Case of the Month
April 2005

41-year-old female — unconscious

Your aid unit is dispatched to a "sick unknown." While en route you are informed that the call has now been upgraded to a medic response. Your patient is a 41-year-old female who is unconscious. When you arrive at the scene a man waves to you from the front door of the house and yells for you to hurry.

As you approach the front door the man states "It's my wife, I don't know what's wrong. I found her asleep and she won't wake up." He leads you through a well-kept house to the master bedroom where you find a slender woman lying on her side, on the bed, on top of the covers. She is wearing a white blouse and black skirt with nylons. She has a "walking cast" on her right foot and ankle. Her skin looks very pale and you notice that she is breathing slowly.

One of your partners stabilizes her head to assure her airway while you check for a pulse. You find a radial pulse of 56 that is somewhat weak. Your other partner takes a blood pressure and finds it to be 94/P. She then prepares and places a partial non-rebreather mask on the patient. You give the medic unit a short radio report and reassess the situation.

LOC	—	Unconscious, not responding to noxious stimuli
RR	—	8
HR	—	56
BP	—	94/Palp
Skin	—	Cool, dry, pale
Eyes	—	2mm and non-reactive
Chest	—	Clear, but respirations are shallow
Abd	—	Unremarkable
Ext	—	Cool and Pale
Pulse Ox	—	Unobtainable

The patient's slow, shallow respirations are your immediate concern. You elect to begin breathing for the patient with your bag-valve mask. You attempt to insert an oral airway but she gags suggesting a strong cough reflex is present, so an oral airway is not needed. A blood sugar level is checked and found to be adequate at 85 mg/dl.

The husband states he arrived home from work and found her on the bed. He tried to wake her up, but could not get her to respond. He immediately called 9-1-1. He has never seen her like this before. She had surgery on her right foot a couple days ago because of a bunion and has been in a lot of pain since. The doctor had phoned in a new prescription for pain relief yesterday which she was going to start on today - a drug called Percocet. She also has a history of migraine headaches.

As you are waiting for the medics to arrive you review the patient's SAMPLE history:

S	—	Unconscious with slow respirations
A	—	No known allergies
M	—	Percocet for pain secondary to her foot surgery, no others
P	—	History of occasional migraine headaches
L	—	Last oral intake unknown
E	—	Husband returned from work to find the patient unconscious and not responding

While breathing for the patient you find that she seems to have some purposeful movement, but not significant. Her color has improved and you are able to get an oxygen saturation of 98%. The second set of vital signs find her with a heart rate of 68 and a blood pressure of 104/P. The medics arrive and reassess her pupils and place her on a heart monitor which shows a normal sinus rhythm.

The patient is examined for needle marks, but the medics are comfortable that the Percocet has caused her decreased level of consciousness and respiratory depression. An IV of Lactated Ringers is started and, after some discussion with the medical control physician, 0.4 mg of Narcan is given IV. Almost instantly the patient's breathing becomes stronger and her level of consciousness comes partially up. It is no longer necessary to breath for the patient, so she is placed on a non-rebreather mask.

The patient is placed in the back of the medic unit and she is transported to the local emergency department where she is monitored until the effects of the Percocet wear off. She is sent home several hours later with a less potent pain reliever.

Narcotics Overdoses
When we think of narcotic overdoses we most often think of the heroin user who has "shot up" a little too much; however, this does not hold true every time. Narcotics, or opiates as they are also known, are one of the most prescribed families of medications. The uses for medicinal narcotics include, cough suppression, control of diarrhea, but most of all, pain relief. Therefore not all of your narcotic overdoses are going to be some seedy teenager with a needle hanging out of his arm. Post surgery pain patients, people with chronic severe pain issues, or patients who have a cough that will not relent to over-the-counter suppressants could run into danger with this family of medications. There is also a growing use of illegally obtained oral narcotics as recreational drugs among younger people.

The symptoms of a narcotic overdose include decreased level of consciousness, depressed or obliterated respiratory drive, very small "pin point" pupils, and lowered vital signs. Severe overdoses result in death. Fortunately the treatment is simple. Usually excellent airway maintenance and oxygen delivery is more than adequate to keep these patients alive until ALS help arrives. Once the medics get there a remarkable medication, naloxone ( Narcan® ), can be given IV or IM to reverse the effects of the narcotic. The big issue for the medics is how much naloxone to give. In a patient who has severe pain, the naloxone will not only get them breathing again, but could wake them up and take away the pain relieving effect of the narcotic. In the heroin user, again it will take away the respiratory depression, but it will also take away their "high" which might make them quite angry. In a person who has a physical addiction to narcotics, naloxone can cause the patient to go into withdrawal. In most cases just enough naloxone to get the patient breathing, but not wake them up, is the correct dosage for in the field. Once they are in the hospital a different decision can be made.

The lesson learned from this case: Not everything is as it initially appears. There were several twists in this call: the patient was a diabetic and post leg surgery which may have lead you to think that these were the cause of her condition. In the face of uncertainty, the EMTs acted on the clinical information they saw-a decreased LOC and slow respiratory rate and started treatment immediately. They did airway management and assured that the paramedics were updated and en route. They took appropriate action without every knowing what was wrong with patient.