Obtunded, Hypotensive, Hypothermic

[Job13_5]

Had a patient yesterday that brought me back to the books and thought I might share. For those that are more learned than me, this will be ridiculously simple, but I had to get the diagnosis from the doc.

Called for a 56 YOF "in and out of consciousness." Arrive to find a female on the bathroom floor, average body type for her age in a clean and well taken care of home. Patient is lying left lateral recumbant, breathing quietly about 24 x/min, very pale with "waxy" appearing skin, barely palpable radial pulse at ~70bpm, very cold to the touch, slightly clammy, oriented but responsive only to voice and reluctant to follow commands 2nd to lethargy. Fire can't get a manual pressure. SpO2 is 97% on RA. Lungs are clear. Husband reports a history of HTN, high cholesterol, hypothyroidism, with associated medications and an allergy to Sulfonamides. Husband reports that the patient has been feeling ill for the past several weeks and was recently diagnosed with an infection (doesn't know what) and prescribed PCN, which she has been taking for about two weeks with no ill effect. Husband reports that the patient has been constipated and using stool softeners. Patient was reported to have been heading to the bathroom when she got suddenly weak, laid on the floor, became somnolent, and husband called 911.

Moved patient to gurney, placed trendelenburg, no palpable radial pulse, can't auscultate a blood pressure. After two IVs and just 500cc of fluid patient has strong radial pulses and a BP of 142/100. Physical exam reveals no neural deficits and right-sided abdominal tenderness w/ nausea...all else is normal except what's been mentioned above. BG is 140, 12-Lead shows no ST changes or blocks with left atrial enlargement, NSR throughout transport.

Delivered the patient to the ED with no changes enroute. (Couldn't get further BPs because the manual cuff went MIA and the automated cuff started throwing faults...figures...however, patient maintained strong radials w/ continuous infusion of NS) ED automated BP was 113/?. IVs were stopped by staff. Patient began to decrease in LOC (over about 10 mins). Manual BP was evaluated at 48 systolic. IVs opened wide. Patient moved to another room, doc called, BP re-evaluated at 135/100, patient is now slightly responsive. Several minutes later patient is unresponsive, and incontinent of feces with a SBP of 66.

At this point I had to leave for another call, but the patient evidently remained hypotensive and was admitted.

Doc told me his initial diagnosis and I had to go do some reading.

Any thoughts?

On a side note. There is one aspect of this patient's presentation that I still don't understand: the fluctuating blood pressures. I have my own thoughts, but they're just conjectures...

[tniuqs]

Ok some "thoughts" here but more questions right now, I have to ask about the initial BP of ~70 (FF EMT ?) most likely a decrease in distal perfusion (pallor, cold and diaphoretic) results in erogenous Pulse Ox readings but then you state sats reading 97% on R.A. Curious that a patient presenting "shock" that the Pulse Ox would read accurately. Maybe that is telling you something about accuracy, maybe "pilot error" ?

Husband reports a history of HTN, high cholesterol, hypothyroidism, with associated medications

Like what meds ? Thyroxine ? and just what anti-hypertensives (beta blockers or ace inhibitors ?) rather important don't yall think ? and is the patient compliant with Rx ?

You seemed to be very "focused" on BP, just where is the Heart Rate (s) and Respiratory Rate (only one time mentioned) Any odd respiratory patterns (like cheyne stokes) besides NSR does't answer my queries. These Vital Signs can be VERY helpful in any senario presentation just saying not getting the whole picture without these little "thangs".

MOST in EMS use GCS i.e. the Glasgow Coma Scale to describe LOC as that would be a superior idea in any scenario presentation it certainly beats (underline in red) lucky for you, that Dustdevil is AWOL.

Patient began to decrease in LOC (over about 10 mins). Manual BP was evaluated at 48 systolic. IVs opened wide. Patient moved to another room, doc called, BP re-evaluated at 135/100, patient is now slightly responsive. Several minutes later patient is unresponsive, and incontinent of feces with a SBP of 66.

Unresponsive to what .. verbal or painful stimulation ?

So I ask you do you do you think this last drop in BP and LOC, could be a result of a Vaso Vagal response due BM ? Then what was stool like ? Diarrhea, runny loose any melena or coffee ground ?Complicating the presentation is the "use" of stool softeners its curious that pt. is using them, as antibiotics typically cause diarrhea, not the other way around.

With your fluid bolus of 500 cc and an improvement in BP associated with increased LOC could be indicative that this patient is in need of fluid resuscitation ? I think this may be the direction your taking this scenario, I cannot "Hang my Hat" on anything with info provided.

Doc told me his initial diagnosis and I had to go do some reading.

Ok so his/her working dx svp.

Without any labs i.e. Lytes, hematocrit, CBC, would really be very helpful here to suggest any Dx and "STAT LABS" can get this info pretty dang fast. Did the MD have that info or was the DX made purely on Clinical Evaluation ? Its pretty hard from the picture you paint to get a "working dx" other than suspected volume depletion, with rapid variance in LOC with associated variances in BP.

cheers

[Job13_5]

I'll try to answer your questions...

I think you misread the first bits. The pt did not have an initial bp per fire, but I felt a weak radial pulse at a rate of 70. Moved the pt to the cot, couldn't get a bp or radial pulse.

