 mL of a 1% solution... In essence, the patient received double the amount of lidocaine he would normally receive.... What I think happened was the nurse or doctor didn't grab the right vial of meds... I'm off to look this up - and also check the books on Ativan/Valium/Sux dosing. Joe Percer, LP > Tube placement is fine. Chest X-ray unknown. Sat and ETCO2 are fine. > Skin is cool and somewhat pale but dry. The key to the scenario is in > figuring > out how much lidocaine he received. > > Here's one of the things you have to know to solve it; How does one figure > > a " percent " solution. > > For example, he received a total of 40 ml of a 2% lidocane solution. How > much lidocaine did he receive? Is it within normal range for > administration or > too much? If too much, could that cause his problems? How much sux did he > receive? For his weight is it too much, just right, or too little? And > does he have enough benzos onboard to keep him " snowed " while he's > paralyzed? > What's the problem with paralyzing a patient but allowing him to remain > conscious? (That's not necessarily what happened, but just asking). Over > the > years I have experienced several occasions where PHYSICIANS did not know > that. > > GG > > In a message dated 4/19/08 11:20:22 AM, paramedic352a@...<paramedic352a%40yahoo.com>writes: > > > > > How's his tube placement? If it somehow got misplaced, that would > > cause his vs to drop or maybe he has a tension pneumo whether from the > > ET tube or being thrown from a horse. Did they do a chest xray after > > the intubation and what is his spo2 and etco2 if it is available. > > Also what is his skin color, moisture, and temp? Or maybe he had a > > reaction to the medications. Regardless, this is a good scenrio. > > > > -- > > > > > > > > > > OK yes I am coming in late on this and from what I am reading all > > seem to be great responses Gene your question about the amount of > > sux...First I am not a huge fan on sux as a pedi treatment BUT to play > > along it is appropriate to double the dose for a pedi patient is it > > not???? > > > am I tapping the right tease in your question there > > > > > > Terrell > > > > > > wegandy1938@ wegandy19 > > > > A bolus of 250 ml of NS brought the blood pressure back to > > normal limits. > > > Now, here's another hint. Does anybody have a question about the > > amount of > > > sux given? > > > > > > GG > > > > > > > > > > > > > > I'd concur with Wes on this one... Did the hospital happen to draw > > a blood > > > > gas upon intubating the patient? What about a head CT to r/o any > > bleeds or > > > > masses? I recognize this is a pharmo review, but should always > > rule out > > > > other things too. > > > > > > > > SX of lidocaine toxicity are seizures, apnea, unconsciousness, and > CV > > > > collapse... Our patient has experienced them all, albiet two of > > them were as > > > > a result of RSI. I'd recommend aggressively treating this kids CV > > collapse. > > > > Start with fluids... PALS fluid challenges are 20ml/kg. Infuse 600 > > ml of NS > > > > and reevaluate the pressure. If that doesn't work, start with some > > Dopamine > > > > 5 mcg/kg/min and titrate up to maintain SBP of 100. That's 150 > > mcg/min of > > > > Dopamine. Mix up 400mg of Dopamine in a 500ml bag of NS or D5 and > > that gives > > > > you a concentration of 800mcg/ml... From there, using a 60gtt set > > you should > > > > infuse it in at around 10-12 gtts / min. Though if this is an > > interfacility > > > > transport -- Bum a pump and take it with you > > > > > > > > Go easy, I'm still green. > > > > > > > > Joe Percer, LP > > > > > > > > It sounds like the subcutaneous lidocaine ended up getting > > administered > > > > > intravenously, causing seizure activity. > > > > > > > > > > To prevent Lidocaine from being absorbed by the vascular system, > > many > > > > > physicians administer Lidocaine with epinephrine, with the > resulting > > > > > vasoconstriction making it less likely that the Lidocaine will > > be absorbed > > > > > into the > > > > > vasculature. > > > > > > > > > > I'd get orders for a barbiturate instead of a benzodiazepine to > > stop the > > > > > seizures. > > > > > > > > > > -Wes Ogilvie, MPA, JD, LP > > > > > -Attorney/Licensed Paramedic > > > > > -Austin, TX > > > > > > > > > > > > > > > In a message dated 4/15/2008 10:57:56 P.M. Central Daylight Time, > > > > > wegandy1938@ wegandy<wegandy1938%wegandy19> writes: > > > > > > > > > > It has been a while since I have posted a scenario, so here > > goes: This one > > > > > > > > > > is primarily for the medics and the medic students who are > > suffering the > > > > > woes > > > > > of pharmacology, although nurses and physicians are welcome to > > chime in, > > > > > but > > > > > please give the medics a chance to be heard before you jump in > > with the > > > > > answers. Thankya vurry mush. > > > > > > > > > > At 1930 hours you are called to a small rural hospital where a > > 10 year old > > > > > > > > > > boy was taken after sustaining a mid-shaft fracture of the femur > > when > > > > > kicked > > > > > by > > > > > a horse. > > > > > > > > > > The hospital opted to attempt external fixation of the femur > before > > > > > transport > > > > > to a tertiary center, and the patient was given 30 mL of 2% > > lidocaine for > > > > > a > > > > > femoral block and another 10 mL injected subcutaneously for > > insertion of a > > > > > > > > > > tibial pin. > > > > > > > > > > The patient weighed 30 kg. Within a half-hour the patient began > > to have > > > > > clonic-tonic seizures. epam 5 mg was given IV, without > > effect, and > > > > > lorazepam 5 mg was then administered IV, also without > > controlling the > > > > > seizures. > > > > > > > > > > The patient was then paralyzed with 60 mg of succinylcholine and > > > > > intubated, > > > > > and you are called to transport him to the tertiary center 40 > > miles away. > > > > > The > > > > > foregoing procedures happened approximately 30 minutes prior to > > your being > > > > > > > > > > called. > > > > > > > > > > On your arrival at the hospital you find the patient unresponsive, > > > > > intubated, > > > > > with the following vital signs: BP 146/96, HR 122, respirations > > 12 by > > > > > vent. > > > > > He has one IV established in the right cephalic vein with an 18 > > gauge > > > > > cath, > > > > > NS running TKO. > > > > > > > > > > You insist upon a 12-lead EKG prior to accepting the patient, > > and one is > > > > > done, revealing a sinus tachycardia at 120 without ectopy or > > significant > > > > > ST/T wave > > > > > changes. > > > > > > > > > > You accept your patient and begin transport. Shortly after you > > leave, his > > > > > BP drops to 82/56. > > > > > > > > > > Please answer the following questions: > > > > > > > > > > 1. What are the possible causes of his seizure activity? > > > > > 2. What are the probable causes of his abnormal vital signs? > > > > > 3. What should you do for him enroute? > > > > > 4. What, if any, problems do you see with his treatment prior to > > your > > > > > arrival? > > > > > > > > > > If you desire more information, history, et cetera, please ask > > and you > > > > > will > > > > > receive. > > > > > > > > > > The prize for winning is (take your choice) shots and beer with > > Hillary > > > > > Clinton, bowling with Barak Obama, or going flying with > McCain. > > > > > > > > > > Gene Gandy > > > > > > > > > > ************ * > > > > > It's Tax Time! Get tips, forms and advice on AOL Money & amp; > > > > > Finance. > > > > > (_http://money.http://money.<wbhttp://mo<WBhttp://mo_ > > > > > (http://money.http://money.<wbhttp://mo<wbhttp://mo) ) > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 19, 2008 Report Share Posted April 19, 2008 Well... Looking up femoral blocks in & Hedges Clinical Procedures in Emergency Medicine 4th Edition shows their recommended dosage of 10-20 mL of the anesthetic of physicians choosing. The ER doc says the toxic dose for Lidocaine is around 4 mg/kg which would make this patient's toxic dose 120 mg... My protocols on pediatric Ativan for status epilepticus are 0.1 mg / kg of Ativan up to a max of 4mg / dose. epam is dosed at 0.3 mg/kg for a max of 10 mg. So it appears that the child was given a bit much of Ativan... Should be adequate for sedation... Sux dosing per