Re: A new Puzzler and a new opportunity to visit Ladonia before the flood

[Guest guest]

I will stick my head out and take a shot at it.

First of all this patient was not a candidate for Fentanyl. Fentanyl should

not be used in a multi system trauma patient that is conscious and

maintaining his own airway. Fentanyl as well as Versed or other sedation

meds can be beneficial to reduce pain in a patient that has received

paralytic therapy.

It appears to me that this patient's pain threshold was decreased by the

Fentanyl and he probably was comfortable moving his neck and back resulting

in paralysis. I would guess that the difficulty breathing is either

hyperventilation in response to not being able to move his extremities or it

could also be a result of the spinal injury / fracture.

I would continue manual c-spin control and began administering Solu-Medrol

30mg/kg bolus. This patient obviously needs to be removed from this auto

ASAP. As far as airway control, if an EJ could be initiated then chances

are ventilatory assistance can be obtained, however for your scenario if he

is barely speaking and unable to move air then advanced airway with either

nasal tracheal or oral tracheal intubation should be done. If unable to

gain airway control and patient continues to be hypoxic then surgical cric.

Just my initial thoughts.

, LP EMS-I

A new Puzzler and a new opportunity to visit Ladonia

before the flood

> You and your partner are taking care of a 26 year old male who is trapped

in

> his upside-down SUV which has rolled off the interstate, down an

embankment

> and into a ravine.

>

> Rescue workers are using the jaws to gain access to him, but going is

slow,

> and their ancient set of jaws keep conking out. He is screaming in pain.

>

> He is basically, as far as you can tell, lying on the ceiling of the

vehicle

> with his head up against the door on the driver's side, his back sort of

over

> the steering wheel and his legs on the passenger side. You can see one

leg

> from where you are, and your partner has through some marvelous set of

> contortions managed to stick him in the EJ and get a line which actually

runs.

>

> You're socking warm fluids to him, because it's cold, and your partner

> prepares to give him some Fentanyl. Fentanyl is new to your service and

your

> partner is doing math out loud. Guy says he weighs 245, so let's see,

that's hmmm,

> how much?

>

> After much discussion and multiplication, it was decided to administer the

> contents of one ampule, 250 mcg. This was done over one minute.

>

> Approximately 3 minutes later the patient began to scream that he couldn't

> breathe. You advised him to calm down and take deep breaths. He said, " I

> can't. .......can't breathe.

>

> You sense his obvious distress. You are unable to gain access to his

airway

> due to position, so you cannot assist ventilations. He can barely speak

now,

> but manages to croak, " Can't breathe, help me, can't move my arms,

> .....help me..... "

>

> Save this patient and you'll enjoy the riches of the Outback in lovely

> Ladonia, or you can stay home and watch soaps.

>

> Mr. Grady.

>

> " You can fool all of the people some of the time, and some of the people

all

> of the time, and that's usually enough. "

>

>

>

[Guest guest]

Why would you administer Solu-Medrol?

Bledsoe, DO, FACEP

Midlothian, TX

[http://www.bryanbledsoe.com]

Re: A new Puzzler and a new opportunity to visit

Ladonia before the flood

I will stick my head out and take a shot at it.

First of all this patient was not a candidate for Fentanyl. Fentanyl should

not be used in a multi system trauma patient that is conscious and

maintaining his own airway. Fentanyl as well as Versed or other sedation

meds can be beneficial to reduce pain in a patient that has received

paralytic therapy.

It appears to me that this patient's pain threshold was decreased by the

Fentanyl and he probably was comfortable moving his neck and back resulting

in paralysis. I would guess that the difficulty breathing is either

hyperventilation in response to not being able to move his extremities or it

could also be a result of the spinal injury / fracture.

I would continue manual c-spin control and began administering Solu-Medrol

30mg/kg bolus. This patient obviously needs to be removed from this auto

ASAP. As far as airway control, if an EJ could be initiated then chances

are ventilatory assistance can be obtained, however for your scenario if he

is barely speaking and unable to move air then advanced airway with either

nasal tracheal or oral tracheal intubation should be done. If unable to

gain airway control and patient continues to be hypoxic then surgical cric.

Just my initial thoughts.

, LP EMS-I

A new Puzzler and a new opportunity to visit Ladonia

before the flood

> You and your partner are taking care of a 26 year old male who is trapped

in

> his upside-down SUV which has rolled off the interstate, down an

embankment

> and into a ravine.

