Guest guest Posted March 31, 2007 Report Share Posted March 31, 2007 You and your partner respond to a fraternity house on the campus of the University for an " unconscious person. " On arrival at the large, Colonial Style house with columns on the front, you find a large crowd of young people milling about, all carrying beer or drinks in paper cups, deafening music playing, and nobody being very cooperative. Finally, just as the campus police arrive, a male comes out the front door and says to follow him. You are led through the house to a large room where there are 15-20 people standing around a young male lying on a filthy couch. One person is doing mouth-to-mouth and another is doing some very slow and ineffectual chest compressions. You ask the two campus cops to clear the room, which they do, and you ask the two people who are trying to help the patient if they know what happened. One says " no " but the other seems like he wants to say something but keeps looking at the cops and hesitates. As you begin to assess the patient, you quietly ask your partner to take the " helper " aside and see if she can get any information from him, while you ask the cops to go and get your stretcher if they don't mind. They are glad to comply. You find what appears to be a post-teen male who is unresponsive to pain, breathing very slowly, cyanotic, and with vomit on his face. You smell what you assume is ETOH, although you can't be sure it's coming from him because the whole place reeks of it and cigarette smoke. He has a rapid radial pulse which you estimate to be ~ 120. You quickly insert a nasopharyngeal airway in the patient and have begun to ventilate with the BVM, but you are feeling poor compliance and difficulty in ventilating, with poor chest expansion, when your partner comes back and says that the patient's friend says the patient told him he was going to do " a Fat Albert " just a few minutes before he collapsed. How will this information affect your treatment decisions with regard to this patient, and what interventions will you employ? What do you conclude has happened to this patient? Gene G. ************************************** See what's free at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 31, 2007 Report Share Posted March 31, 2007 Jules, I will comment below! Gene > >>> You quickly insert a nasopharyngeal airway in the patient and have > begun to > >>ventilate with the BVM, but you are feeling poor compliance and > difficulty in > >>ventilating, with poor chest expansion, when your partner comes back > and says > >>that the patient's friend says the patient told him he was going to > do " a Fat > >>Albert " just a few minutes before he collapsed. > > I guess it didn't help nausea in this instance... > Will want to consider other drugs, what the pot was laced with if > anything...consider a meth connection.. > A perfectly reasonable thought. Consideration of other drugs is the thing. But Pot and Meth are not involved. > > >> How will this information affect your treatment decisions with > regard to this > >>patient, and what interventions will you employ? > > Suction and intubation > IV > Narcan (incase other drugs on board) > Narcan results in the patient opening his eyes but doesn't improve his tidal volume. You still find him difficult to bag. > Get as full of a history as possible to rule out medical > condition/allergies condition/a > Grayson--diesel bolus being prepared to code. > > >>>What do you conclude has happened to this patient? > Off the top of my head, based solely on these clues without going > through ALL differentials. t > > 1. Aspiration of emesis > Not the problem. > 2. Acute ETOH poisoning. > Not the problem, but a contributor. > 3. Possible drug interaction/ 3. Possible drug interaction/<wbr> > something else..consider other " recreational " drug use > > jules > > So what is the drug that's involved? What's a " Fat Albert? " GG > ************ ******** ******** ******* > See what's free at http://www.aol.http > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 31, 2007 Report Share Posted March 31, 2007 Gene, According to the Office of the National Drug Control Policy, Fentanyl is also known as " Fat Albert. " Symptoms of a fentanyl overdose may include trouble or slow breathing, extreme weakness or dizziness, extremely tired, pinpoint pupils, cold and clammy skin, inability to think and fainting. Alcohol can increase dizziness or drowsiness caused by fentanyl. Exposure to heat or an increase in body temperature also can cause adverse affects. This patient is difficult to bag because he as most likely aspirated. Do do the patient being unable to control his own airway, advanced airway techniques should be put in place. You should also assess body temp and fluid intake. If hypotension develops, you should treat accordingly. Narcan can be used to reverse fentanyl. When