Call to an ACF (assisted care facility... basically low level nursing)

[Eydawn]

How would you guys handle this call? Just curious... something that actually happened at my facility about 4 nights ago.

100 year old female (sharp as a tack and sweeter than pie) pushes her call light, tells the care provider (yours truly) that she just doesn't feel right and she's "never felt like this before in my life." She's lying supine, pale, drenched in a cold sweat, but does not complain of dizziness, chest pain or shortness of breath. LPN is grabbed to assess her, can't obtain manual BP, gets an electronic BP at 58/40. Resident just started amoxicillin this evening for a minor infection from a root canal, has had exactly one dose at 6pm (it's now 12am).

We call 911, get a response... and then the general feeling is that there's probably nothing going on, she's chatty, feels fine, just feels "uncomfortable"... FD gets a BP at 60/40, EMS gets a BP at 90/50. Pulse is "regularly irregular" with hx Afib. Talking about how this is all just a big load of fuss and there's been no car accident so do we really need all these firemen (ROFL on the inside, trying not to show how funny I find this as this big fire guy is standing next to me...)

What do you guys think? Consistent with some sort of allergic reaction? That's where my LPN's brain went... my brain went cardiac before the LPN pulled up the resident's computer records.

I can't give you much more info, because frankly (even as a shift manager) I don't have anything else to give... we've got very limited health info on our folks aside from major diagnoses, previous events (usually what lands them with us in the first place) and their medication record.

Where does your brain go on this as a paramedic? What kind of assessment would you do before you moved her? Would you have her self-ambulate at all or would you do a direct transfer from bed to ambo cot?

Wendy

CO EMT-B

[JPINFV]

NOOOO... this is pulling me back to pharm and I'm really hating antibiotics right now.

Amoxicillin falls under the category of aminopenicillins, which I don't have listed any complications beyond those general for all penicillins.

Complications for penicillin:

Hypersensitivity, including upto anaphalaxis. PCN is a hapten, so by itself, its not big enough to trigger an immune response or immune memory. However, when it's bound to other proteins it can trigger a response and cause the immune system to both the PCN-protein complex as well as to PCN itself (however at a much lower rate than the complex).

Super infection (c-diff)

Seizures

A hypersensitivity like reaction in patients with syphilis (Jarisch-Herxheimer Reaction).

Diarrhea

[Richard B the EMT]

She's lying supine, pale, drenched in a cold sweat, but does not complain of dizziness, chest pain or shortness of breath

That, alone, without specifics, is at the least, an indication that SOMETHING is going on. As for allergic reaction to the penicillin, due to the gap between the dose, and the time the "help" is requested, as a BLS person myself, I would think it to be not the case, but still monitor breathing and airway, possibly supplemental O2 by local protocol administration device and liter flow.

However, unless the BPs are near whatever this patient has as their "normal" reading when the patient is NOT making a complaint, I would have some concerns in that area.

So, BLS application of supplemental O2, ALS running a base line 12 lead EKG, consult with OLMC, and/or transport to the nearest appropriate ER for more definitive care.

Again, I may not know what it is, but

There's something happening here,

and what it is, ain't exactly clear...

[Mateo_1387]

Interesting case Wendy.

If I were on that call and with the information you provided, I would probably...

Check vital signs, temperature included, orthostatic blood pressure, listen to lung sounds and heart tones along with a physical exam, neurological exam, 12 lead, and of course explore the history to help guide us to a working differential or diagnosis.

Saying that her mind is sharp, her normal, does this mean during this incident she had some degree of altered mental status? Some things, based on the limited information I would be considering are infection, pulmonary embolism, stroke, heart arrhythmia, myocardial infarction, dehydration. These are just some things to consider. Being in the room with the patient may change the list.

[DwayneEMTP]

Global diaphoresis always brings my little brain to full attention. I've rarely seen it in a sick person where something really shitty wasn't going on, but usually in those with sugar, cardiac issues or decompensating shock.

