MAN DOWN!

          Being dispatched to a "man down" is common in EMS. Small or rural EMS systems often see the lion's share of "man down" calls on weekends, when frequenting pubs and taverns is at a peak. By comparison, in larger urban systems, "man down" calls are daily events, often many times each day. To add insult to injury, large systems have to deal with the weekend increase as well.

     Along with the frequency of occurrence, "man down" calls also present the challenge of figuring out just what put your patient down in the first place.

     In this month's edition of BTB, we'll look at how you can quickly rule out the three biggest life threats for your "man down." There are many reasons a person might be unconscious and unresponsive, but we will focus on the three that involve more time-intensive interventions.

Think Heart
     The human heart is a wonder of technology, and, with little to no maintenance per se, it serves us for a lifetime. Day in and day out, the heart must maintain a constant flow of blood at just the right pressure to make certain our metabolic needs are met.

     When patients have increased vagal tone resulting in slow pulse rates, you should expect to hear them complaining of weakness, being overly tired or having no energy. With slow cardiac rates, expect decreased mentation as well, which may be tied to a chief complaint of being confused or "just not thinking right." But while patients with slow pulse rates are certainly at risk, they usually don't just collapse to the floor.

     On the other hand, a sudden collapse secondary to a heart problem usually points toward something catastrophic, such as pulseless v-tach or ventricular fibrillation. Quickly look for "defensive wounds," i.e., scuffed palms or shoulders that imply the patient had enough mental wherewithal to attempt to break his fall with his hands or mitigate damage by rolling onto a shoulder. He is very high risk and most likely needs immediate intervention. A broken nose and/or cracked front teeth with associated facial abrasions are usually the end results of someone doing a "face plant."

     Medications like antidysrhythmics (amiodarone) let you know the patient has already had problems with unstable cardiac rhythms. Look for the telltale scar from a pacemaker/AED implantation.

     If you confirm that you have an apneic, pulseless patient, start CPR immediately while you wait for the AED to be applied. Also keep in mind that definitive care for the critical cardiac patient does not occur in the street setting, but rather at a cardiac center. Limit scene interventions to the bare essentials so you can quickly get the patient en route, with all other care being done on the fly.

Think Sugar
     Diabetics are challenged to maintain healthy blood sugar levels on a daily basis. To do so, they must maintain a balance between food intake, insulin levels and exercise. When a diabetic runs amok, more often than not the diabetic "triangle" is compromised in one of three common ways. First, the person can have a normal breakfast, take his usual dose of insulin, but then overexert himself. This mismatch of too much work for the available energy stores lets the patient run out of fuel and he passes out. With option #2, something distracts him and he forgets to eat breakfast; however, he still takes his insulin. But because he neglected to add new fuel, the existing energy stores quickly burn up, and, in short order, down he goes. The third combination of events occurs when the diabetic eats breakfast, takes his insulin, but forgets that he took it and takes a second dose. Even with his normal food intake and normal daily exertion, the double dose of insulin burns through his fuel supply very quickly, and, once again, it's down to the ground.

     It is a given that the blood sugar level should be checked on any patient who is down from an unknown etiology.

Think Head
     Though the human brain represents only about 2% of body weight, it uses approximately 20% of the body's cardiac output and oxygen supply. In addition, the brain needs a constant supply of oxygen and glucose, but can store neither. Therefore, the brain always manipulates physiology to make certain that its biologic needs are met with adequate sugar, oxygen and perfusion pressure. Assuming that sugar levels have been ruled out as a primary cause, it's time to look at other possible causes.

     Clues that may point to the head as the problem include medications for hypertension (beta or calcium channel blockers, diuretics) or anxiety (benzodiazepines), or for atrial fibrillation (blood thinners like Coumadin and/or a cardiac glycocide like digoxin or Lanoxin). Also be alert for patients taking OTC diet aids, many of which are amphetamine analogs that can cause lethal rises in blood pressure. Also note any obvious physical signs such as facial asymmetry or droop, excessive drooling, aphasia, unequal grips, etc. A recent history of severe headaches, visual disturbances, TIA or failing the Cincinnati Stroke Test may further flesh out the diagnosis.

     Securing the airway, providing oxygen, monitoring for dysrhythmias and quickly delivering the patient to the appropriate facility can make the difference between a patient with a future and no patient at all.

     After quickly ruling out these three emergencies, you can move on to those less life-threatening/time-intensive possible causes for your patient going to the ground.

     Until next month...

Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.