Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 Unless the physician is willing to accompany me with the patient, I'm relying on protocols and/or my online medical control. The patient's condition may have been exacerbated by the atrovent/ipatropium nebulizer treatment.? It is contraindicated in patients with known sensitivity to peanut or soy products. Personally, I'm leaning towards another dose of epinephrine to provide vasoconstriction to reverse the hypotension as well as to provide bronchodilation.?? I'll hold off on the albuterol until we get the airway opened up enough for the nebulized route to be effective enough to provide bronchodilation.? I'm discontinuing the atrovent treatment due to the contraindication.? And the paralytic isn't going to make this difficult airway (due to bronchoconstriction) easier, so it's on hold for now.? I need to block histamine release (Benadryl), reduce inflammation (Solu-Medrol), and provide vasoconstriction and bronchodilation (epinephrine).?? Sound right? -Wes Ogilvie, MPA, JD, Lic. P./NREMT-P -Attorney/Licensed Paramedic/EMS Instructor -Austin, Texas Case Study You are dispatched to a local walk-in care clinic for a patient in respiratory distress. En route to the call dispatch notifies you that you are responding to a 47 year old male with a possible allergic reaction. Upon arrival the attending physician tells you the patient ate lunch at a local restaurant and may have come into contact with something containing peanuts. The patient had a minor reaction to peanut butter two years ago, and has avoided peanut products since. The physician gives you the following information: When the patient presented to the clinic he was in respiratory distress, had petechiae to the eyes and face, and had the following vital signs: BP 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He had loud expiratory wheezing that could be heard from across the room. The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST with occasional PVC, and an IV of NS was started. While beginning treatment the patient's SPO2 decreased to 82 percent and his respiratory distress worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the IV was started, he received Solu-Medrol 125mg IV. He was started on a double DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes the patient became worse, with the following vital signs: BP 82/30, HR 144, RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 0.3mg, IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When the patient became obtunded he was intubated with a 7.0 ETT with O2 wide open, given an inline DuoNeb treatment, and was given Benadryl 25mg IV. Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by BVM, SPO2 84%. The patient is very difficult to ventilate and has loud expiratory wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, and chest wall. He is responsive to painful stimuli and occasionally reaches for the ETT. The physician asks you to give the patient a paralytic, a second dose of Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if needed. Your turn: You are transporting to an emergency room 18 miles away. Would you follow the physician request, call for other orders, or follow your protocols? What part of the physician orders would you consider detrimental to the patient? Bonus question: What part of the previous treatment may have made the patient worse? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 Okay, I'll be the first to respond, but only in part. AND I DON " T WANT TO GO TO LADONIA! (My ex-wife is there on her honeymoon with a bandoleer wearing trauma junkie!) According to what I've " read " and according to our protocols, once the patient is in our care, we follow our protocols. A similar question of this nature was on an exam I took while doing some CE. I answered " follow the physician's request " which was WRONG. I looked at it from a " business " , as well as,a safety standpoint. Obviously, if you work for a private service(especially), you don't want to P.O. the Doc. So, listen, move the patient to your unit, and FOLLOW PROTOCOL. I think that also stands for ANY service(follow protocol). As far as treatment? I'd contact the receiving hospital and give an initial report. I would question the Decadron and Solu-Medrol. I could be wrong, but that's why I'm on this list:TO LEARN! Subject: Case Study To: texasems-l Date: Wednesday, May 13, 2009, 3:32 PM You are dispatched to a local walk-in care clinic for a patient in respiratory distress. En route to the call dispatch notifies you that you are responding to a 47 year old male with a possible allergic reaction. Upon arrival the attending physician tells you the patient ate lunch at a local restaurant and may have come into contact with something containing peanuts. The patient had a minor reaction to peanut butter two years ago, and has avoided peanut products since. The physician gives you the following information: When the patient presented to the clinic he was in respiratory distress, had petechiae to the eyes and face, and had the following vital signs: BP 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He had loud expiratory wheezing that could be heard from across the room. The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST with occasional PVC, and an IV of NS was started. While beginning treatment the patient's SPO2 decreased to 82 percent and his respiratory distress worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the IV was started, he received Solu-Medrol 125mg IV. He was started on a double DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes the patient became worse, with the following vital signs: BP 82/30, HR 144, RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 0.3mg, IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When the patient became obtunded he was intubated with a 7.0 ETT with O2 wide open, given an inline DuoNeb treatment, and was given Benadryl 25mg IV. Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by BVM, SPO2 84%. The patient is very difficult to ventilate and has loud expiratory wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, and chest wall. He is responsive to painful stimuli and occasionally reaches for the ETT. The physician asks you to give the patient a paralytic, a second dose of Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if needed. Your turn: You are transporting to an emergency room 18 miles away. Would you follow the physician request, call for other orders, or follow your protocols? What part of the physician orders would you consider detrimental to the patient? Bonus question: What part of the previous treatment may have made the patient worse? Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 Bingo!! The Atrovent is contraindicated in patients with sensitivity to soy or peanut products. Now, how 'bout that epi with a HR of 164? What other options could we look at to reduce the HR and bring up the blood pressure? For the next part....Benadryl and Solu-Medrol sound good. What other drug would you expect the receiving facility to give as a histamine blocker? I would agree that online medical control or protocols would be better than the current prescribed treatment. Awesome job!! > > > Unless the physician is willing to accompany me with the patient, I'm > relying on protocols and/or my online medical control. > > The patient's condition may have been exacerbated by the > atrovent/ipatropium nebulizer treatment.? It is contraindicated in patients > with known sensitivity to peanut or soy products. > > Personally, I'm leaning towards another dose of epinephrine to provide > vasoconstriction to reverse the hypotension as well as to provide > bronchodilation.?? I'll hold off on the albuterol until we get the airway > opened up enough for the nebulized route to be effective enough to provide > bronchodilation.? I'm discontinuing the atrovent treatment due to the > contraindication.? And the paralytic isn't going to make this difficult > airway (due to bronchoconstriction) easier, so it's on hold for now.? I need > to block histamine release (Benadryl), reduce inflammation (Solu-Medrol), > and provide vasoconstriction and bronchodilation (epinephrine).?? > > Sound right? > > -Wes Ogilvie, MPA, JD, Lic. P./NREMT-P > -Attorney/Licensed Paramedic/EMS Instructor > -Austin, Texas > > Case Study > > You are dispatched to a local walk-in care clinic for a patient in > respiratory distress. En route to the call dispatch notifies you that you > are responding to a 47 year old male with a possible allergic reaction. > > Upon arrival the attending physician tells you the patient ate lunch at a > local restaurant and may have come into contact with something containing > peanuts. The patient had a minor reaction to peanut butter two years ago, > and has avoided peanut products since. The physician gives you the following > information: > > When the patient presented to the clinic he was in respiratory distress, > had petechiae to the eyes and face, and had the following vital signs: BP > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He had > loud expiratory wheezing that could be heard from across the room. > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST > with occasional PVC, and an IV of NS was started. While beginning treatment > the patient's SPO2 decreased to 82 percent and his respiratory distress > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the IV > was started, he received Solu-Medrol 125mg IV. He was started on a double > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes > the patient became worse, with the following vital signs: BP 82/30, HR 144, > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 0.3mg, > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When the > patient became obtunded he was intubated with a 7.0 ETT with O2 wide open, > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by BVM, > SPO2 84%. The patient is very difficult to ventilate and has loud expiratory > wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, and > chest wall. He is responsive to painful stimuli and occasionally reaches for > the ETT. > > The physician asks you to give the patient a paralytic, a second dose of > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if > needed. > > Your turn: You are transporting to an emergency room 18 miles away. Would > you follow the physician request, call for other orders, or follow your > protocols? What part of the physician orders would you consider detrimental > to the patient? > > Bonus question: What part of the previous treatment may have made the > patient worse? > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 I think it would be appropriate to call medical control for specific treatment orders or for an order to follow protocols. I don't see anything wrong with the Decadron or Solu-Medrol, although the effects of IM Decadron probably will not be noticed during our transport time. Thanks for the post, Neil On Wed, May 13, 2009 at 3:54 PM, learningmedic airmedic51@...