our protocol is 1 mg / kg except in infants where it's 2 mg/kg... It has to do with the lean body mass versus fat content, and how the sux is metabolized, if I " m regurgitating what I've read properly... Infants have more fat, and therefore require more succinylcholine... What would I have done differently? Controlled pain with opiod agents, I've found that fentanyl seems to work great for orthopedic pain and I love using it when it's available to me. Perhaps the external fixation of the femur could've been done under moderate sedation, lord knows the kid doesn't need to see someone drilling pins into his leg anyway... Nice scenario, requires you to hit resources you might otherwise not consider... Joe Percer, LP > Okay percent solutions are based on 1 gram of medicine in fluid... In this > case, 50 mL of a 2% solution would contain 1 gram total of Lidocaine (This > part I know is right, because we carry 50 ml 2% vials in our drug box for > mixing lido gtts)... So that's 20mg / mL which means if he's gotten a total > of 40 mL of solution, then he's received a whopping 800mg total of > Lidocaine... A quick google which doesn't suffice as I intend to go look it > up in a moment in a book shows a typical femoral nerve block is initially > dosed with 30-40 mL of a 1% solution... In essence, the patient received > double the amount of lidocaine he would normally receive.... What I think > happened was the nurse or doctor didn't grab the right vial of meds... > > I'm off to look this up - and also check the books on Ativan/Valium/Sux > dosing. > > Joe Percer, LP > > > > > > Tube placement is fine. Chest X-ray unknown. Sat and ETCO2 are fine. > > Skin is cool and somewhat pale but dry. The key to the scenario is in > > figuring > > out how much lidocaine he received. > > > > Here's one of the things you have to know to solve it; How does one > > figure > > a " percent " solution. > > > > For example, he received a total of 40 ml of a 2% lidocane solution. How > > > > much lidocaine did he receive? Is it within normal range for > > administration or > > too much? If too much, could that cause his problems? How much sux did > > he > > receive? For his weight is it too much, just right, or too little? And > > does he have enough benzos onboard to keep him " snowed " while he's > > paralyzed? > > What's the problem with paralyzing a patient but allowing him to remain > > conscious? (That's not necessarily what happened, but just asking). Over > > the > > years I have experienced several occasions where PHYSICIANS did not know > > that. > > > > GG > > > > In a message dated 4/19/08 11:20:22 AM, paramedic352a@...<paramedic352a%40yahoo.com>writes: > > > > > > > > How's his tube placement? If it somehow got misplaced, that would > > > cause his vs to drop or maybe he has a tension pneumo whether from the > > > ET tube or being thrown from a horse. Did they do a chest xray after > > > the intubation and what is his spo2 and etco2 if it is available. > > > Also what is his skin color, moisture, and temp? Or maybe he had a > > > reaction to the medications. Regardless, this is a good scenrio. > > > > > > -- > > > > > > > > > > > > > > OK yes I am coming in late on this and from what I am reading all > > > seem to be great responses Gene your question about the amount of > > > sux...First I am not a huge fan on sux as a pedi treatment BUT to play > > > along it is appropriate to double the dose for a pedi patient is it > > > not???? > > > > am I tapping the right tease in your question there > > > > > > > > Terrell > > > > > > > > wegandy1938@ wegandy19 > > > > > > A bolus of 250 ml of NS brought the blood pressure back to > > > normal limits. > > > > Now, here's another hint. Does anybody have a question about the > > > amount of > > > > sux given? > > > > > > > > GG > > > > > > > > > > > > > > > > > > I'd concur with Wes on this one... Did the hospital happen to draw > > > a blood > > > > > gas upon intubating the patient? What about a head CT to r/o any > > > bleeds or > > > > > masses? I recognize this is a pharmo review, but should always > > > rule out > > > > > other things too. > > > > > > > > > > SX of lidocaine toxicity