Meds: vigamox, PCN, phenergan, levothyroxine, maxzide, zestril, flexeril, fioricet, asa, premerin, zocor.

Respirations were 14 regular and shallow.

GCS was 14 -- opens eyes to voice -- throughout transport

GCS was 11 when pt started to decrease in LOC (2,5,4)

GCS was 3 when unresponsive.

She did not have a vagal episode 2nd to BM because she never made it to the toilet.

No lab information. Doc's working diagnosis was before labs, imaging, etc.

Edited September 27, 2010 by Job13_5

[tniuqs]

I think you misread the first bits. The pt did not have an initial bp per fire, but I felt a weak radial pulse at a rate of 70. Moved the pt to the cot, couldn't get a bp or radial pulse.

OOPS I stand corrected, FF couldn't get a BP ... so with decrease in B/P was there compensation in Heart Rate i.e tachycardia or did a pulse rate of 70 remain a constant en route.

btw trendelenburg has lost favour as the studies suggest it is useless.

Meds: vigamox, PCN, phenergan, levothyroxine, maxzide, zestril, flexeril, fioricet, asa, premerin, zocor.

Respirations were 14 regular and shallow.

Well that kinda changes the picture a tad ... hmmm.

GCS was 14 -- opens eyes to voice -- throughout transport

GCS was 11 when pt started to decrease in LOC (2,5,4)

GCS was 3 when unresponsive

.

Thanks.

She did not have a vagal episode 2nd to BM because she never made it to the toilet.

Could you explain that theory ?

No lab information. Doc's working diagnosis was before labs, imaging, etc.

So what was the MD working dx ?

[DartmouthDave]

Hello,

Nice case study. I will take a shot here:

The cool, hypoglycemic, hypotensive patient that has been feeling unwell for a week or so could be Septic. But the waxy skin dose not fit.

The waxy skin is what makes me lean to the thyroid. Endocrine is my weak point so bear with me here.

I am thinking hypothyroidism that has worsened in to Myxedema Coma. Myxedmea is a state of decompensated hypothyroidism caused by a stressful event....in this case a long period of illness.

I have seen one Myexedma Coma a few years back. Fits this bill...kind of. It was a medical ward patient whose levothyroxin had 'fallen' off the MAR.

It could be her medications ----> vigamox, PCN, phenergan, levothyroxine, maxzide, zestril, flexeril, fioricet, asa, premerin, zocor.

I don't know much about the ones in BOLD......so I am going to research them some.

Have to run...

Cheers....

Edited September 27, 2010 by DartmouthDave

[Job13_5]

As for vagaling, I said no because she wasn't bearing down with a BM. That doesn't rule out vagal nerve issues, of course.

The doctor worked her as a myxedema coma (spot on DartmouthDave!): hypothyroidism, hypothermic, hypotension, recent infection, waxy skin.

From what I read, she fits the bill.

Edited September 27, 2010 by Job13_5

[HBEMT]

Ok...let me start with "I know nothing!" being I just finished emt school...So I'm just throwing this out there....Is it possible this patient had appendicitis which was somewhat controlled by the antibiotics but not strong enough to prevent it from bursting ..constipation may be a side effect of inflammed appendix and surrounding bowels and if it burst, then the internal bleed might cause the low b/p and signs of shock which was only exascerbated by the diuretics? Thinking the hypothyroidism might be a little less significant than previously thought...ok, dont hurt me!

[Bieber]

This sounds very much like a myxedema coma to me. The history of recent illness could have caused her thyroid hormone levels to fall, and if I'm not mistaken can't penicillin also cause thyroid hormone levels to drop as well?

[DwayneEMTP]

OOPS I stand corrected, FF couldn't get a BP ... so with decrease in B/P was there compensation in Heart Rate i.e tachycardia or did a pulse rate of 70 remain a constant en route.

btw trendelenburg has lost favour as the studies suggest it is useless.

Well that kinda changes the picture a tad ... hmmm.

.

Thanks.

Could you explain that theory ?

So what was the MD working dx ?

Was is just your goal to bust his balls here, or were you going to participate in a way that is productive for the scenario? My guess would be, as this is a scenario based forum where the goal is to investigate as a group and develp a DD and treatment plan, that the docs DD was left out on purpose. And if you couldn't surmise that he put V V way down on his list of differentials as most people don't bear down for a bowel movement until they are actually at the toilet, and it is most often the bearing down that causes the reaction, well, then you just weren't trying very hard. Could she have Vagaled sooner? Of course, but to try and make him sound foolish for making a reasonable assumption just seems to be another of your attempts to appear superior, but once again failing.

Having said that, I've never understood the medical communities love affair with the GCS. Unless you describe which category received which rating (which many do but is not technically part of the scale) leading to the total then I don't really see it's value. I had no trouble at all following his mental status description. I am truly curious, what did you learn from the GCS that you didn't know from his previous description of patient mentation? What new information were you thanking him for?

Awesome scenario! I wish I'd gotten to it sooner and had been able to participate...Thanks for posting it! It takes big balls/ovaries to post scenarios as there are a lot of really smart people here that are going to ask you questions that you may or may not know the answers too. Good on you for jumping in.

Dwayne