You are your partner are working an ALS rig in an urban setting, when you are dispatched to an assisted living community for a reported unresponsive party. When you enter the dwelling, you see a late 60s male lying in the door jam between the bedroom and the living room. The patient’s wife is on scene and hysterical, but is able to tell you that the patient was acting “weak” at dinner which was approximately 1700; she states that the patient excused himself early from the dining room, going back to their apartment. Around 1815, the wife states that she returned to the room, and found the patient “slumped over” on the ground next to his bed not responding when she would shout his name. There are no obvious signs of trauma, and the three nurses on scene all state that this is their first night with the patient, and do not know what type of medical problems that he has.
- Patient is a GCS of 6
- Does not open eyes
- Occasionally moans to painful stimuli
- Occasionally flails right arm, batting at NRB
- Absent radial pulses; irregular carotid pulses; fluctuates between 60-220
- Cheyne-Stokes breathing pattern
- L/S are clear= in all fields
- = Rise/fall of chest
- No obvious indicators of trauma
- Pupils are dilated/= bilaterally
- Patient has a demand pacemaker
- Patient has a drainage shunt from a recent cholecystectomy; does not appear to be red, inflamed, or have any obvious drainage
- Jaw is clenched
- Unable to palpate radial pulses
- Automatic BP cuff gives readings of 110/60-220/178…
- HR: Irregular; fluctuates between 60-220; maintains primarily around the 80-90
- RR: Fluctuates between 2-40
- Skin is pale, cool, and moist
- BGL: 349mg/dl
- SpO2: 85% on R/A
INITIAL DIAGNOSTICS AND TREATMENT
- NPA placed; 15lpm O2 via NRB until patient could be transferred to commission; transitioned to BVM once in commission
- Requested first responders for man power due to patient condition
- Bilateral large bore IVs with fluid boluses started
- C-Collar placed due to unknown etiology of unresponsiveness
The crew opted to transport to the nearest facility which is a verified PCI/Stroke facility, but does not have any trauma resources, and is 4-5 minutes away from the scene. The crew opted to maintain a BLS airway with an NPA, suction, and a BVM. No paralytics were available; the only induction agents available are midazolam and fentanyl. Due to the obvious poor state of cardiac output, crew withholds induction agents. Patient delivered to ED with continued absent radial pulses (maintains irregular carotids) despite 750ml 0.09% NS bolus. SpO2 increases to 98% with a BVM; EtCO2 maintains around 15mmHg. Patient is inducted with etomidate/succinylcholine in the ED and intubated. Follow up reveals that the patient has an ejection fraction of 10% with a non-elevated white count. CT head/chest negative for thrombosis. Troponin is negative.
- Are there any other diagnostic tests you would have run?
- Would your treatment have differed had there been an extended transport time?
- Do you feel that push dose pressors have a role in prehospital intubation?
- If an extended transport time would have happened, would you consider a pressor agent? What would have been your first choice?