are seizures, apnea, unconsciousness, and > > CV > > > > > collapse... Our patient has experienced them all, albiet two of > > > them were as > > > > > a result of RSI. I'd recommend aggressively treating this kids CV > > > collapse. > > > > > Start with fluids... PALS fluid challenges are 20ml/kg. Infuse 600 > > > ml of NS > > > > > and reevaluate the pressure. If that doesn't work, start with some > > > Dopamine > > > > > 5 mcg/kg/min and titrate up to maintain SBP of 100. That's 150 > > > mcg/min of > > > > > Dopamine. Mix up 400mg of Dopamine in a 500ml bag of NS or D5 and > > > that gives > > > > > you a concentration of 800mcg/ml... From there, using a 60gtt set > > > you should > > > > > infuse it in at around 10-12 gtts / min. Though if this is an > > > interfacility > > > > > transport -- Bum a pump and take it with you > > > > > > > > > > Go easy, I'm still green. > > > > > > > > > > Joe Percer, LP > > > > > > > > > > It sounds like the subcutaneous lidocaine ended up getting > > > administered > > > > > > intravenously, causing seizure activity. > > > > > > > > > > > > To prevent Lidocaine from being absorbed by the vascular system, > > > many > > > > > > physicians administer Lidocaine with epinephrine, with the > > resulting > > > > > > vasoconstriction making it less likely that the Lidocaine will > > > be absorbed > > > > > > into the > > > > > > vasculature. > > > > > > > > > > > > I'd get orders for a barbiturate instead of a benzodiazepine to > > > stop the > > > > > > seizures. > > > > > > > > > > > > -Wes Ogilvie, MPA, JD, LP > > > > > > -Attorney/Licensed Paramedic > > > > > > -Austin, TX > > > > > > > > > > > > > > > > > > In a message dated 4/15/2008 10:57:56 P.M. Central Daylight > > Time, > > > > > > wegandy1938@ wegandy<wegandy1938%wegandy19> writes: > > > > > > > > > > > > It has been a while since I have posted a scenario, so here > > > goes: This one > > > > > > > > > > > > is primarily for the medics and the medic students who are > > > suffering the > > > > > > woes > > > > > > of pharmacology, although nurses and physicians are welcome to > > > chime in, > > > > > > but > > > > > > please give the medics a chance to be heard before you jump in > > > with the > > > > > > answers. Thankya vurry mush. > > > > > > > > > > > > At 1930 hours you are called to a small rural hospital where a > > > 10 year old > > > > > > > > > > > > boy was taken after sustaining a mid-shaft fracture of the femur > > > when > > > > > > kicked > > > > > > by > > > > > > a horse. > > > > > > > > > > > > The hospital opted to attempt external fixation of the femur > > before > > > > > > transport > > > > > > to a tertiary center, and the patient was given 30 mL of 2% > > > lidocaine for > > > > > > a > > > > > > femoral block and another 10 mL injected subcutaneously for > > > insertion of a > > > > > > > > > > > > tibial pin. > > > > > > > > > > > > The patient weighed 30 kg. Within a half-hour the patient began > > > to have > > > > > > clonic-tonic seizures. epam 5 mg was given IV, without > > > effect, and > > > > > > lorazepam 5 mg was then administered IV, also without > > > controlling the > > > > > > seizures. > > > > > > > > > > > > The patient was then paralyzed with 60 mg of succinylcholine and > > > > > > intubated, > > > > > > and you are called to transport him to the tertiary center 40 > > > miles away. > > > > > > The > > > > > > foregoing procedures happened approximately 30 minutes prior to > > > your being > > > > > > > > > > > > called. > > > > > > > > > > > > On your arrival at the hospital you find the patient > > unresponsive, > > > > > > intubated, > > > > > > with the following vital signs: BP 146/96, HR 122, respirations > > > 12 by > > > > > > vent. > > > > > > He has one IV established in the right cephalic vein with an 18 > > > gauge > > > > > > cath, > > > > > > NS running TKO. > > > > > > > > > > > > You insist upon a 12-lead EKG prior to accepting the patient, > > > and one is > > > > > > done, revealing a sinus tachycardia at 120 without ectopy or > > > significant > > > > > > ST/T wave > > > > > > changes. > > > > > > > > > > > > You accept your patient and begin