>wrote: > > > Okay, I'll be the first to respond, but only in part. AND I DON " T WANT TO > GO TO LADONIA! > (My ex-wife is there on her honeymoon with a bandoleer wearing trauma > junkie!) > > According to what I've " read " and according to our protocols, once the > patient is in our care, we follow our protocols. A similar question of this > nature was on an exam I took while doing some CE. I answered " follow the > physician's request " which was WRONG. I looked at it from a " business " , as > well as,a safety standpoint. > > Obviously, if you work for a private service(especially), you don't want to > P.O. the Doc. So, listen, > move the patient to your unit, and FOLLOW PROTOCOL. I think that also > stands for ANY service(follow protocol). > > As far as treatment? I'd contact the receiving hospital and give an initial > report. I would question the Decadron and Solu-Medrol. I could be wrong, but > that's why I'm on this list:TO LEARN! > > > > > > > > From: drdugud drdugud@... > > Subject: Case Study > To: texasems-l > Date: Wednesday, May 13, 2009, 3:32 PM > > You are dispatched to a local walk-in care clinic for a patient in > respiratory distress. En route to the call dispatch notifies you that you > are responding to a 47 year old male with a possible allergic reaction. > > Upon arrival the attending physician tells you the patient ate lunch at a > local restaurant and may have come into contact with something containing > peanuts. The patient had a minor reaction to peanut butter two years ago, > and has avoided peanut products since. The physician gives you the following > information: > > When the patient presented to the clinic he was in respiratory distress, > had petechiae to the eyes and face, and had the following vital signs: BP > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He had > loud expiratory wheezing that could be heard from across the room. > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST > with occasional PVC, and an IV of NS was started. While beginning treatment > the patient's SPO2 decreased to 82 percent and his respiratory distress > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the IV > was started, he received Solu-Medrol 125mg IV. He was started on a double > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes > the patient became worse, with the following vital signs: BP 82/30, HR 144, > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 0.3mg, > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When the > patient became obtunded he was intubated with a 7.0 ETT with O2 wide open, > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by BVM, > SPO2 84%. The patient is very difficult to ventilate and has loud expiratory > wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, and > chest wall. He is responsive to painful stimuli and occasionally reaches for > the ETT. > > The physician asks you to give the patient a paralytic, a second dose of > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if > needed. > > Your turn: You are transporting to an emergency room 18 miles away. Would > you follow the physician request, call for other orders, or follow your > protocols? What part of the physician orders would you consider detrimental > to the patient? > > Bonus question: What part of the previous treatment may have made the > patient worse? > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 I'm more worried about the lack of breathing than the elevated HR, which I believe is caused by the hypoxia.? So, absent other criteria, I'm probably going to consider epinephrine again.? If I have it as an option in my protocols and/or formulary, I might consider terbutaline. I might expect to see the receiving ER administer Tagamet as a H2 blocker.? (Question on my end -- why doesn't EMS use this drug?) While I could consider dopamine to bring up the BP, I'm loathe to do that unless I really, really have to.??I might consider another liter of IV fluids. -Wes Ogilvie, MPA, JD, Lic. P./NREMT-P -Attorney/Licensed Paramedic/EMS Instructor -Austin, Texas Case Study > > You are dispatched to a local walk-in care clinic for a patient in > respiratory distress. En route to the call dispatch notifies you that you > are responding to a 47 year old male with a possible allergic reaction. > > Upon arrival the attending physician tells you the patient ate lunch at a > local restaurant and may have come into contact with something containing > peanuts. The patient had a minor reaction to peanut butter two years ago, > and has avoided peanut products since. The physician gives you the following > information: > > When the patient presented to the clinic he was in respiratory distress, > had petechiae to the eyes and face, and had the following vital signs: BP > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He had > loud expiratory wheezing that could be heard from across the room. > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST > with occasional PVC, and an IV of NS was started. While beginning treatment > the patient's SPO2 decreased to 82 percent and his respiratory distress > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the IV > was started, he received Solu-Medrol 125mg IV. He was started on a double > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes > the patient became worse, with the following vital signs: BP 82/30, HR 144, > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 0.3mg, > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When the > patient became obtunded he was intubated with a 7.0 ETT with O2 wide open, > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by BVM, > SPO2 84%. The patient is very difficult to ventilate and has loud expiratory > wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, and > chest wall. He is responsive to painful stimuli and occasionally reaches for > the ETT. > > The physician asks you to give the patient a paralytic, a second dose of > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if > needed. > > Your turn: You are transporting to an emergency room 18 miles away. Would > you follow the physician request, call for other orders, or follow your > protocols? What part of the physician orders would you consider detrimental > to the patient? > > Bonus question: What part of the previous treatment may have made the > patient worse? > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 I'm more worried about the lack of breathing than the elevated HR, which I believe is caused by the hypoxia.? So, absent other criteria, I'm probably going to consider epinephrine again.? If I have it as an option in my