using Narcan to reverse Fentanyl, you will have to administer more than the typical dosage normally used. Fentanyl's effects are essentially indistinguishable from those of heroin except that is has a shorter duration of action. Fentanyl is significantly more potent than heroin and 50-80 times potent than morphine. A toxscreen will be negative for opiates when fentanyl has been used. Fentanyl is not detected by standard urine opiate immunoassays; therefore, opioid exposures should not be ruled out based on toxscreen results. To sum it up, this patient needs airway control, environmental precautions, blood pressure monitored closely, and most importantly, high doses of Narcan. Thiamine can also be used in the event that the patient is a chronic alcoholic. ************************************** See what's free at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 31, 2007 Report Share Posted March 31, 2007 >>> You quickly insert a nasopharyngeal airway in the patient and have begun to >>ventilate with the BVM, but you are feeling poor compliance and difficulty in >>ventilating, with poor chest expansion, when your partner comes back and says >>that the patient's friend says the patient told him he was going to do " a Fat >>Albert " just a few minutes before he collapsed. I guess it didn't help nausea in this instance... Will want to consider other drugs, what the pot was laced with if anything...consider a meth connection... >> How will this information affect your treatment decisions with regard to this >>patient, and what interventions will you employ? Suction and intubation IV Narcan (incase other drugs on board) Get as full of a history as possible to rule out medical condition/allergies/medications Grayson--diesel bolus being prepared to code. >>>What do you conclude has happened to this patient? Off the top of my head, based solely on these clues without going through ALL differentials... 1. Aspiration of emesis 2. Acute ETOH poisoning. 3. Possible drug interaction/OD..if the cannabis was laced with something else..consider other " recreational " drug use jules ************************************** See what's free at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 31, 2007 Report Share Posted March 31, 2007 Since I'm sure Gene has a much deeper cause going here and my first response was very " obvious " observations.. I would wonder about a history of: Myasthenia Gravis---Cannabis is a " fairly " commonly used to help with symptoms in Neuromuscular disorders.. Jules Another puzzler You and your partner respond to a fraternity house on the campus of the University for an " unconscious person. " On arrival at the large, Colonial Style house with columns on the front, you find a large crowd of young people milling about, all carrying beer or drinks in paper cups, deafening music playing, and nobody being very cooperative. Finally, just as the campus police arrive, a male comes out the front door and says to follow him. You are led through the house to a large room where there are 15-20 people standing around a young male lying on a filthy couch. One person is doing mouth-to-mouth and another is doing some very slow and ineffectual chest compressions. You ask the two campus cops to clear the room, which they do, and you ask the two people who are trying to help the patient if they know what happened. One says " no " but the other seems like he wants to say something but keeps looking at the cops and hesitates. As you begin to assess the patient, you quietly ask your partner to take the " helper " aside and see if she can get any information from him, while you ask the cops to go and get your stretcher if they don't mind. They are glad to comply. You find what appears to be a post-teen male who is unresponsive to pain, breathing very slowly, cyanotic, and with vomit on his face. You smell what you assume is ETOH, although you can't be sure it's coming from him because the whole place reeks of it and cigarette smoke. He has a rapid radial pulse which you estimate to be ~ 120. You quickly insert a nasopharyngeal airway in the patient and have begun to ventilate with the BVM, but you are feeling poor compliance and difficulty in ventilating, with poor chest expansion, when your partner comes back and says that the patient's friend says the patient told him he was going to do " a Fat Albert " just a few minutes before he collapsed. How will this information affect your treatment decisions with regard to this patient, and what interventions will you employ? What do you conclude has happened to this patient? Gene G. ************************************** See what's free at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted March 31, 2007 Report Share Posted March 31, 2007 Gene, If i'm correct a " Fat Albert " would be a quarter gram of cocaine. wegandy1938@... wrote: Jules, I will comment below! Gene > >>> You quickly insert a nasopharyngeal airway in the patient and have > begun to > >>ventilate with the BVM, but you are feeling poor compliance and > difficulty in > >>ventilating, with poor chest expansion, when your partner comes back > and says > >>that the patient's friend says the patient told him he was going to > do " a Fat > >>Albert " just a few minutes before he collapsed. > > I guess it didn't help nausea in this instance... > Will want to consider other drugs, what the pot was laced with if > anything...consider a meth connection.. > A perfectly reasonable thought. Consideration of other drugs is the thing. But Pot and Meth are not involved. > > >> How will this information affect your treatment decisions with > regard to this > >>patient, and what interventions will you employ? > > Suction and intubation > IV > Narcan (incase other drugs on board) > Narcan results in the patient opening his eyes but doesn't improve his tidal volume. You still find him difficult to bag. > Get as full of a history as possible to rule out medical > condition/allergies condition/a > Grayson--diesel bolus being prepared to code. > > >>>What do you conclude has happened to this patient? > Off the top of my head, based solely on these clues without going > through ALL differentials. t > > 1. Aspiration of emesis > Not the problem. > 2. Acute ETOH poisoning. > Not the problem, but a contributor. > 3. Possible drug interaction/ 3. Possible drug interaction/<wbr> > something else..consider other " recreational " drug use > > jules > > So what is the drug that's involved? What's a " Fat Albert? " GG > ************ ******** ******** ******* > See what's free at http://www.aol.http > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 1, 2007 Report Share Posted April 1, 2007 Fentanyl OD, with 'wooden chest', (myasthenia gravis) Narcan, paralytics if necessary, extreme diesel bolus Another puzzler You quickly insert a nasopharyngeal airway in the patient and have begun to ventilate with the BVM, but you are feeling poor compliance and difficulty in ventilating, with poor chest expansion, when your partner comes back and says that the patient's friend says the patient told him he was going to do " a Fat Albert " just a few minutes before he collapsed. How will this information affect your treatment decisions with regard to this patient, and what interventions will you employ? What do you conclude has happened to this patient? Gene G. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 1, 2007 Report Share Posted April 1, 2007 I believe " Fat Albert " is a slang term for 1/4 gram of cocaine. Since I'm BLS only, I'd suction then bag him, then call for ALS. Kirk EMT-B ************************************** See what's free at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 1, 2007 Report Share Posted April 1, 2007 Ok so I'm a still only an EMT B but being a young I can tell you that when I was in college, Fat Albert was a reference to cocaine. Now it references fentanyl. (and just for the record I learned this working in corrections) Fentanyl is a synthetic drug similar to heroin but more powerful. Its a common drug for pain treatment and is liked by students who can make it easily in a lab or is stolen from cancer patients, long term care facilities, etc. Side effects include vomiting and slow respiration rates, and it affects the CNS, look for pin point pupils. Treat as a heroin overdose with prompt transport (immediate iv access,narcan at .5 mg first dose?, assist respirations with bvm, cardiac monitor)... Thats my two cents... ez EMT B/FF Group Newbie > > You and your partner respond to a fraternity house on the campus of the > University for an " unconscious person. " > > On arrival at the large, Colonial Style house with columns on the front, you > find a large crowd of young people milling about, all carrying beer or drinks > in paper cups, deafening music playing, and nobody being very cooperative. > > Finally, just as the campus police arrive, a male comes out the front door > and says to follow him. You are led through the house to a large room where > there are 15-20 people standing around a young male lying on a filthy couch. > One person is doing mouth-to-mouth and another is doing some very slow and > ineffectual chest compressions. > > You ask the two campus cops to clear the room, which they do, and you ask the > two people who are trying to help the patient if they know what happened. > One says " no " but the other seems like he wants to say something but keeps > looking at the cops and hesitates. > > As you begin to assess the patient, you quietly ask your partner to take the > " helper " aside and see if she can get any information from him, while you ask > the cops to go and get your stretcher if they don't mind. They are glad to > comply. > > You find what appears to be a post-teen male who is