transport. Shortly after you > > > leave, his > > > > > > BP drops to 82/56. > > > > > > > > > > > > Please answer the following questions: > > > > > > > > > > > > 1. What are the possible causes of his seizure activity? > > > > > > 2. What are the probable causes of his abnormal vital signs? > > > > > > 3. What should you do for him enroute? > > > > > > 4. What, if any, problems do you see with his treatment prior to > > > your > > > > > > arrival? > > > > > > > > > > > > If you desire more information, history, et cetera, please ask > > > and you > > > > > > will > > > > > > receive. > > > > > > > > > > > > The prize for winning is (take your choice) shots and beer with > > > Hillary > > > > > > Clinton, bowling with Barak Obama, or going flying with > > McCain. > > > > > > > > > > > > Gene Gandy > > > > > > > > > > > > ************ * > > > > > > It's Tax Time! Get tips, forms and advice on AOL Money & amp; > > > > > > Finance. > > > > > > (_http://money.http://money.<wbhttp://mo<WBhttp://mo_ > > > > > > (http://money.http://money.<wbhttp://mo<wbhttp://mo) ) > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 19, 2008 Report Share Posted April 19, 2008 Good going Joe. The classic description of a percent solution is this: % = # of Grams in 100 ml. Thus, a 10% solution is 10 Grams in 100 ml. A 2% solution is 2 grams in 100 ml. Knowing that, you can work the formula for # of ml to give for any amount of mgs of drug. There are many approaches to drug administration problems. It doesn't matter whether you use ratios or simple arithmetic. Find a method that you understand and works for you and stick to it. When I teach medics to do drug calcs, the first thing I tell them is, if you have a problem, ask ME. NEVER ask another medic or, especially a nurse. The reason is that they may be using a method different from the one I'm teaching, and they will just confuse you beyond redemption. Nurses are generally taught to use about 15 more calculations than necessary. I don't say that to blast nurses, who can't help the way they were taught, but nurse educators generally tend to make things way more difficult than they ought to be and seemingly have never heard of the KISS principle. Now, before you begin to harpoon me with curare tipped spears, let me say that my sister is a nurse, some of my best friends are nurses, and I bear them no animosity whatsoever. Nurses don't generally have to figure doses quickly and while dodging sniper fire (with NO apologies to Hillary) while doing a corkscrew approach. LOL. The way they are taught is quite correct; it's just that there are simplified ways that are better for field use. That's all. OK. I've got my flack jacket and helmet on..................INCOMING!!!! Oh crap. What have I done? I'm calling in air! I teach the " clock method " for all drips, and simple calcs for injections and IVPs. My students can figure a dopamine drip in their heads before most nurses can find the chart. That's not to demean nurses. Once they learn the clock method, they can do it just as well. But I have never seen a nurse educator (hospital) who knew about the clock method. Have you? If you ARE a nurse educator who teaches the stuff simply, I'll bow to you anytime. I'll even have lunch with you at the hospital cafeteria and I'll buy, provided you'll let me use your employee discount. I'll have the chicken and broccoli casserole. LOL. For those medics who like problems, here's another one from one of my drug calc exams: How many ml of a 4% solution must be added to 500 ml of IV solution to achieve a solution concentration of 4 mg/ml? How many gtt with a 60 gtt set (remember, lots of EMS folks don't have IV pumps yet) must be given for a 2 mg/min infusion? GG GG > > Okay percent solutions are based on 1 gram of medicine in fluid... In this > case, 50 mL of a 2% solution would contain 1 gram total of Lidocaine (This > part I know is right, because we carry 50 ml 2% vials in our drug box for > mixing lido gtts)... So that's 20mg / mL which means if he's gotten a total > of 40 mL of solution, then he's received a whopping 800mg total of > Lidocaine... A quick google which doesn't suffice as I intend to go look