Interesting case

[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.

[HERBIE1]

Update on the patient:

ER gave him 4 units of blood, plus the Dopamine and still never got his pressure about 60/P. His CT showed a enough blood in his belly to nearly obscure the aneurysm. Apparently after we dropped him off he developed all the classic S&S's. Line of demarcation at the T-12 level, back pain, etc. Spent 45 minutes in the ER- too long, IMHO, but most of that time was spent waiting for the surgeon- he was not in house at the time.

Made it to surgery, repaired, and he's now up and around, probably discharged today or tomorrow.

Everyone was amazed the guy even made it to the OR without coding, much less survive the surgery.

It simply was not his time.

[Aussieaid]

Excellent case study. Strong work going with your instincts and taking this guy to a trauma center. That probably saved his life even though there was a delay for the surgeon.

It's good to read about atypical presentations so we don't get complacent and tunnel vision. My initial thought was he was having a massive ICH but if he was bleeding that much into his brain to cause the signs of shock that he had, he would have herniated already. I thought of a AAA after you mentioned the suprapubic ache but like you didn't think the signs fit. Good call following your gut feeling. Often our gut gives us the right answer when our brain tries to tell us otherwise.

LS we don't know what this guy's "normal" glucose levels are. 205 could be low for him but more likely he had a surge in glucose from the catecholamine release with the shock. That's why trauma patients and critically ill patients have higher glucose levels. It would be more of a concern for a diabetic crisis if he was hypoglycemic. Good thinking along the lines of diabetic problems though as they could present very similarly and can mimic a stroke as well. Incredibly lucky guy!!!

Lots of kudos to Herbie!

Happy Thanksgiving all.

[HERBIE1]

Excellent case study. Strong work going with your instincts and taking this guy to a trauma center. That probably saved his life even though there was a delay for the surgeon.

It's good to read about atypical presentations so we don't get complacent and tunnel vision. My initial thought was he was having a massive ICH but if he was bleeding that much into his brain to cause the signs of shock that he had, he would have herniated already. I thought of a AAA after you mentioned the suprapubic ache but like you didn't think the signs fit. Good call following your gut feeling. Often our gut gives us the right answer when our brain tries to tell us otherwise.

LS we don't know what this guy's "normal" glucose levels are. 205 could be low for him but more likely he had a surge in glucose from the catecholamine release with the shock. That's why trauma patients and critically ill patients have higher glucose levels. It would be more of a concern for a diabetic crisis if he was hypoglycemic. Good thinking along the lines of diabetic problems though as they could present very similarly and can mimic a stroke as well. Incredibly lucky guy!!!

Lots of kudos to Herbie!

Happy Thanksgiving all.

Thanks. Very interesting call. I LOVE these things- trauma may be exciting for many- it's always fun to see the various ways people get broke, but I love a good medical mystery. Keeps the brain working.

We were wishing we had a student with us for exactly the reasons you stated- atypical presentations are always tough for a new provider to wrap their heads around. You finish school and have a laundry list of common S&S's that you learn to look for, and you want your patient to fit that criteria. Problem is, too often the patient- and their disease process- does not believe in following the script. LOL

Sometimes you forget to actually look at the patient, evaluate them, add everything up, and THEN come up with a working hypothesis as to what may be going on.

Happy Thanksgiving to you too, aussie!

[Happiness]

Hey Herbie I have a question. In my 15 yrs I have had this twice and I wanted to know if when you ascolated his chest or ab. did you notice a swoshing sound. We medivaced a guy many years ago and he was already diagnosed and I had the opportunity to hear this sound. It is very distinctive just wondering is you noticed it.

[HERBIE1]

Hey Herbie I have a question. In my 15 yrs I have had this twice and I wanted to know if when you ascolated his chest or ab. did you notice a swoshing sound. We medivaced a guy many years ago and he was already diagnosed and I had the opportunity to hear this sound. It is very distinctive just wondering is you noticed it.

Just listened to the lung sounds, but never heard what you described. I imagine it would also depend on exactly where the aneurysm was, how big it was, and how badly it was dissecting. I never asked for the exact location of the tear, but I assume it was very low so even if we listened to bis abdomen, I wonder if we would have heard it.

Interesting- I never even thought we could auscultate for this, but what you say does make sense.

[zippyRN]

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

has this post been stuck in the ether for 10 years ?