unresponsive to pain, > breathing very slowly, cyanotic, and with vomit on his face. You smell what you > assume is ETOH, although you can't be sure it's coming from him because the > whole place reeks of it and cigarette smoke. He has a rapid radial pulse > which you estimate to be ~ 120. > > You quickly insert a nasopharyngeal airway in the patient and have begun to > ventilate with the BVM, but you are feeling poor compliance and difficulty in > ventilating, with poor chest expansion, when your partner comes back and says > that the patient's friend says the patient told him he was going to do " a Fat > Albert " just a few minutes before he collapsed. > > How will this information affect your treatment decisions with regard to this > patient, and what interventions will you employ? What do you conclude has > happened to this patient? > > Gene G. > > > > > ************************************** > See what's free at http://www.aol.com. > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 1, 2007 Report Share Posted April 1, 2007 Hi , You're right on target except for the aspiration. That is not the reason for the difficulty in ventilating the patient. There's another reason which is peculiar to fentanyl. GG In a message dated 4/1/07 1:44:48 AM, Txguy001 writes: > Gene, > > According to the Office of the National Drug Control Policy, Fentanyl is > also known as " Fat Albert. " Symptoms of a fentanyl overdose may include > trouble or slow breathing, extreme weakness or dizziness, extremely tired, pinpoint > pupils, cold and clammy skin, inability to think and fainting. Alcohol can > increase dizziness or drowsiness caused by fentanyl. Exposure to heat or an > increase in body temperature also can cause adverse affects. > > This patient is difficult to bag because he as most likely aspirated. Do > do the patient being unable to control his own airway, advanced airway > techniques should be put in place. You should also assess body temp and fluid > intake. If hypotension develops, you should treat accordingly. > > Narcan can be used to reverse fentanyl. When using Narcan to reverse > Fentanyl, you will have to administer more than the typical dosage normally used. > Fentanyl's effects are essentially indistinguishable from those of heroin > except that is has a shorter duration of action. Fentanyl is significantly > more potent than heroin and 50-80 times potent than morphine. Â A toxscreen will > be negative for opiates when fentanyl has been used. Fentanyl is not > detected by standard urine opiate immunoassays; therefore, opioid exposures should > not be ruled out based on toxscreen results. > > To sum it up, this patient needs airway control, environmental precautions, > blood pressure monitored closely, and most importantly, high doses of > Narcan. Thiamine can also be used in the event that the patient is a chronic > alcoholic. > > > > > > > See what's free at AOL.com. ************************************** See what's free at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 1, 2007 Report Share Posted April 1, 2007 That may be a regional name, but coke is not the drug most associate with Fat Albert. Gene > > I believe " Fat Albert " is a slang term for 1/4 gram of cocaine. Since I'm > BLS only, I'd suction then bag him, then call for ALS. > > Kirk > EMT-B > > ************ ******** ******** ************<wbr>*********http://www.aol.http > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 1, 2007 Report Share Posted April 1, 2007 , Welcome and thanks for your input. Bingo! Right on target. The scenario is coming together. I think most of the points have been made. I'll post a summary a little later after all have had their say. Gene G. > > Ok so I'm a still only an EMT B but being a young I can tell you that > when I was in college, Fat Albert was a reference to cocaine. > > Now it references fentanyl. (and just for the record I learned this > working in corrections) > > Fentanyl is a synthetic drug similar to heroin but more powerful. Its > a common drug for pain treatment and is liked by students who can > make it easily in a lab or is stolen from cancer patients, long term > care facilities, etc. > > Side effects include vomiting and slow respiration rates, and it > affects the CNS, look for pin point pupils. > > Treat as a heroin overdose with prompt transport (immediate iv > access,narcan at .5 mg first dose?, assist respirations with bvm, > cardiac monitor)... > > Thats my two cents... > > ez > EMT B/FF > Group Newbie > > --- In texasems-l@yahoogrotexasem, wegandy1938@, wegandy1 > > > > You and your partner respond to a fraternity house on the campus of > the > > University for an " unconscious person. " > > > > On arrival at the large, Colonial Style house with columns on the > front, you > > find a large crowd of young people milling about, all carrying beer > or drinks > > in paper cups, deafening