it > up in a moment in a book shows a typical femoral nerve block is initially > dosed with 30-40 mL of a 1% solution... In essence, the patient received > double the amount of lidocaine he would normally receive.... What I think > happened was the nurse or doctor didn't grab the right vial of meds... > > I'm off to look this up - and also check the books on Ativan/Valium/ I' > dosing. > > Joe Percer, LP > > On Sat, Apr 19, 2008 at 6:13 PM, <wegandy1938@wegandy> wrote: > > > Tube placement is fine. Chest X-ray unknown. Sat and ETCO2 are fine. > > Skin is cool and somewhat pale but dry. The key to the scenario is in > > figuring > > out how much lidocaine he received. > > > > Here's one of the things you have to know to solve it; How does one figure > > > > a " percent " solution. > > > > For example, he received a total of 40 ml of a 2% lidocane solution. How > > much lidocaine did he receive? Is it within normal range for > > administration or > > too much? If too much, could that cause his problems? How much sux did he > > receive? For his weight is it too much, just right, or too little? And > > does he have enough benzos onboard to keep him " snowed " while he's > > paralyzed? > > What's the problem with paralyzing a patient but allowing him to remain > > conscious? (That's not necessarily what happened, but just asking). Over > > the > > years I have experienced several occasions where PHYSICIANS did not know > > that. > > > > GG > > > > In a message dated 4/19/08 11:20:22 AM, paramedic352a@paramedic< > paramedic352a%paramedic35><wbr>wr > > > > > > > > How's his tube placement? If it somehow got misplaced, that would > > > cause his vs to drop or maybe he has a tension pneumo whether from the > > > ET tube or being thrown from a horse. Did they do a chest xray after > > > the intubation and what is his spo2 and etco2 if it is available. > > > Also what is his skin color, moisture, and temp? Or maybe he had a > > > reaction to the medications. Regardless, this is a good scenrio. > > > > > > -- > > > > > > > > > > > > > > OK yes I am coming in late on this and from what I am reading all > > > seem to be great responses Gene your question about the amount of > > > sux...First I am not a huge fan on sux as a pedi treatment BUT to play > > > along it is appropriate to double the dose for a pedi patient is it > > > not???? > > > > am I tapping the right tease in your question there > > > > > > > > Terrell > > > > > > > > wegandy1938@ wegandy19 > > > > > > A bolus of 250 ml of NS brought the blood pressure back to > > > normal limits. > > > > Now, here's another hint. Does anybody have a question about the > > > amount of > > > > sux given? > > > > > > > > GG > > > > > > > > > > > > > > > > > > I'd concur with Wes on this one... Did the hospital happen to draw > > > a blood > > > > > gas upon intubating the patient? What about a head CT to r/o any > > > bleeds or > > > > > masses? I recognize this is a pharmo review, but should always > > > rule out > > > > > other things too. > > > > > > > > > > SX of lidocaine toxicity are seizures, apnea, unconsciousness, and > > CV > > > > > collapse... Our patient has experienced them all, albiet two of > > > them were as > > > > > a result of RSI. I'd recommend aggressively treating this kids CV > > > collapse. > > > > > Start with fluids... PALS fluid challenges are 20ml/kg. Infuse 600 > > > ml of NS > > > > > and reevaluate the pressure. If that doesn't work, start with some > > > Dopamine > > > > > 5 mcg/kg/min and titrate up to maintain SBP of 100. That's 150 > > > mcg/min of > > > > > Dopamine. Mix up 400mg of Dopamine in a 500ml bag of NS or D5 and > > > that gives > > > > > you a concentration of 800mcg/ml... From there, using a 60gtt set > > > you should > > > > > infuse it in at around 10-12 gtts / min. Though if this is an > > > interfacility > > > > > transport -- Bum a pump and take it with you > > > > > > > > > > Go easy, I'm still green. > > > > > > > > > > Joe Percer, LP > > > > > > > > > > It sounds like the subcutaneous lidocaine ended up getting > > > administered > > > > > > intravenously, causing seizure activity. > > > > > > > > > > > > To prevent Lidocaine