It is hard to develop a differential with any confidence without at least a decent set of vitals. BGL is a must, and I'm guessing it's going to be low whether or not it's the primary issue. Cardiomyopathy secondary to the root canal? It seems like I've heard rumors of this but have never bothered to run it down on my own. But a 12 lead is a no brainer here as well seems to me.

Perhaps, and I'm really talking out of my rear now, she's soaked secondary to some type of neural pathology simply because she's old, but I would expect it to be the other way around?

I'm also not confident of an allergic issue here due to the time span, but again, I'm not sure if that thinking is solid or not.

It would be nice to have a history, but lets get some rock solid vitals, Os, lung sounds, neuro exam, IV so I can manage her pressure, more lung sounds, 12lead, BGL, go ahead and sit her up as Matty said, see if she passes out, trot her over to the ER so the smart folks can figure it out.

Just taking a shot, but I'm going to guess that this will turn out to be metabolic and not primarily cardiac, though will likely be a combination of the two.

Or...as the other night. 98 year old unresponsive female. Laundry list of meds but the ones that stand out are benzos TID delivered on time, no narcs. Pupils so pinpoint that there is no pupil visible, RR 10/min, HR 56, BP 66/0. Give .5 Narcan IN (Intranasal atomizer) and she's responsive before we finish getting IV access and loading her onto the cot, all vitals improved. I suggest that perhaps her medications got switched but am reassured by the RN that "that's just not possible." So, I'd like to go on record as being the first medic in history to reverse a benzo OD with Narcan.

This is what can make nursing home calls tricky.

Dwayne

[jwraider]

#1 With that BP did she have a radial pulse? Since you said they felt an irregular pulse I'm guessing they did find one. Whether she had one all along or she got excited and her heart went faster when everyone arrived who knows. If not this would be a much more serious case it sounds like EMS showed up and found an OK BP to go along with a normal LOC.

With this kind of call all the answers you can get are in the initial assessment... LOC.. ABCs and skin signs...

For me an elderly patient with a recent infection and a low BP is probably septic despite how hot their skin may or may not be. That's my best guess for you and first thing I'd rule out.

I might do orthostatics if it was safe but otherwise Sp02, 02, monitor, blood sugar check (can add to an infection differential), and of course IV with fluids to keep her BP above 90 sys along with further questioning.

[fiznat]

Without actually being there and without more information, any guess at the etiology here would be just that... a wild guess. We don't even really know whether this patient was hypotensive or not, as there are 3 different blood pressures ranging 30 points systolic. A blood pressure of 90/whatever might even be normal for this 100 year old patient.

I think in general in these kinds of situations it is better to do a complete assessment from head to toe before you start getting caught up in etiology. Wild guesses without all of the information have the nasty tendency to color an assessment before all the information is really discovered, which can sometimes be a big problem.

[Aussieaid]

There is a strong possibility that she was actually septic and the dose of antibiotics caused a massive cytokine release resulting in her hypotension. In the very elderly they may not have a temperature and some of the other signs for you to pick up on the sepsis and she already has a known infection which may not have been as minor as was thought to be. Amoxicillin usually has a shorter half life than 6 hours but in the elderly a lot of drugs take longer to metabolize. She could also be hypotensive from septic shock where one dose of oral antibiotics has not been enough to halt the septic cascade.

At the very least she needed to be taken to the ER for a full cardiac and septic work up. With her presentation I would not be having her self ambulate.

Remember that things you can blow off in a younger person can be life threatening in a geriatric patient.

Cheers,

Gypsy.

[HERBIE1]

I'm wondering if the antibiotic was prophylactic or if there was an infection going on. I would be leaning towards metabolic issues- ie septic shock, based on the BP. As for ambulating- no way. Cardiac is possible, but it wouldn't be high on my list.

Fluids wide, high flow o2 and fly. I'd guess she has a massive course of iV antibiotics in her future.

NH patients are tricky.

[p3medic]

I'd be doubtfuly of an immune response as the BP drop seems to have been transient. Whatever occured seems to have been self limiting. I didn't see a heart rate in the OP's post, a vagal episode is quite possible, although we have some other more serious diff's to consider.