Let's move on to our third case. You start on your Saturday night overnight shift, and your first patient is one of your regular alcoholic street people found down on the street unable to walk.

His friend was worried because he said he complained of abdominal pain despite drinking a whole lot of moonshine.

So he called 911.

The paramedics noted that he appeared drunk,

but had normal vital signs and oxygenation saturation. After transport to the hospital,

he complained of worsening abdominal pain. At that time, his blood pressure was 120 over 70,

heart rate of 82, temp at 35.8, and respiratory rate of 22, with an oxygen saturation

of 99% on room air. A few hours later, in your ED, his GCS score fell to 6, and his respiratory

rate increased to 32. There were no focal neurologic signs, and the physical examination was otherwise

unremarkable. A rapid sequence intubation was performed with propofal and sucks. This is a good

spot to talk about the elements of the coma cocktail. So speaking of the coma cocktail,

whether you use the mnemonic don't dextrose, oxygen, nalaxone,

thymine, things have evolved, right? Previously, flamazinol was in that, and that's kind of changed.

I think dextrose highlights the importance in comatose patients to check sugar as an additional

vital. I don't give dextrose to people who aren't hypoglycemic. I think with naloxone or narcan, think about opioid overdoses.

I think that if someone is acting like they're on an opioid, I'll think about using it.

Where you have caution is often people will take a combination of overdoses or a combination of ingestions.

So their pupils might not be the only clue.

Someone who might have something sympathetic medic on board prior and an opioid, you might not

have pinpoint pupils.

Where I'd rely on more is probably the low rest rate.

With regards to the coma patient, though, if someone is profoundly comatose, I'm not sure,

...