from being absorbed by the vascular system, > > > many > > > > > > physicians administer Lidocaine with epinephrine, with the > > resulting > > > > > > vasoconstriction making it less likely that the Lidocaine will > > > be absorbed > > > > > > into the > > > > > > vasculature. > > > > > > > > > > > > I'd get orders for a barbiturate instead of a benzodiazepine to > > > stop the > > > > > > seizures. > > > > > > > > > > > > -Wes Ogilvie, MPA, JD, LP > > > > > > -Attorney/Licensed Paramedic > > > > > > -Austin, TX > > > > > > > > > > > > > > > > > > In a message dated 4/15/2008 10:57:56 P.M. Central Daylight Time, > > > > > > wegandy1938@ wegandy<wegandy1938wegandy193> writes: > > > > > > > > > > > > It has been a while since I have posted a scenario, so here > > > goes: This one > > > > > > > > > > > > is primarily for the medics and the medic students who are > > > suffering the > > > > > > woes > > > > > > of pharmacology, although nurses and physicians are welcome to > > > chime in, > > > > > > but > > > > > > please give the medics a chance to be heard before you jump in > > > with the > > > > > > answers. Thankya vurry mush. > > > > > > > > > > > > At 1930 hours you are called to a small rural hospital where a > > > 10 year old > > > > > > > > > > > > boy was taken after sustaining a mid-shaft fracture of the femur > > > when > > > > > > kicked > > > > > > by > > > > > > a horse. > > > > > > > > > > > > The hospital opted to attempt external fixation of the femur > > before > > > > > > transport > > > > > > to a tertiary center, and the patient was given 30 mL of 2% > > > lidocaine for > > > > > > a > > > > > > femoral block and another 10 mL injected subcutaneously for > > > insertion of a > > > > > > > > > > > > tibial pin. > > > > > > > > > > > > The patient weighed 30 kg. Within a half-hour the patient began > > > to have > > > > > > clonic-tonic seizures. epam 5 mg was given IV, without > > > effect, and > > > > > > lorazepam 5 mg was then administered IV, also without > > > controlling the > > > > > > seizures. > > > > > > > > > > > > The patient was then paralyzed with 60 mg of succinylcholine and > > > > > > intubated, > > > > > > and you are called to transport him to the tertiary center 40 > > > miles away. > > > > > > The > > > > > > foregoing procedures happened approximately 30 minutes prior to > > > your being > > > > > > > > > > > > called. > > > > > > > > > > > > On your arrival at the hospital you find the patient unresponsive, > > > > > > intubated, > > > > > > with the following vital signs: BP 146/96, HR 122, respirations > > > 12 by > > > > > > vent. > > > > > > He has one IV established in the right cephalic vein with an 18 > > > gauge > > > > > > cath, > > > > > > NS running TKO. > > > > > > > > > > > > You insist upon a 12-lead EKG prior to accepting the patient, > > > and one is > > > > > > done, revealing a sinus tachycardia at 120 without ectopy or > > > significant > > > > > > ST/T wave > > > > > > changes. > > > > > > > > > > > > You accept your patient and begin transport. Shortly after you > > > leave, his > > > > > > BP drops to 82/56. > > > > > > > > > > > > Please answer the following questions: > > > > > > > > > > > > 1. What are the possible causes of his seizure activity? > > > > > > 2. What are the probable causes of his abnormal vital signs? > > > > > > 3. What should you do for him enroute? > > > > > > 4. What, if any, problems do you see with his treatment prior to > > > your > > > > > > arrival? > > > > > > > > > > > > If you desire more information, history, et cetera, please ask > > > and you > > > > > > will > > > > > > receive. > > > > > > > > > > > > The prize for winning is (take your choice) shots and beer with > > > Hillary > > > > > > Clinton, bowling with Barak Obama, or going flying with > > McCain. > > > > > > > > > > > > Gene Gandy > > > > > > > > > > > > ************ * > > > > > > It's Tax Time! Get tips, forms and advice on AOL Money & amp; > > > > > > Finance. > > > > > > (_http://money.http://money.<wbhttp://mo<WBhttp://mo_ > > > > > > (http://money.http://money.<wbhttp://mo<wbhttp://mo) ) > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.