Interesting case

[HERBIE1]

OK- first time putting out a scenario, so here goes. (Recent call)

1700hrs

Called for a 60 year old male seizure patient.

Arrive to find said male, sitting in passenger seat of car, being attended to by first responders. Wife- driver- said her husband suddenly stopped talking to her and could not be aroused, so she pulled over and called for help. They had just left their house a couple minutes ago. Despite the nature of the call, she describes no seizure activity. Says he has been fine all day- no complaints, nothing unusual, no prior history of syncope or similar episodes.

PMH-

CVA approx 1 year ago- minor speech deficits.

Htn

Cardiac

Type II Diabetic

Meds unknown, but is compliant with them

Wife knows he's on a "blood thinner", BP pills, "diabetic pills"

NKA

Patient is very pale, slightly diaphoretic, responds only to deep pain. Cap refill severely diminished, nail beds white

Vitals-

Pupils equal, reactive, but dilated

Abdomen soft, nontender

No palpable BP

Respiratory rate 18 and shallow

Lungs clear and equal

Pulse oximetry- approx 75%- hypoperfusing

Glucose- 205

Sinus Tach in Lead 2 on the monitor- no ectopy (No 12 Lead available)

Pt placed in Trendelnberg, IV wide open, nonrebreather, O2 sats still same

Pt begins to arouse, vitals rechecked and essentially unchanged, and c/o "ache" in suprapubic area. Said he had one small episode of diarrhea earlier, nausea, no vomiting, poor appetite all day- ate little.

Denies SOB, denies chest pain.

Fluids wide enroute to ER- still no BP enroute, remains alert, still c/o same "ache", and nausea

10 minute transport to ER uneventful

OK-

Let's hear it....

(Just to be clear, this is more about thoughts on a possible DX than treatment.)

Edited November 19, 2010 by HERBIE1

[Richard B the EMT]

(BLS personnel responding)

Dehydration? Also, were you administering saline or glucose via that IV?

[DwayneEMTP]

First, though I adore her desire to attempt to arouse her husband while driving I'm not sure that it's the safest practice. I always make sure that I'm driving when that happens...because I'm responsible...Just sayin...

Were you able to feel any pulses? Carotid, what did it feel like?

Temperature?

Posturing?

On first blush I would be looking for a dysrhythmia and/or CVA, his meds sort of fit, but you'll have to try and track that down through pulse quality without a 12 lead.

Second thought would be towards a vasculopathy, or as always, a combination of all...

Dwayne

[Happiness]

This actually sounds like a pt I just had not long ago.

My call

71 female

called for a fall

pt fell dislocated L shoulder

HX Stroke, triple bypass, type II diabeties, severe arthritis

When the hospital finally was able to pop the shoulder into place they admitted her for observations. With in 2 days she was medivaced out she had just deteriated over time. They discovered she had lung blood clots. They put her on a blood thinner and brought her home.

With in 2 days again she deteriated and again was medivaced out. As it turned out the blood thinner was to strong and had started internal bleeding. When they tried to regulate the blood thinners the clots came back. After about 3 days they got it straight and she is again a vibrant community memeber. She has a bit of rehablitation to go but will live to see her grandson recieve his masters degree.

Dont know if that is what this case but is sounds about the same.....

[HERBIE1]

(BLS personnel responding)

Dehydration? Also, were you administering saline or glucose via that IV?

Noirmal saline.

No evidence of dehydration, but that was a quick initial thought.

[HERBIE1]

First, though I adore her desire to attempt to arouse her husband while driving I'm not sure that it's the safest practice. I always make sure that I'm driving when that happens...because I'm responsible...Just sayin...

LOL

Smart ass...

Were you able to feel any pulses? Carotid, what did it feel like?

Carotid pulses present, appeared to be equal, but weak.

Temperature?

Slight;y cool, although his jacket was open and the car windows and doors were open in 40 degree weather.

Posturing?

Nope.

On first blush I would be looking for a dysrhythmia and/or CVA, his meds sort of fit, but you'll have to try and track that down through pulse quality without a 12 lead.

