Overdoses

[HeatherISU]

I have a situation that occurred and I was wondering about alternatives that could have been explored.

Late night admit 20yo F with polydrug intentional overdose on an Emergency Detention. Up from ER coming in and out of extreme agitation then lethargy. The pt would really fall asleep while talking. Apneic episodes 10-15 seconds with desats into 75%, pt remains pink. One nurse had to sternal rub her awake, and she would become agitated again.

Pt received no medications other than NS in ER. No charcoal r/t pt stating took meds IV. No narcan given. (pt positive for benzos and opiates)

Telephone call made to admitting doctor. I told him exactly as I have listed above. I'm still new, and I mentioned our detox policies (which are evidently for alcoholics, not ODs...which he made clear in a very annoyed manor. Oops!) He says to me... "I can't give her ativan because of her apnea. Narcan will just make her crazier. Go for a rapid sequence intubation"

I wasn't expecting him to say intubation, but I wrote down the order and informed the other nurses assisting with her admission. I got some "Are you serious?!" reactions, and one nurse in particular seemed annoyed by this, as if we were intubating her instead of actually caring for her... or taking the easy way out. I asked a senior nurse who opinion I absolutely trust, and she said that intubation made sense since she was at risk for anpea/seizures with an unprotected airway.

What have you seen done in these situations? Were there alternatives? Was intubation too extreme or justified? Thanks for any input. I know doctors rely heavily on our assessments given over a telephone report, so knowing a future "recommendation" for the SBAR report would be lovely.

[PiPhi2004]

LOL if its a 1 on 1 I guess you could, but heck you cant protect her airway for her, even if you're sitting beside her! With compromise in respiratory status she bought herself some tube time, and definitely shes at huge risk for aspiration!

[Mrs.Rollins, ASN, RN]

You guys hit it right on the head. She was intubated/sedated with propofol. (She barely responded to the versed.) Extubated in the AM. I just had one nurse that thought I was crazy and actually said that she would have drug her med cart in there to sit with her and manually wake her up from each apneic spell to avoid intubation.

This is an ICU nurse? What is she smoking and where can I get some of it?

[steelydanfan]

" She was admitted from the ER with poor ventilations, lethargy"...why wasn't she intubated in the ER with those symptoms? Sounds like she had been unable to protect her airway long before she got to you!

[jjjeep4]

it was correct at the moment.....significant apnea and desat along with decreased loc indicates need for rapid airway protection.

But....when an od comes in, if your facility does not have one, make a note of each drug od/time of ingestion/half-life/major expected sequela from each drug- utilize hospital computer system and your pharmacist aggressively. Also, check if poison control has been notified....it is not required, but if we need it, nurses can call (they can telllyou more in 60 seconds and will aggressively track a complex od over days and provide great followup)...

All od should be considered hi risk for alt ment status and rapid deterioration...intubation is frequently needed....and should always be a potential plan.

[rghbsn, BSN, RN]

Excellent post by matt2401.

Don't forget the ever-popular GCS score and the mantra: less than 8, intubate. Apnea for 10-15 seconds on a regular basis is never good...if it's a OSA situation, you can justify BiPap, but on a pt. that requires a sternal rub for arousal you would just be asking to fill her belly with air and end up (again) in a asperiation pneumonia situation. I don't know if you have any standing orders or protocols, but a blood gas (if not obtained prior) would have been appropriate to have ordered before calling the MD is possible. I am not sure why some of the other nurses were suprised of annoyed, intubation was the safest route to go there...

[2bnursenikki82]

Our ER tubes OD pt's almost immediately. They don't play!!

I had one like that a month or so ago...tubed in ER, kept her sedated over night and they extubated at 0700. (then we had to sit on her and her suicide precautions for 2 days because tele was full...)

[Fink]

:angryfireWe have to keep them in our ICU until a mental health evaluation or the probate judge issues a court ordered committment. Our ICU acts like a prison and we are the wardens instead of nurses. That really irritates me!

[rghbsn, BSN, RN]

I hear you, Fink...last year we had one of our mental health facilities in the city shut it's doors. Our ED and ICU's have been overrun with OD's, SI, and the like. They had to build a new section of the ED to house all of the IVC (involuntary commitment) pt's while they wait for transport to various mental health agencies. Most are hours away, beds are hard to get, and they usually only pick up once a day at best...so if you don't have all the "i's" dotted and "t's" crossed in time, it's another 24 hours of sitting on them in the ED.

In the ICU, the IVC's are supposed to be seen within 24 hours by psych, but sometimes they just call and give an order on the phone (especially over the weekend) so the pt. can be "re"evaluated later, when it's more convenient for the doctor.

I've had septic patients on the vent, triple lumen, propofol, dopamine and xigris in the ED because there was no bed in the ICU...because of the IVC that hadn't been cleared by psych yet.

Frustrating is mild...but I understand where you're coming from. It's one of the reasons I love my job now. Fly them in, give report, go get the next one.