>

> Rescue workers are using the jaws to gain access to him, but going is

slow,

> and their ancient set of jaws keep conking out. He is screaming in pain.

>

> He is basically, as far as you can tell, lying on the ceiling of the

vehicle

> with his head up against the door on the driver's side, his back sort of

over

> the steering wheel and his legs on the passenger side. You can see one

leg

> from where you are, and your partner has through some marvelous set of

> contortions managed to stick him in the EJ and get a line which actually

runs.

>

> You're socking warm fluids to him, because it's cold, and your partner

> prepares to give him some Fentanyl. Fentanyl is new to your service and

your

> partner is doing math out loud. Guy says he weighs 245, so let's see,

that's hmmm,

> how much?

>

> After much discussion and multiplication, it was decided to administer the

> contents of one ampule, 250 mcg. This was done over one minute.

>

> Approximately 3 minutes later the patient began to scream that he couldn't

> breathe. You advised him to calm down and take deep breaths. He said, " I

> can't. .......can't breathe.

>

> You sense his obvious distress. You are unable to gain access to his

airway

> due to position, so you cannot assist ventilations. He can barely speak

now,

> but manages to croak, " Can't breathe, help me, can't move my arms,

> .....help me..... "

>

> Save this patient and you'll enjoy the riches of the Outback in lovely

> Ladonia, or you can stay home and watch soaps.

>

> Mr. Grady.

>

> " You can fool all of the people some of the time, and some of the people

all

> of the time, and that's usually enough. "

>

>

>

[Guest guest]

Both mild respiratory difficulty, and the feeling of paralysis (myesthenia

gravis) are side effects of Fentanyl, the respiratory difficulty is more

common than the myesthenia gravis.

If one carries Narcan, you could administer that, may or may not work,

because the half life of Narcan is so short, you may need to set up a drip.

Prepare to assist ventilations as soon as you can gain access.

Mike " Thanks but no thanks for Ladonia " Hatfield

A new Puzzler and a new opportunity to visit Ladonia

before the flood

> You and your partner are taking care of a 26 year old male who is trapped

in

> his upside-down SUV which has rolled off the interstate, down an

embankment

> and into a ravine.

>

> Rescue workers are using the jaws to gain access to him, but going is

slow,

> and their ancient set of jaws keep conking out. He is screaming in pain.

>

> He is basically, as far as you can tell, lying on the ceiling of the

vehicle

> with his head up against the door on the driver's side, his back sort of

over

> the steering wheel and his legs on the passenger side. You can see one

leg

> from where you are, and your partner has through some marvelous set of

> contortions managed to stick him in the EJ and get a line which actually

runs.

>

> You're socking warm fluids to him, because it's cold, and your partner

> prepares to give him some Fentanyl. Fentanyl is new to your service and

your

> partner is doing math out loud. Guy says he weighs 245, so let's see,

that's hmmm,

> how much?

>

> After much discussion and multiplication, it was decided to administer the

> contents of one ampule, 250 mcg. This was done over one minute.

>

> Approximately 3 minutes later the patient began to scream that he couldn't

> breathe. You advised him to calm down and take deep breaths. He said, " I

> can't. .......can't breathe.

>

> You sense his obvious distress. You are unable to gain access to his

airway

> due to position, so you cannot assist ventilations. He can barely speak

now,

> but manages to croak, " Can't breathe, help me, can't move my arms,

> .....help me..... "

>

> Save this patient and you'll enjoy the riches of the Outback in lovely

> Ladonia, or you can stay home and watch soaps.

>

> Mr. Grady.

>

> " You can fool all of the people some of the time, and some of the people

all

> of the time, and that's usually enough. "

>

>

>

[Guest guest]

The fentanyl dose is rather low, and the Patients LOC is fairly high, so I

would first suspect a cardio-respiratory issue rather than oversedation as

the cause of the dyspnea.

High flow O2 should have already been applied and a BVM and OPA or NPA pre

sized and ready for immediate deployment. ET and Combi should be at easy

reach.

Possiblities would include pneumo or hemothorax or perhaps a cardiac

tamponade, based on the obvious extreme amount of energy involved in the

wreck. I hope a field needle thoracotomy is not required, in this

particularly hostile environment.

Eliminating cardio-respiratory issues (if it is quiet enough to properly

auscultate the chest) would suggest a closed head injury as another

potential cause for the dyspnea.