music playing, and nobody being very > cooperative. > > > > Finally, just as the campus police arrive, a male comes out the > front door > > and says to follow him. You are led through the house to a large > room where > > there are 15-20 people standing around a young male lying on a > filthy couch. > > One person is doing mouth-to-mouth and another is doing some very > slow and > > ineffectual chest compressions. > > > > You ask the two campus cops to clear the room, which they do, and > you ask the > > two people who are trying to help the patient if they know what > happened. > > One says " no " but the other seems like he wants to say something > but keeps > > looking at the cops and hesitates. > > > > As you begin to assess the patient, you quietly ask your partner to > take the > > " helper " aside and see if she can get any information from him, > while you ask > > the cops to go and get your stretcher if they don't mind. They > are glad to > > comply. > > > > You find what appears to be a post-teen male who is unresponsive to > pain, > > breathing very slowly, cyanotic, and with vomit on his face. You > smell what you > > assume is ETOH, although you can't be sure it's coming from him > because the > > whole place reeks of it and cigarette smoke. He has a rapid > radial pulse > > which you estimate to be ~ 120. > > > > You quickly insert a nasopharyngeal airway in the patient and have > begun to > > ventilate with the BVM, but you are feeling poor compliance and > difficulty in > > ventilating, with poor chest expansion, when your partner comes > back and says > > that the patient's friend says the patient told him he was going to > do " a Fat > > Albert " just a few minutes before he collapsed. > > > > How will this information affect your treatment decisions with > regard to this > > patient, and what interventions will you employ? What do you > conclude has > > happened to this patient? > > > > Gene G. > > > > > > > > > > ************ ******** ******** ******* > > See what's free at http://www.aol.http > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 1, 2007 Report Share Posted April 1, 2007 Gene, Since the term " fat albert " varies from locale to locale (cocaine, fentanyl and a strain of Canadian Cannabis), there are several things to consider with this patient. Obviously ETOH would be a consideration or a contributing factor. Given the age group, environment and in the absence of tell-tale signs of IV drug use (syringes, track marks etc...), the fact that Cannabis alone does not knock out respirations and the statement " He was about to do a...., " I would strongly consider GHB as the main culprit for this patient's condition. In that case, aggressive airway management with ventilatory support would be the first priority followed by IV establishment, cardiac monitoring, obtaining a d-stick and a very thorough secondary assessment. It would not hurt to consider narcan after establishing the patient has an acceptable blood glucose level. Once the airway is secure and cleared, most of the rest can be completed during transport. Bacco ************************************** See what's free at http://www.aol.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 1, 2007 Report Share Posted April 1, 2007 Don't be misled by the " absence of tell-tale signs of IV drug use. " Actually this is an injected overdose of fentanyl. So, I'll try to pull together all the great answers that have been posted and summarize. This patient injected an unknown amount of a street drug containing fentanyl. A search of the immediate area would have turned up a syringe. Because the dose was far more than a therapeutic dose, the patient suffered an almost immediate respiratory arrest, coupled with muscular tetany of the muscles of respiration. Treatment is ventilation with 100% oxygen first, IV, narcan titrated to effect, check blood glucose level and give sugar as needed, consider thiamine since ETOH consumption history is unknown, and it won't hurt. If the patient cannot be ventilated because of muscle spasms, consider a neuromuscular blocker and intubation. According to the literature I read preparing this scenario, nalaxone usually reverses the muscular tetany but may not. The condition is seldom, if ever, seen with therapeutic doses of fentanyl, because it is the speed of administration rather than the amount that usually causes the problem. However, with mega doses, given rapidly, muscular rigidity, particularly of the respiratory muscles, can occur. It may require a neuromuscular blockade to reverse it. Fentanyl overdoses have increased alarmingly in some areas of the country within the last year. Many patients, unaware of what they are taking, die of respiratory failure almost immediately. Many are found " sitting up. " Chicago and the Midwest lead the way in fentanyl overdoses, but, as Grayson showed, they