Weird But True

[DartmouthDave]

Hello,

Sorry, been away for awhile. Sold my house and have one new job and maybe a HEMS gig (very anxious).

Fiznat,

It was a hard call for the crew. The patient was in a great deal of pain and they felt that it was worsening his clinical condition. Alas, Morphine was the only drug they had available. I have read about Ketamine in pre-hospital pain control as well as Fentanyl. Better drug, I think, if available.

Quickfire wrote:

As for SIRS, why was his HR so low with a BP like that? From what I understand (which probably isnt much) He should have been getting tachy, as a compensatory response to the hypovolemia. Was there something else found to account for this? Or was he previously borderline hypotensive and possibly tolerated it better.

I agree. I was very weird. Nor dose this patients clinical picture mesh with any clinical description of SIRS that I have read. One theory was a mild cardiac contusion (despite a normal look cardiac echo, negative troponins). Who knows?!?

Chbare,

Could be. The fellow wasn't the best at recalling medication he was one.

Cheers....

PS... If anybody has other weird but true case please feel free!

Hello,

Sorry, been away for awhile. Sold my house and have one new job and maybe a HEMS gig (very anxious).

Fiznat,

It was a hard call for the crew. The patient was in a great deal of pain and they felt that it was worsening his clinical condition. Alas, Morphine was the only drug they had available. I have read about Ketamine in pre-hospital pain control as well as Fentanyl. Better drug, I think, if available.

Quickfire wrote:

As for SIRS, why was his HR so low with a BP like that? From what I understand (which probably isnt much) He should have been getting tachy, as a compensatory response to the hypovolemia. Was there something else found to account for this? Or was he previously borderline hypotensive and possibly tolerated it better.

I agree. I was very weird. Nor dose this patients clinical picture mesh with any clinical description of SIRS that I have read. One theory was a mild cardiac contusion (despite a normal look cardiac echo, negative troponins). Who knows?!?

Chbare,

Could be. The fellow wasn't the best at recalling medication he was one.

Cheers....

PS... If anybody has other weird but true case please feel free!

[DartmouthDave]

Hello,

Here is an other odd one that I saw awhile back.

Case#2:

EMS is dispatched to a local baseball game for a 18 year-old male that is complaining of chest, back, flank and abdominal pain.

Upon arrival they find the patient laying on the gorund in 10/10 pain that is described both as 'sharp' and 'dull and aching' in nature.

The pain has been getting worse over the last few days with a dramatic worsening of the pain in the last 15 minutes.

The patient also feels quite nauseated and has had two episodes emesis.

The patient has no medical history. Dose not take medications. Nor, dose he drink or take any illegal drugs.

The patient's skin is pale and diaphoretic. He is alert and orientated. His VS are:

HR 120

BP 79/50

Resp 28

SpO2 99%

Radial Pulse: weak

EKG: A 15-lead EKG is done and it shows ST elevation in V4R and V5R with Sinus Tachycardia

The crew starts IVx2 and give a 1L NS with a slight rise in BP and slight drop in HR.

So, what the heck could be causing this much pain and an isolated right-sided MI in a health 18 year-old male??

Have to run. Mulling it over....

Cheers

[Quakefire]

What was the indication for a right sided 12 lead? Not normal proceedure here anyway. Has he been out of the country recently? I'm thinking there must be some kind of parasite or something

[Mateo_1387]

What was the indication for a right sided 12 lead? Not normal proceedure here anyway. Has he been out of the country recently? I'm thinking there must be some kind of parasite or something

Hypotension

Tachycardia

10/10 chest pains, what I assume are radiating to the back, abdomen and flank

Significant nausea, with vomiting

The shock state and significant nausea are plenty reason to check the right ventricle for indications of right coronary artery occlusion. The crew may have performed at standard 12 lead first, found ST elevations in the inferior leads, and then done the right side check for the right ventricle involvement.

[Quakefire]

Thanks Mateo I kinda assumed that the 12 lead was non diagnostic

[DartmouthDave]

Hello,

Here is the interesting part.

For some unknown reason the patient had developed a thoracic aortic aneurysm (TAA) that started at the aortic arch. A CXR was done and the cardiac silhouette was enlarged. A CT/Angio showed a TAA that started just above the aortic valve and well passed the aortic arch. It was also leaking and had numerous hematomas. The pain was from compression of various nerves within the chest. The abdominal pain was from a compromised blood supply to the gut. As it was explained to me the hematomas and expanding aneurysm can actually reduce the lumen of the aorta itself.

I wish I had some follow up. This is a case that I saw quite awhile back when I was quite new. Still, interesting.

Cheers