DartmouthDave Posted December 30, 2010 Author Posted December 30, 2010 Hello, I was just listing all the possible Dx present in the discussion so far. Sorry about forgetting to post the BP sooner. Trying to post during breaks at work isn't a good idea at all. OK, so you have a couple of IV and place the patient on a NRB and transfer him to the stretcher. An addition set of VS are done as well. GCS: 15/15 Arms: Strong Legs: Absent motor function Resp: 30's Rapid and Shallow SpO2: 91-92% EtCo: Not available...sorry EKG: Sinus Tachycardia 120`s BP: 160/78 Temp: 37 You drain the 3L dwell from the pt abd and no pulsating masses are note. He feels better with the pressure gone from his abd. He still complains of a bad back pain as well. Cheers 1
Lone Star Posted December 30, 2010 Posted December 30, 2010 (edited) Gravitational edema in the lower extremities? Is the patient coughing much? If so, is the cough productive or dry? How would you describe any sputum production? *edited to add additional questions* Edited December 30, 2010 by Lone Star
Aussieaid Posted December 30, 2010 Posted December 30, 2010 RSI at this point ? ... you got way more balls than me, and Bilevel support way over CPAP for me, VS dictating as the last thing buddy needs is an increase in WOB with CPAP, and just when will EMS learn to ask the RTs anything about ventilation ... sheesh ! I agree with Bilevel NIPPV over CPAP and that is what I would automatically apply. However most ground crews who are lucky enough to have access to any form of NIPPV often only have CPAP without the PS available. Semantics really. If my other treatment plans had failed to raise his SpO2 above 90% then yes, I would have gone for intubation (note I said if all else fails I would RSI/intubate). I would have tried NIPPV while setting up for intubation if draining the abdomen and NRB wasn't helping. Luckily he has improved with his SpO2 so I would put it on a back burner but be prepared for it. I don't intubate on respiratory rate alone but failure to oxygenate is a pretty good indicator to intubate in my experience. I would rather intubate when they hopefully still have some reserves left than wait until they have nothing left and have them code on me. Other advantages would be to decrease the overall stress levels and hopefully help mitigate a little of whatever is causing his distress - respiratory, neuromuscularly and hemodynamically. I don't think I would treat his BP at this point until we have a better idea of what is going on exactly. I would give him some narcotics and a little sedation though which should help the BP anyway. (Thinking aortic aneurysm/dissection still). DVT are more typical a precursor to PE than abdominal aortic atherosclerosis leading to PE, yes there is a immobility factor, but I would rule out PE as soon as I saw an improvement with administration of O2, as in the vast majority of life threatening PE cases they DO NOT improve in saturations with an increase in FiO2, " a nice to know clinical observation" Now I WILL take you to task on coagulation factors, far more likely a lack of clotting factors with the typical renal failure patient, PE is just not a good fit to my way of thinking. I was not suggesting a blood clot embolus either rather an atherosclerotic emboli or multiple, one going to the lungs and one going to the spinal arterial supply causing an infarct. However he has improved slightly with O2 which may or may not rule out a PE in the lungs. In the CHF patient higher O2 flows are increasing mortality morbidity, latest research and yes I know, I didnt believe it either but the research is really pointing to this .. so just to be a smarty pants I would to be picky and use SPO2 as a target as opposed to just blow hair back arbitrarily. The fact that his lung sounds are clear leads me to think it is not CHF in nature. I know he has a history of CHF but I don't think it is causing his dyspnea right now. His dyspnea could just be related to significant anemia as well. I would still keep pernicious anemia as a DD despite the lack of any obvious GI history. It can cause dyspnea and paralysis. At this point I am still treating supportively rather than a specific diagnosis. (Of course I would not be hanging around on scene trying to figure it out. Let's hit the road, Jack!) The lower back pain is still keeping AAA/Dissection at the top of my list. Of course there is probably a totally different diagnosis that hasn't been brought up yet. Thanks for making me think Dave. 1
tniuqs Posted December 30, 2010 Posted December 30, 2010 Legs: Absent motor function Resp: 30's Rapid and Shallow SpO2: 91-92% EtCo: Not available...sorry EKG: Sinus Tachycardia 120`s BP: 160/78 Temp: 37 You drain the 3L dwell from the pt abd and no pulsating masses are note. He feels better with the pressure gone from his abd. He still complains of a bad back pain as well. Cheers
DartmouthDave Posted January 2, 2011 Author Posted January 2, 2011 (edited) Hello, The legs are flaccid with no sensation. LOC is 15/15 and end organ perfusion is acceptable. No fancy kit like an iSTAT. The lungs are still clear. The dwell is clear. No sings of infection and no edema or sings of infection in the legs. Just poor colour, temperature and a weak pulses. Which is a normal state for this patient. The PD cath is clean and well care for. So, your on the way to the ED. The patient settles some with MS (or Fentanyl). His rep rate is still in the 30's and his stats are 90% on a NRB. The back pain has also diminished some with the pain control. Here is the million dollar question: Is is GBS or a AAA? Cheers Happy New Year Edited January 2, 2011 by DartmouthDave
Lone Star Posted January 2, 2011 Posted January 2, 2011 Hello, The legs are flaccid with no sensation. LOC is 15/15 and end organ perfusion is acceptable. No fancy kit like an iSTAT. The lungs are still clear. The dwell is clear. No sings of infection and no edema or sings of infection in the legs. Just poor colour, temperature and a weak pulses. Which is a normal state for this patient. The PD cath is clean and well care for. So, your on the way to the ED. The patient settles some with MS (or Fentanyl). His rep rate is still in the 30's and his stats are 90% on a NRB. The back pain has also diminished some with the pain control. Here is the million dollar question: Is is GBS or a AAA? Cheers Happy New Year Is the patient complaining of the sensations spreading to other parts of the body, or is it localized in just the distal lower extremities?
Aussieaid Posted January 2, 2011 Posted January 2, 2011 I'm going to have to go with GBS over AAA as I think it fits more of the symptoms. The back pain is not the most common symptom but a deep aching back pain can occur.
DartmouthDave Posted January 2, 2011 Author Posted January 2, 2011 Hello, It turned out that the patient had GBS. Care by EMS was supportive in nature (O2, pain control, IV). In the ED he had a CT to rule out a AAA. The back pain was related to the progression of the GBS. Odd, but true. The patient also required a tube shortly after arrival in the hospital. Excellent work everybody. Cheers PS..... BTW, if he needed intubation in the field what drugs would people use? =)
Lone Star Posted January 2, 2011 Posted January 2, 2011 Hello, It turned out that the patient had GBS. Care by EMS was supportive in nature (O2, pain control, IV). In the ED he had a CT to rule out a AAA. The back pain was related to the progression of the GBS. Odd, but true. The patient also required a tube shortly after arrival in the hospital. Excellent work everybody. Cheers PS..... BTW, if he needed intubation in the field what drugs would people use? =) Obviously, mere 'medic students' aren't allowed to play "Guess What's Wrong With This Patient". Just let me know where I can pick up my cheesy parting gifts as I leave the stage. I asked two specific questions, and neither were acknowledged, let alone given an answer.
DartmouthDave Posted January 2, 2011 Author Posted January 2, 2011 Hello, Yes, I missed your post with the question about the productive or non-productive cough. However, my last post's purpose was to acts as summation of what various posters were discussing (AussieAid, Tniuqs and yours). I like to post interesting patients that I see and have seen over the years for something to do. I am not in it to snub people. Second, I do not have as much time as I use to type out responses as well. That is a factor as well. So, if I have offended you I am sorry. Cheers
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