protocols and/or formulary, I might consider terbutaline. I might expect to see the receiving ER administer Tagamet as a H2 blocker.? (Question on my end -- why doesn't EMS use this drug?) While I could consider dopamine to bring up the BP, I'm loathe to do that unless I really, really have to.??I might consider another liter of IV fluids. -Wes Ogilvie, MPA, JD, Lic. P./NREMT-P -Attorney/Licensed Paramedic/EMS Instructor -Austin, Texas Case Study > > You are dispatched to a local walk-in care clinic for a patient in > respiratory distress. En route to the call dispatch notifies you that you > are responding to a 47 year old male with a possible allergic reaction. > > Upon arrival the attending physician tells you the patient ate lunch at a > local restaurant and may have come into contact with something containing > peanuts. The patient had a minor reaction to peanut butter two years ago, > and has avoided peanut products since. The physician gives you the following > information: > > When the patient presented to the clinic he was in respiratory distress, > had petechiae to the eyes and face, and had the following vital signs: BP > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He had > loud expiratory wheezing that could be heard from across the room. > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST > with occasional PVC, and an IV of NS was started. While beginning treatment > the patient's SPO2 decreased to 82 percent and his respiratory distress > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the IV > was started, he received Solu-Medrol 125mg IV. He was started on a double > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes > the patient became worse, with the following vital signs: BP 82/30, HR 144, > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 0.3mg, > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When the > patient became obtunded he was intubated with a 7.0 ETT with O2 wide open, > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by BVM, > SPO2 84%. The patient is very difficult to ventilate and has loud expiratory > wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, and > chest wall. He is responsive to painful stimuli and occasionally reaches for > the ETT. > > The physician asks you to give the patient a paralytic, a second dose of > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if > needed. > > Your turn: You are transporting to an emergency room 18 miles away. Would > you follow the physician request, call for other orders, or follow your > protocols? What part of the physician orders would you consider detrimental > to the patient? > > Bonus question: What part of the previous treatment may have made the > patient worse? > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 I'm more worried about the lack of breathing than the elevated HR, which I believe is caused by the hypoxia.? So, absent other criteria, I'm probably going to consider epinephrine again.? If I have it as an option in my protocols and/or formulary, I might consider terbutaline. I might expect to see the receiving ER administer Tagamet as a H2 blocker.? (Question on my end -- why doesn't EMS use this drug?) While I could consider dopamine to bring up the BP, I'm loathe to do that unless I really, really have to.??I might consider another liter of IV fluids. -Wes Ogilvie, MPA, JD, Lic. P./NREMT-P -Attorney/Licensed Paramedic/EMS Instructor -Austin, Texas Case Study > > You are dispatched to a local walk-in care clinic for a patient in > respiratory distress. En route to the call dispatch notifies you that you > are responding to a 47 year old male with a possible allergic reaction. > > Upon arrival the attending physician tells you the patient ate lunch at a > local restaurant and may have come into contact with something containing > peanuts. The patient had a minor reaction to peanut butter two years ago, > and has avoided peanut products since. The physician gives you the following > information: > > When the patient presented to the clinic he was in respiratory distress, > had petechiae to the eyes and face, and had the following vital signs: BP > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He had > loud expiratory wheezing that could be heard from across the room. > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST > with occasional PVC, and an IV of NS was started. While beginning treatment > the patient's SPO2 decreased to 82 percent and his respiratory distress > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the IV > was started, he received Solu-Medrol 125mg IV. He was started on a double > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes > the patient became worse, with the following vital signs: BP 82/30, HR 144, > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 0.3mg, > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When the > patient became obtunded he was intubated with a 7.0 ETT with O2 wide open, > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by BVM, > SPO2 84%. The patient is very difficult to ventilate and has loud expiratory > wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, and > chest wall. He is responsive to painful stimuli and occasionally reaches for > the ETT. > > The physician asks you to give the patient a paralytic, a second dose of > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if > needed. > > Your turn: You are transporting to an emergency room 18 miles away. Would > you follow the physician request, call for other orders, or follow your > protocols? What part of the physician orders would you consider detrimental > to the patient? > > Bonus question: What part of the previous treatment may have made the > patient worse? > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 I'm all about the fluid. My only concern with the epi was the current HR of 164, but I understand where you are coming