If SAO2 levels contine to drop and LOC deteriorate, I would begin aggressive

airway management (this may also be a nice time to try a little Narcan, in

case we have a hyupersensitivity to opiates), escalating as indicated.

When the Fire Department opens the vehicle up, this person would qualify for

a visit to the regional Trauma Center due to the mechnaism and extended

extrication. Distance will dictate whether air or ground transport should

be used.

But I could be wrong..........

TD

A new Puzzler and a new opportunity to visit Ladonia

before the flood

> You and your partner are taking care of a 26 year old male who is trapped

in

> his upside-down SUV which has rolled off the interstate, down an

embankment

> and into a ravine.

>

> Rescue workers are using the jaws to gain access to him, but going is

slow,

> and their ancient set of jaws keep conking out. He is screaming in pain.

>

> He is basically, as far as you can tell, lying on the ceiling of the

vehicle

> with his head up against the door on the driver's side, his back sort of

over

> the steering wheel and his legs on the passenger side. You can see one

leg

> from where you are, and your partner has through some marvelous set of

> contortions managed to stick him in the EJ and get a line which actually

runs.

>

> You're socking warm fluids to him, because it's cold, and your partner

> prepares to give him some Fentanyl. Fentanyl is new to your service and

your

> partner is doing math out loud. Guy says he weighs 245, so let's see,

that's hmmm,

> how much?

>

> After much discussion and multiplication, it was decided to administer the

> contents of one ampule, 250 mcg. This was done over one minute.

>

> Approximately 3 minutes later the patient began to scream that he couldn't

> breathe. You advised him to calm down and take deep breaths. He said, " I

> can't. .......can't breathe.

>

> You sense his obvious distress. You are unable to gain access to his

airway

> due to position, so you cannot assist ventilations. He can barely speak

now,

> but manages to croak, " Can't breathe, help me, can't move my arms,

> .....help me..... "

>

> Save this patient and you'll enjoy the riches of the Outback in lovely

> Ladonia, or you can stay home and watch soaps.

>

> Mr. Grady.

>

> " You can fool all of the people some of the time, and some of the people

all

> of the time, and that's usually enough. "

>

>

>

[Guest guest]

Okay, I've been out of the field for going on seven years now, but what

the heck. I'll hang it out here and risk humiliation by taking a quick

shot at this. Anaphylaxis. Epi.

Rob

[Guest guest]

Hmmm...first obvious problem: if both partners are involved in " much

discussion " about administering this new drug, at least one of us

should have cosidered consulting our protocols- never a bad idea if

there's ever any doubt. One of us probably had to go all the way back

to the rig to get the drug, since it's locked up- should have

referenced that info then. Now we can only hope our math skills will

help us get a job if this ends our careers.

If all the details are given, then we really didn't know the extent

of this patient's injuries. For example, we could only see one of his

legs- did he still have two? What about the other missing pieces-

such as multisystem trauma? Maybe we should have treated his pain

with verbal support and encouragement instead of narcotics- at least

until we could have done a proper assessment. Ah, well- at least we

made a decision and took action...so now what?

Seems we might have given him too much too quick. We might have found

that our protocol guidelines call for a slower administration, and

titrated to effect. For now, the rapid administration seems to have

caused muscle rigidity which has compromised his chest wall's ability

to move air. The dose given might be appropriate for the patient's

age and size, if needed to control his pain (might need even more),

but in another minute or so he might also be alt loc with decreasing

respirations. At least it's something we should be able to undo, if

we can pull our collective heads out and remember that Narcan will

reverse the effects of the fentanyl. We better get a couple of 'em

drawn up, though 'cause it looks like we'll be here a while, and the

agonist might very well outlast the antagonist.

Meanwhile, FD might consider fetching a reciprocating saw with a

couple of good metal cutting blades- beats the heck outta jaws &

hydraulic cutters in many cases.

> You and your partner are taking care of a 26 year old male who is

trapped in

> his upside-down SUV which has rolled off the interstate, down an

embankment

> and into a ravine.

>

> Rescue workers are using the jaws to gain access to him, but going

is slow,

> and their ancient set of jaws keep conking out. He is screaming in

pain.

>

> He is basically, as far as you can tell, lying on the ceiling of

the vehicle

> with his head up against the door on the driver's side, his back

sort of over

> the steering wheel and his legs on the passenger side. You can see

one leg

> from where you are, and your partner has through some marvelous set

of

> contortions managed to stick him in the EJ and get a line which

actually runs.