can be anywhere (he's in Louisiana). Anyone with further information about fentanyl overdoses, please post. Gene Gandy > > Gene, > > Since the term " fat albert " varies from locale to locale (cocaine, fentanyl > and a strain of Canadian Cannabis), there are several things to consider > with > this patient. Obviously ETOH would be a consideration or a contributing > factor. Given the age group, environment and in the absence of tell-tale > signs > of IV drug use (syringes, track marks etc...), the fact that Cannabis alone > does not knock out respirations and the statement " He was about to do > a...., " > I would strongly consider GHB as the main culprit for this patient's > condition. > > In that case, aggressive airway management with ventilatory support would be > the first priority followed by IV establishment, cardiac monitoring, > obtaining a d-stick and a very thorough secondary assessment. It would not > hurt to > consider narcan after establishing the patient has an acceptable blood > glucose level. Once the airway is secure and cleared, most of the rest can > be > completed during transport. > > Bacco > > > > ************ ******** ******** ************<wbr>*********http://www.aol.http > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted April 2, 2007 Report Share Posted April 2, 2007 Excellent point, Larry. Thank you. Gene > > Also check the mouth. Fentanyl patches are often placed in the mouth > and chewed and sucked on to get the drug out. I've pulled sometimes 2 > or 3 patches out of the same person. > > LT > > wegandy1938@wegandy wrote: > > Don't be misled by the " absence of tell-tale signs of IV drug use. " > > Actually this is an injected overdose of fentanyl. > > > > So, I'll try to pull together all the great answers that have been posted > and > > summarize. > > > > This patient injected an unknown amount of a street drug containing > fentanyl. > > A search of the immediate area would have turned up a syringe. > > > > Because the dose was far more than a therapeutic dose, the patient > suffered > > an almost immediate respiratory arrest, coupled with muscular tetany of > the > > muscles of respiration. > > > > Treatment is ventilation with 100% oxygen first, IV, narcan titrated to > > effect, check blood glucose level and give sugar as needed, consider > thiamine since > > ETOH consumption history is unknown, and it won't hurt. > > > > If the patient cannot be ventilated because of muscle spasms, consider a > > neuromuscular blocker and intubation. > > > > According to the literature I read preparing this scenario, nalaxone > usually > > reverses the muscular tetany but may not. The condition is seldom, if > ever, > > seen with therapeutic doses of fentanyl, because it is the speed of > > administration rather than the amount that usually causes the problem. > However, with > > mega doses, given rapidly, muscular rigidity, particularly of the > respiratory > > muscles, can occur. It may require a neuromuscular blockade to reverse it. > > > > Fentanyl overdoses have increased alarmingly in some areas of the country > > within the last year. Many patients, unaware of what they are taking, die > of > > respiratory failure almost immediately. Many are found " sitting up. " > > > > Chicago and the Midwest lead the way in fentanyl overdoses, but, as > > Grayson showed, they can be anywhere (he's in Louisiana). > > > > Anyone with further information about fentanyl overdoses, please post. > > > > Gene Gandy > > > > > > In a message dated 4/2/07 12:48:44 AM, fremsdallas@fremsda writes: > > > > > >> Gene, > >> > >> Since the term " fat albert " varies from locale to locale (cocaine, > fentanyl > >> and a strain of Canadian Cannabis), there are several things to consider > >> with > >> this patient. Obviously ETOH would be a consideration or a contributing > >> factor. Given the age group, environment and in the absence of tell-tale > >> signs > >> of IV drug use (syringes, track marks etc...), the fact that Cannabis > alone > >> does not knock out respirations and the statement " He was about to do > >> a...., " > >> I would strongly consider GHB as the main culprit for this patient's > >> condition. > >> > >> In that case, aggressive airway management with ventilatory support would > be > >> the first priority followed by IV establishment, cardiac monitoring, > >> obtaining a d-stick and a very thorough secondary assessment. It would > not > >> hurt to > >> consider narcan after establishing the patient has an acceptable blood > >> glucose level. Once the airway is secure and cleared, most of the rest > can > >> be > >> completed during transport. > >> > >> Bacco > >> > >> > >> > >> ************ ******** ******** ************<wbr>******** > http://www.aol.http > >> > >> Quote Link to comment Share on other sites More sharing options...
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