from. H2 blocker is exactly what I had in mind. I'm not sure why EMS doesn't carry H2 blockers. I believe they may have to be refrigerated, but I would have to look it up to be sure. The other thing I would really like to see is a waveform from his ETCO2. It isn't going to change anything, but I would be curious to see just how closed down he is. Thanks for the post, Neil > > > I'm more worried about the lack of breathing than the elevated HR, which I > believe is caused by the hypoxia.? So, absent other criteria, I'm probably > going to consider epinephrine again.? If I have it as an option in my > protocols and/or formulary, I might consider terbutaline. > > I might expect to see the receiving ER administer Tagamet as a H2 blocker.? > (Question on my end -- why doesn't EMS use this drug?) > > While I could consider dopamine to bring up the BP, I'm loathe to do that > unless I really, really have to.??I might consider another liter of IV > fluids. > > -Wes Ogilvie, MPA, JD, Lic. P./NREMT-P > -Attorney/Licensed Paramedic/EMS Instructor > -Austin, Texas > > Case Study > > > > You are dispatched to a local walk-in care clinic for a patient in > > respiratory distress. En route to the call dispatch notifies you that you > > are responding to a 47 year old male with a possible allergic reaction. > > > > Upon arrival the attending physician tells you the patient ate lunch at a > > local restaurant and may have come into contact with something containing > > peanuts. The patient had a minor reaction to peanut butter two years ago, > > and has avoided peanut products since. The physician gives you the > following > > information: > > > > When the patient presented to the clinic he was in respiratory distress, > > had petechiae to the eyes and face, and had the following vital signs: BP > > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He > had > > loud expiratory wheezing that could be heard from across the room. > > > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST > > with occasional PVC, and an IV of NS was started. While beginning > treatment > > the patient's SPO2 decreased to 82 percent and his respiratory distress > > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the > IV > > was started, he received Solu-Medrol 125mg IV. He was started on a double > > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes > > the patient became worse, with the following vital signs: BP 82/30, HR > 144, > > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 > 0.3mg, > > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When > the > > patient became obtunded he was intubated with a 7.0 ETT with O2 wide > open, > > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by > BVM, > > SPO2 84%. The patient is very difficult to ventilate and has loud > expiratory > > wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, > and > > chest wall. He is responsive to painful stimuli and occasionally reaches > for > > the ETT. > > > > The physician asks you to give the patient a paralytic, a second dose of > > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if > > needed. > > > > Your turn: You are transporting to an emergency room 18 miles away. Would > > you follow the physician request, call for other orders, or follow your > > protocols? What part of the physician orders would you consider > detrimental > > to the patient? > > > > Bonus question: What part of the previous treatment may have made the > > patient worse? > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 I'm all about the fluid. My only concern with the epi was the current HR of 164, but I understand where you are coming from. H2 blocker is exactly what I had in mind. I'm not sure why EMS doesn't carry H2 blockers. I believe they may have to be refrigerated, but I would have to look it up to be sure. The other thing I would really like to see is a waveform from his ETCO2. It isn't going to change anything, but I would be curious to see just how closed down he is. Thanks for the post, Neil > > > I'm more worried about the lack of breathing than the elevated HR, which I > believe is caused by the hypoxia.? So, absent other criteria, I'm probably > going to consider epinephrine again.? If I have it as an option in my > protocols and/or formulary, I might consider terbutaline. > > I might expect to see the receiving ER administer Tagamet as a H2 blocker.? > (Question on my end -- why doesn't EMS use this drug?) > > While I could consider dopamine to bring up the BP, I'm loathe to do that > unless I really, really have to.??I might consider another liter of IV > fluids. > > -Wes Ogilvie, MPA, JD, Lic. P./NREMT-P > -Attorney/Licensed Paramedic/EMS Instructor > -Austin, Texas > > Case Study > > > > You are dispatched to a local walk-in care clinic for a patient in > > respiratory distress. En route to the call dispatch notifies you that you > > are responding to a 47 year old male with a possible allergic reaction. > > > > Upon arrival the attending physician tells you the patient ate lunch at a > > local restaurant and may have come into contact with something containing > > peanuts. The patient had a minor reaction to peanut butter two years ago, > > and has avoided peanut products since. The physician gives you the > following > > information: > > > > When the patient presented to the clinic he was in respiratory distress, > > had petechiae to the eyes and face, and had the following vital signs: BP > > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He > had > > loud expiratory wheezing that could be heard from across the room. > > > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST > > with occasional PVC, and an IV of NS was started. While beginning > treatment > > the patient's SPO2 decreased to 82 percent and his respiratory distress > > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the > IV > > was started, he received