>

> You're socking warm fluids to him, because it's cold, and your

partner

> prepares to give him some Fentanyl. Fentanyl is new to your

service and your

> partner is doing math out loud. Guy says he weighs 245, so let's

see, that's hmmm,

> how much?

>

> After much discussion and multiplication, it was decided to

administer the

> contents of one ampule, 250 mcg. This was done over one minute.

>

> Approximately 3 minutes later the patient began to scream that he

couldn't

> breathe. You advised him to calm down and take deep breaths. He

said, " I

> can't. .......can't breathe.

>

> You sense his obvious distress. You are unable to gain access to

his airway

> due to position, so you cannot assist ventilations. He can barely

speak now,

> but manages to croak, " Can't breathe, help me, can't move my

arms,

> .....help me..... "

>

> Save this patient and you'll enjoy the riches of the Outback in

lovely

> Ladonia, or you can stay home and watch soaps.

>

> Mr. Grady.

>

> " You can fool all of the people some of the time, and some of the

people all

> of the time, and that's usually enough. "

>

>

>

[Guest guest]

Well lets see if I can make another trip to Ladonia. I'm not really

all that confident as I have no experiance with Fentanyl.

The most obvious mistake made was the admin. of the Fentanyl.

As the research revieled, it is an opiate based narcotic. The pain

control for this patient would be great, but we have no access to

the airway. Basic pharmacology tells us that we do not administer

narcotics without the ability to provide respiratory support.

Theoreticly, the Narcan should work to reverse the respiratory

compromise. If that is indead what the cause is. The time frame

following the administration and the presence of common side effects

for this medication would lead me to believe it is.

That said, it would appear that our first and most important

priority is to get the patient out and enroute to the hospital. Once

out we can make more informed treatment decisions based on

assessment findings. Hell, once we get him off that piece of metal

stuck in his back, the pain could stop. Until then we should try non-

medication based pain control. Talk to the patient, reassure,

inform, etc.

As far as other drugs go, for pain mgt. I would prefer MS or

nubain but thats only because I'm more familiar with them. If we

were out for sedation I would prefer Etomidate 0.3 mg/kg to max

adult dose of 20 mg. It is a very effective sedative and does not

cause the vasodilation of Valium or Versed, making it better for

head injuries. However, I would give any of this stuff until I could

get to the patients airway. Especially the Etomidate.

Thats my shot.

EMT-P, EMS-I

>

[Guest guest]

Usually dose (2-50mcg/Kg)

If this patient was given 250mcg (0.25mg) of fentanyl, an equivalent dose

of 25mg of Morphine would be the same.

and if this drug was given to fast, the adverse effect would be muscular

rigidity.

wegandy1938@...

om

To

11/11/2003 09:26

PM cc

Subject

Please respond to A new Puzzler and a

@yahoog new opportunity to visit Ladonia

roups.com before the flood

You and your partner are taking care of a 26 year old male who is trapped

in

his upside-down SUV which has rolled off the interstate, down an embankment

and into a ravine.

Rescue workers are using the jaws to gain access to him, but going is slow,

and their ancient set of jaws keep conking out.  He is screaming in pain.

He is basically, as far as you can tell,  lying on the ceiling of the

vehicle

with his head up against the door on the driver's side, his back sort of

over

the steering wheel and his legs on the passenger side.  You can see one leg

from where you are, and your partner has through some marvelous set of

contortions managed to stick him in the EJ and get a line which actually

runs.

You're socking warm fluids to him, because it's cold, and your partner

prepares to give him some Fentanyl.  Fentanyl is new to your service and

your

partner is doing math out loud.  Guy says he weighs 245, so let's see,

that's hmmm,

how much?

After much discussion and multiplication, it was decided to administer the

contents of one ampule, 250 mcg.  This was done over one minute.

Approximately 3 minutes later the patient began to scream that he couldn't

breathe.  You advised him to calm down and take deep breaths.  He said, " I

can't.  .......can't breathe.

You sense his obvious distress.  You are unable to gain access to his

airway

due to position,  so you cannot assist ventilations.  He can barely speak

now,

but manages to croak,   " Can't breathe, help me, can't move my arms,

......help me..... "

Save this patient and you'll enjoy the riches of the Outback in lovely

Ladonia, or you can stay home and watch soaps.

Mr. Grady.

" You can fool all of the people some of the time, and some of the people

all

of the time, and that's usually enough. "