"Feelin' cruddy."

[Bieber]

You are a member of a dual paramedic county EMS truck stationed inside the limits of a large city dispatched to the far edge of the county thirty minutes outside of the city (that side of the county has been dumped and you're the closest available unit) to respond to a "sick person" in one of the smaller towns of the county. You arrive at a rural house that appears pricey and well kept with no medications/oxygen/other pertinent findings present. The town's volunteer fire department is first on scene (BLS/first responder only) and advises the patient is a 400 lbs male located in the back bedroom of the house who complains of "feeling cruddy" since yesterday.

Patient presents alert and oriented x3 lying supine on his bed with no shirt on, a patent airway, unlabored respirations that don't appear brady or tachypneic, with warm, dry skin maybe a little pale in color. You have plenty of firefighters available and the only obstacle to extrication is a five step patio and a "mega-mover" tarp for moving bariatric patients.

Edited November 10, 2010 by Bieber

[fakingpatience]

A 400 pound guy with no medications? Something doesn't seem right there...

When you ask him more specifically what "cruddy" feels like, what does he say his symptoms are? Vitals, especially a BGL. If he isn't already on diabetes medication, my suspicion would be that it is just not diagnosed yet. Hyperglycemia could lead to the dry skin and "cruddy" feeling, and symptoms are slower to present.

Next question... can he walk? No need to carry someone who is just feeling a little ill, if all their vitals are good, and no reason to think cardiac/ respiratory/ anything that would get exacerbated w/ exertion.

[Bieber]

A 400 pound guy with no medications? Something doesn't seem right there...

When you ask him more specifically what "cruddy" feels like, what does he say his symptoms are? Vitals, especially a BGL. If he isn't already on diabetes medication, my suspicion would be that it is just not diagnosed yet. Hyperglycemia could lead to the dry skin and "cruddy" feeling, and symptoms are slower to present.

Next question... can he walk? No need to carry someone who is just feeling a little ill, if all their vitals are good, and no reason to think cardiac/ respiratory/ anything that would get exacerbated w/ exertion.

Patient's complaining of general malaise and some weakness/dizziness. No respiratory distress, no chest pain/discomfort. No nausea/vomiting, diarrhea/melena or abdominal pain. Patient denies any recent medication changes/additions/discontinuations and states he's taken his medications today. Patient also states he has been getting over the flu recently, no meds taken for it.

PMH: AMI (heart attack at 21 and at 33), IDDM, HTN

Meds: nitro, ASA, carvedilol, simvastatin, HCTZ, Klor-Con, insulin

Allergies: PCN

Vitals

HR 35

BP: 110/70 with +orthostatic changes (90/60 sitting accompanied by near-syncope)

BGL: 110

RR: 20 NL

SpO2: 92 RA

4-lead: junctional rhythm rate of 35 with brief (<10 sec) moments of regular sinus rhythm

12-lead: non-diagnostic

With exertion patient's skin becomes paler and mottled, especially in the face and extremities. No change in mentation, only complaints with sitting the patient up/exertion is generalized weakness.

Treatment?

Edited November 10, 2010 by Bieber

[island emt]

A 400 pounder that doesn't have labored respirations ::: Not very likely!

Odds are this is a classic case of TOOOOOO fat to live syndrome.

Cardiac, diabetes, hypertension, and a stroke waiting to happen .

Or could be a simple case of too many twinkies.

:-}

Edited November 10, 2010 by island emt

[Timmy]

Chest auscultation?

Has he been compliant with medications?

Im very cautious of the PHX AMI at such young ages!

Lets have some 02 (10L via mask)

Id like to get a line in and run some fluids for the postral hypotention.

He has symptomatic bradycardia (poor output from the symptoms of excertion) so I wouldnt rule out giving some atropine (considering his weight Id like to give 1mg)

Im not quiet sure what non diagnostic ECG means but Im guessing there is not heart blocks.

At the hospital will probably Dig load him.

If were not responding to the atropine then consider pacing if the patient remains symptomatic and adequate perfusion is diminishing.

Is there any other information youd like to share?

Edited November 10, 2010 by Timmy

[Bieber]

Chest auscultation?

Has he been compliant with medications?

I’m very cautious of the PHX AMI at such young ages!

Let’s have some 02 (10L via mask)

I’d like to get a line in and run some fluids for the postral hypotention.

He has symptomatic bradycardia (poor output from the symptoms of excertion) so I wouldnt rule out giving some atropine (considering his weight I’d like to give 1mg)

I’m not quiet sure what non diagnostic ECG means but I’m guessing there is not heart blocks.

At the hospital will probably Dig load him.

If were not responding to the atropine then consider pacing if the patient remains symptomatic and adequate perfusion is diminishing.

Is there any other information you’d like to share?

Lung sounds clear and equal bilaterally. He states he's been compliant with all of his medications.

Sorry, I thought non-diagnostic was a more universal term, apparently not! No ST elevation/depression, T-wave inversion or other signs indicative of ischemia or infarct. No heart blocks noted but there are some signs of left ventricular hypertrophy.

You got your line, after a 250cc bolus he's up to 120/80 with some improvement in color but no definitive change in rate. He continues to have periodic episodes of regular sinus rhythm rate of 70 that last a few seconds. Decrease in weakness, increase in SpO2 to 98 on 10 LPM via NRB.

Atropine brings his rate up to 100, which completely relieves his weakness and gets his color back to normal, next blood pressure is 130/90. Repeat 12-lead is still non-diagnostic with no signs of ischemia/infarct or block. 4-lead is now a junctional tachycardia.

Thoughts on a diagnosis?

[DartmouthDave]

Hello,

If this fellow has had two AMI maybe he had a intermittent hemiblock?

I saw a patient once that had a LBBB and an anterior hemiblock. He would get brady from time to time when he blocked his posterior pathway.

That is my shot in the dark. CCU stuff isn't my strongest point.

Now, some would argue that Atropine won't work on anything below the AV node. But, I have seen Atropine work times that one would not suspect.

Have to run....my friend and his two children have arrived. All hell is breaking lose!!!

[Bieber]

That's along the same lines as what I was thinking, Dave. All throughout transport I was sitting there thinking this guy had to have had an MI that took out his SA node (or at least severely damaged it). I did ask him about his carvedilol, but he denied having taken too much of it or any recent changes/noncompliance in his medications.

Because the patient maintained cerebral perfusion (no change in mental status) and a pressure >100 systolic, I decided to give supportive treatment only. I consulted with the physician at the hospital and he agreed to monitor the patient and to go ahead with 0.5 mg of atropine if he started to crap out on me, but though he continued to look like crap throughout transport he stayed stable and I didn't have to intervene with fluids or raise his rate.

The patient in this scenario ended up being hyperkalemic. I wish I'd found out more about the cause of the hyperkalemia, but I'm guessing he must have taken too much of his potassium by accident or that his electrolytes must have gotten a little screwed up while he had the flu.

[Kiwiology]

Hyperkalemia should show on a 12 lead ECG if you have such capability.

[Bieber]

Hyperkalemia should show on a 12 lead ECG if you have such capability.

You know, I don't have the 12 lead anymore, but I don't think I saw anything concerning on it. No peaked T waves, no ST changes there might have been some pathological Q waves from his previous MI's but I can't remember. It was a pretty benign 12 lead if I'm recalling correctly--nothing that led me toward hyperkalemia or a STEMI, anyway.