Solu-Medrol 125mg IV. He was started on a double > > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes > > the patient became worse, with the following vital signs: BP 82/30, HR > 144, > > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 > 0.3mg, > > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When > the > > patient became obtunded he was intubated with a 7.0 ETT with O2 wide > open, > > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by > BVM, > > SPO2 84%. The patient is very difficult to ventilate and has loud > expiratory > > wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, > and > > chest wall. He is responsive to painful stimuli and occasionally reaches > for > > the ETT. > > > > The physician asks you to give the patient a paralytic, a second dose of > > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if > > needed. > > > > Your turn: You are transporting to an emergency room 18 miles away. Would > > you follow the physician request, call for other orders, or follow your > > protocols? What part of the physician orders would you consider > detrimental > > to the patient? > > > > Bonus question: What part of the previous treatment may have made the > > patient worse? > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 I'm all about the fluid. My only concern with the epi was the current HR of 164, but I understand where you are coming from. H2 blocker is exactly what I had in mind. I'm not sure why EMS doesn't carry H2 blockers. I believe they may have to be refrigerated, but I would have to look it up to be sure. The other thing I would really like to see is a waveform from his ETCO2. It isn't going to change anything, but I would be curious to see just how closed down he is. Thanks for the post, Neil > > > I'm more worried about the lack of breathing than the elevated HR, which I > believe is caused by the hypoxia.? So, absent other criteria, I'm probably > going to consider epinephrine again.? If I have it as an option in my > protocols and/or formulary, I might consider terbutaline. > > I might expect to see the receiving ER administer Tagamet as a H2 blocker.? > (Question on my end -- why doesn't EMS use this drug?) > > While I could consider dopamine to bring up the BP, I'm loathe to do that > unless I really, really have to.??I might consider another liter of IV > fluids. > > -Wes Ogilvie, MPA, JD, Lic. P./NREMT-P > -Attorney/Licensed Paramedic/EMS Instructor > -Austin, Texas > > Case Study > > > > You are dispatched to a local walk-in care clinic for a patient in > > respiratory distress. En route to the call dispatch notifies you that you > > are responding to a 47 year old male with a possible allergic reaction. > > > > Upon arrival the attending physician tells you the patient ate lunch at a > > local restaurant and may have come into contact with something containing > > peanuts. The patient had a minor reaction to peanut butter two years ago, > > and has avoided peanut products since. The physician gives you the > following > > information: > > > > When the patient presented to the clinic he was in respiratory distress, > > had petechiae to the eyes and face, and had the following vital signs: BP > > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He > had > > loud expiratory wheezing that could be heard from across the room. > > > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST > > with occasional PVC, and an IV of NS was started. While beginning > treatment > > the patient's SPO2 decreased to 82 percent and his respiratory distress > > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the > IV > > was started, he received Solu-Medrol 125mg IV. He was started on a double > > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes > > the patient became worse, with the following vital signs: BP 82/30, HR > 144, > > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 > 0.3mg, > > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When > the > > patient became obtunded he was intubated with a 7.0 ETT with O2 wide > open, > > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by > BVM, > > SPO2 84%. The patient is very difficult to ventilate and has loud > expiratory > > wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, > and > > chest wall. He is responsive to painful stimuli and occasionally reaches > for > > the ETT. > > > > The physician asks you to give the patient a paralytic, a second dose of > > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if > > needed. > > > > Your turn: You are transporting to an emergency room 18 miles away. Would > > you follow the physician request, call for other orders, or follow your > > protocols? What part of the physician orders would you consider > detrimental > > to the patient? > > > > Bonus question: What part of the previous treatment may have made the > > patient worse? > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 Depending on how trusting my medical director is, I might " jump " over to the asthma/bronchospasm protocols to see what other options I might have, such as magnesium sulfate or maybe nebulized epinephrine. -Wes Ogilvie, MPA, JD, Lic.P./NREMT-P -Attorney/Licensed Paramedic/EMS Instructor -Austin, Texas Case Study > > > > You are dispatched to a local walk-in care clinic for a patient in > > respiratory distress. En route to the call dispatch notifies you that you > > are responding to a 47 year old male with a possible allergic reaction. > > > > Upon arrival the attending physician tells you the patient ate lunch at a > > local restaurant and may have come into contact with something containing > > peanuts. The patient had a minor reaction to peanut butter two years ago, > > and has avoided peanut products since. The physician gives you the > following > > information: > > > > When the patient presented to the clinic he was in respiratory distress, > > had petechiae to the eyes