Until we found out he had no BP, CVA was an initial possibility, and as for cardiac, we were also thinking of a massive MI, but no obvious arrythmia..

Second thought would be towards a vasculopathy, or as always, a combination of all...

Dwayne

You are on the right track here.

Here's the rub. He had that- "I'm getting ready to die" color you see in massive GI bleeds, but there was no evidence of that- even though he was on a blood thinnner of some type. Again- without knowing what anticoagulant, it could have been anything from Coumadin to Plavix, to ASA.

Our 2 thoughts were massive MI, and...

After the exam and TX, we were thinking a Triple A. Why? I'm not sure but we were both on the same page with this idea- even though no obvious S&S existed. No pulsating masses, but no, we did not compare lower pulses- by this time he was semi conscious and I was trying to get as much history as possible and pushing fluids to get a BP. In line with our thinking, I began asking about the quality of the pain- no tearing, no burning- just a dull ache. He also specifically denied back pain. We were equidistant between 2 hospitals- one not so great, and the other was a Level 2 trauma center, and we figured this was a surgical case, and if it WAS a AAA, he would at least have a chance there. Got to the ER, we voiced what our guess was going on to the nurses(as if they cared, LOL)

There was a medic from a local private there picking up another patient(turns out he's also a part time flight medic from another area), and heard us discussing the call. He asked why we thought it was a AAA. We honestly couldn't give him a straight answer other than a feeling, his presentation, and his horrible vitals. The guy probably thought we were nuts.

As I was finishing the report, that medic went back to check on the patient (probably just to prove we were idiots) came back and reported they had 2 liters of fluid on board, Dopamine going, they were getting ready to hang blood- they confirmed the dissecting AAA via ultrasound, and still were only able to get a BP of 60 by palp. The medic looked at us like we were Miss Cleo or something. We told him that being right one out of a thousand times is a pretty good average.

The patient FINALLY began to c/o the classic back pain and tearing sensations in his abdomen, but no pulsating mass. They were also waiting for the surgeon to arrive. As we were leaving, the patient was still conscious- not yet intubated, and the surgeon had just arrived to evaluate the patient.

The last we heard was the patient made it to the OR, but we don't know if he survived the surgery.

Not much we could do for this guy except push fluids. No, we did not check pedal pulses, but with no palpable BP, that would have been essentially pointless- not to mention a diabetic who probably already has CAD and poor peripheral circulation. Diesel therapy- and the proper ER- were this guy's best bet from us.

[Lone Star]

Said he had one small episode of diarrhea earlier, nausea, no vomiting, poor appetite all day- ate little.

There's something about that statement that isn't sitting right with me. Even though the patient is NIDDM, and BGL is 205 (which is higher than the 80-120 averages we're taught). Did he take his meds today?

This is ringing like a diabetic episode, just because the BGL is high, and the patient ate very little....the glucose is just floating around in the circulatory system and not going where it's needed.

[HERBIE1]

There's something about that statement that isn't sitting right with me. Even though the patient is NIDDM, and BGL is 205 (which is higher than the 80-120 averages we're taught). Did he take his meds today?

This is ringing like a diabetic episode, just because the BGL is high, and the patient ate very little....the glucose is just floating around in the circulatory system and not going where it's needed.

Well, all I can go by is what he said. A glucose level of 205 is nothing I would be worried about- at least in the context of what was going on. It certainly would not explain his hypotension, syncope, or decreased mentation- not nearly high enough.

[fiznat]

Good call. With acute hypotension in the absence of trauma you should be looking at "pump" and "tank" problems first. Sounds like your intuition was correct on this one, but there should definitely be a 12 lead ECG in your differential there somewhere!

Edited November 21, 2010 by fiznat

[HERBIE1]

Good call. With acute hypotension in the absence of trauma you should be looking at "pump" and "tank" problems first. Sounds like your intuition was correct on this one, but there should definitely be a 12 lead ECG in your differential there somewhere!

12 leads are not an option with us yet. Been trained, still waiting for the updated equipment.