and face, and had the following vital signs: BP > > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He > had > > loud expiratory wheezing that could be heard from across the room. > > > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST > > with occasional PVC, and an IV of NS was started. While beginning > treatment > > the patient's SPO2 decreased to 82 percent and his respiratory distress > > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the > IV > > was started, he received Solu-Medrol 125mg IV. He was started on a double > > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes > > the patient became worse, with the following vital signs: BP 82/30, HR > 144, > > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 > 0.3mg, > > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When > the > > patient became obtunded he was intubated with a 7.0 ETT with O2 wide > open, > > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by > BVM, > > SPO2 84%. The patient is very difficult to ventilate and has loud > expiratory > > wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, > and > > chest wall. He is responsive to painful stimuli and occasionally reaches > for > > the ETT. > > > > The physician asks you to give the patient a paralytic, a second dose of > > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if > > needed. > > > > Your turn: You are transporting to an emergency room 18 miles away. Would > > you follow the physician request, call for other orders, or follow your > > protocols? What part of the physician orders would you consider > detrimental > > to the patient? > > > > Bonus question: What part of the previous treatment may have made the > > patient worse? > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 Depending on how trusting my medical director is, I might " jump " over to the asthma/bronchospasm protocols to see what other options I might have, such as magnesium sulfate or maybe nebulized epinephrine. -Wes Ogilvie, MPA, JD, Lic.P./NREMT-P -Attorney/Licensed Paramedic/EMS Instructor -Austin, Texas Case Study > > > > You are dispatched to a local walk-in care clinic for a patient in > > respiratory distress. En route to the call dispatch notifies you that you > > are responding to a 47 year old male with a possible allergic reaction. > > > > Upon arrival the attending physician tells you the patient ate lunch at a > > local restaurant and may have come into contact with something containing > > peanuts. The patient had a minor reaction to peanut butter two years ago, > > and has avoided peanut products since. The physician gives you the > following > > information: > > > > When the patient presented to the clinic he was in respiratory distress, > > had petechiae to the eyes and face, and had the following vital signs: BP > > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He > had > > loud expiratory wheezing that could be heard from across the room. > > > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST > > with occasional PVC, and an IV of NS was started. While beginning > treatment > > the patient's SPO2 decreased to 82 percent and his respiratory distress > > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the > IV > > was started, he received Solu-Medrol 125mg IV. He was started on a double > > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes > > the patient became worse, with the following vital signs: BP 82/30, HR > 144, > > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 > 0.3mg, > > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When > the > > patient became obtunded he was intubated with a 7.0 ETT with O2 wide > open, > > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by > BVM, > > SPO2 84%. The patient is very difficult to ventilate and has loud > expiratory > > wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, > and > > chest wall. He is responsive to painful stimuli and occasionally reaches > for > > the ETT. > > > > The physician asks you to give the patient a paralytic, a second dose of > > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if > > needed. > > > > Your turn: You are transporting to an emergency room 18 miles away. Would > > you follow the physician request, call for other orders, or follow your > > protocols? What part of the physician orders would you consider > detrimental > > to the patient? > > > > Bonus question: What part of the previous treatment may have made the > > patient worse? > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 Depending on how trusting my medical director is, I might " jump " over to the asthma/bronchospasm protocols to see what other options I might have, such as magnesium sulfate or maybe nebulized epinephrine. -Wes Ogilvie, MPA, JD, Lic.P./NREMT-P -Attorney/Licensed Paramedic/EMS Instructor -Austin, Texas Case Study > > > > You are dispatched to a local walk-in care clinic for a patient in > > respiratory distress. En route to the call dispatch notifies you that you > > are responding to a 47 year old male with a possible allergic reaction. > > > > Upon arrival the attending physician tells you the patient ate lunch at a > > local restaurant and may have come into contact with something containing > > peanuts. The patient had a minor reaction to peanut butter two years ago, > > and has avoided peanut products since. The physician gives you the > following > > information: > > > > When the patient presented to the clinic he was in respiratory distress, > > had petechiae to the eyes and face, and had the following vital signs: BP > > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. He > had > > loud expiratory wheezing that could be heard from across the room. > > > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing ST > > with occasional PVC, and an IV of NS was started. While beginning > treatment > > the patient's SPO2 decreased to 82 percent and his respiratory distress > > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once the > IV > > was started, he received Solu-Medrol 125mg IV. He was started on a double > > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within minutes > > the patient became worse, with the following vital signs: BP 82/30, HR > 144, > > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 > 0.3mg, > > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. When > the > > patient became obtunded he was intubated with a 7.0 ETT with O2 wide > open, > > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by > BVM, > > SPO2 84%. The patient is very difficult to ventilate and has loud > expiratory > > wheezing. Skin is bright red. He has petechiae to the eyes, face, neck, > and > > chest wall. He is responsive to painful stimuli and occasionally reaches > for > > the ETT. > > > > The physician asks you to give the patient a paralytic, a second dose of > > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi if > > needed. > > > > Your turn: You are transporting to an emergency room 18 miles away. Would > > you follow the physician request, call for other orders, or follow your > > protocols? What part of the physician orders would you consider > detrimental > > to the patient? > > > > Bonus question: What part of the previous treatment may have made the > > patient worse? > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted May 13, 2009 Report Share Posted May 13, 2009 I'd like capnography also. I question the DuoNeb for two reasons: First is the contraindication for people allergic to peanuts; the second is giving atropine to somebody already in tachycardia. H2 blocker would be appropriate. GG > > > > I'm all about the fluid. My only concern with the epi was the current HR > of > 164, but I understand where you are coming from. H2 blocker is exactly > what > I had in mind. I'm not sure why EMS doesn't carry H2 blockers. I believe > they may have to be refrigerated, but I would have to look it up to be > sure. > The other thing I would really like to see is a waveform from his ETCO2. > It > isn't going to change anything, but I would be curious to see just how > closed down he is. > > Thanks for the post, > > Neil > > > > > > > > > I'm more worried about the lack of breathing than the elevated HR, which > I > > believe is caused by the hypoxia.? So, absent other criteria, I'm > probably > > going to consider epinephrine again.? If I have it as an option in my > > protocols and/or formulary, I might consider terbutaline. > > > > I might expect to see the receiving ER administer Tagamet as a H2 > blocker.? > > (Question on my end -- why doesn't EMS use this drug?) > > > > While I could consider dopamine to bring up the BP, I'm loathe to do > that > > unless I really, really have to.??I might consider another liter of IV > > fluids. > > > > -Wes Ogilvie, MPA, JD, Lic. P./NREMT-P > > -Attorney/Licensed Paramedic/EMS Instructor > > -Austin, Texas > > > > Case Study > > > > > > You are dispatched to a local walk-in care clinic for a patient in > > > respiratory distress. En route to the call dispatch notifies you that > you > > > are responding to a 47 year old male with a possible allergic > reaction. > > > > > > Upon arrival the attending physician tells you the patient ate lunch > at a > > > local restaurant and may have come into contact with something > containing > > > peanuts. The patient had a minor reaction to peanut butter two years > ago, > > > and has avoided peanut products since. The physician gives you the > > following > > > information: > > > > > > When the patient presented to the clinic he was in respiratory > distress, > > > had petechiae to the eyes and face, and had the following vital signs: > BP > > > 92/44, HR 114, RR 28, SPO2 88% on room air, and a temp of 98.3 oral. > He > > had > > > loud expiratory wheezing that could be heard from across the room. > > > > > > The patient was placed on O2 @ 6 LPM via NC, cardiac monitor showing > ST > > > with occasional PVC, and an IV of NS was started. While beginning > > treatment > > > the patient's SPO2 decreased to 82 percent and his respiratory > distress > > > worsened. He was given Epi 1:1 0.3 mg SQ, Decadron 16mg IM, and once > the > > IV > > > was started, he received Solu-Medrol 125mg IV. He was started on a > double > > > DuoNeb treatment, and the IV was open for a 1 liter bolus. Within > minutes > > > the patient became worse, with the following vital signs: BP 82/30, HR > > 144, > > > RR 40, and SPO2 66%. The patient was given another SQ dose of Epi 1:1 > > 0.3mg, > > > IV Epi 1:10,000 0.5mg, and the staff began ventilations with a BVM. > When > > the > > > patient became obtunded he was intubated with a 7.0 ETT with O2 wide > > open, > > > given an inline DuoNeb treatment, and was given Benadryl 25mg IV. > > > > > > Your findings are as follows: Vital signs: BP 92/38, HR 164, RR 20 by > > BVM, > > > SPO2 84%. The patient is very difficult to ventilate and has loud > > expiratory > > > wheezing. Skin is bright red. He has petechiae to the eyes, face, > neck, > > and > > > chest wall. He is responsive to painful stimuli and occasionally > reaches > > for > > > the ETT. > > > > > > The physician asks you to give the patient a paralytic, a second dose > of > > > Benadryl and Solu-Medrol, continuous DuoNeb treatments, and more Epi > if > > > needed. > > > > > > Your turn: You are transporting to an emergency room 18 miles away. > Would > > > you follow the physician request, call for other orders, or follow > your > > > protocols? What part of the physician orders would you consider > > detrimental > > > to the patient? > > > > > > Bonus question: What part of the previous treatment may have made the > > > patient worse? > > > > > > Quote Link to comment Share on other sites More sharing options...
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