usmc_chris Posted July 15, 2011 Posted July 15, 2011 Well, I accidentally double posted this earlier, and apparently both threads somehow got deleted, so I'll try it again. You are working on a double Paramedic ambulance with a non-driving EMT-B trainee. It is a sunny day, about 84 degrees F. You are dispatched to a 58 y/o male pt complaining of severe dizziness and sweating, pulled over in the parking lot of a local business. The call is EMD-coded as a 31D4, unconscious/fainting. You have an approximate 4 minute response time. While enroute, you are updated by dispatch that your patient is now complaining of "heavy" breathing. You arrive on scene, and the heavy rescue truck from the local fire department staffed with a single paid FF/EMT-B is on scene. The EMT is leaning over the patient in the driver's seat, and upon witnessing your arrival waves frantically for you to come over to your patient. Tell me what you want to do and what you want to know!
Kiwiology Posted July 16, 2011 Posted July 16, 2011 What has this bloke been up to? Coming from work? Headed home from the strip club etc? Standard ambo alphabet soup special - BP, RR, HR, ECG, SPO2, temp, GCS Respiratory - rate, depth, work of breathing, lung sounds Primary and secondary survey Medical history Sounds like this bloke is either having a massive friggin infarct, a CHF episode or maybe hypogycaemia Could also be an adrenal gland tumor ... or you know 200 things in between
usmc_chris Posted July 16, 2011 Author Posted July 16, 2011 What has this bloke been up to? Coming from work? Headed home from the strip club etc? Standard ambo alphabet soup special - BP, RR, HR, ECG, SPO2, temp, GCS Respiratory - rate, depth, work of breathing, lung sounds Primary and secondary survey Medical history Sounds like this bloke is either having a massive friggin infarct, a CHF episode or maybe hypogycaemia Could also be an adrenal gland tumor ... or you know 200 things in between Upon looking at the pt, he is seated in the driver's seat, and you and your partner give each other the "look." It's both in the back of your minds that he looks like an imminent arrest. He is profoundly pale and diaphoretic, alert and oriented but slightly lethargic. Pt is c/o extremely severe dizziness and mild nausea. Cincinnati stroke scale is negative. Because of the public place and the proximity of the ambulance, you immediately pull the pt out of the car and move him into the back to begin working on him. He tells you that he just left home, is headed to work, only made it about a 1/2 mile when this began. He tells you that he had turned to look in the mirror and kind of felt a "pop" in his neck, however denies any recent trauma. Spine is non-tender to palpation, mild 2/10 pain to the left posterior area of his neck, a dull sensation. No recent illness. BP 138/97, RR 20, HR 83, rhythm strip shows regular sinus rhythm, no AV heart block or bundle branch block. SpO2 is 98% on RA. GCS is 15. Temp is 36.8 C. Respirations are easy and unlabored, although pt is very worried, relates he feels like "crap." Breath sounds are clear/equal bilaterally in all fields. Medical history is hyperlipidemia and depression. Pt is taking Atorvastatin and Zoloft, denies any other medications or medical history. NKDA. Pt continues to tell you that he doesn't feel so good, no alleviation of the dizziness or nausea after lying down.
Medic Baby 171 Posted July 16, 2011 Posted July 16, 2011 How do his pupils look/react? Is it a possible overdose? Did he eat or drink anything out of the normal (maybe early allergic reaction)?
DwayneEMTP Posted July 16, 2011 Posted July 16, 2011 We know immediately that the presentation doesn't match the vitals. This guys could be in trouble, so lets look at other possible causes. Of course he could just be playing with some dope he's hiding from his wife. I'm going to lift him from the car, no walking for now. Take the automated cuff from the fireman and cut off the friggin' hose off and get a new set of vitals on my own. We are going to need a better history than we've gotten so far. Is he compliant on his meds? Does he have the bottles on him? Lets verify that the remaining pills match the dosage/prescription date. I want an IV on him right away, I'll ask my partner to do that. Pupils? You state a rhythm strip shows no cardiomyopathy, yet a rhythm strip wouldn't show such things. Did you mean a 12 lead? If not, then he needs one right away. What is his pulse quality? I guarantee you that there is something that this guy isn't telling us regarding this situation...we need to figure out what it is. Dwayne
Kiwiology Posted July 16, 2011 Posted July 16, 2011 It might be a panic attack If he is that severely nauseous, put an IV in and give him some ondansetron
FireEMT2009 Posted July 16, 2011 Posted July 16, 2011 Imma go old school here but, here it goes. Airway? is it patent? Breathing?- RR, Lung sounds, depth and quality? Circulation- Pulse, strength quality and regularity, major bleeds perfusion? Place the patient on a nonrebreather 15 lpm Reassess vitals do full workup, pupils, skin tenting, grips, can i get a temperature in farinheit please? im not good in celsius, EKG followed by 12 lead, BGL, stroke test also get a good look over of the vehicles, such as pill bottles, wallet with a file of life, medical id braclelets, any information that can lead you to any kind of conclusion. Rapid transport with two IVs running on TKO for now just in case
usmc_chris Posted July 16, 2011 Author Posted July 16, 2011 Let's see if I can get it right this time. I had my whole reply typed and my browser went back two pages instead of deleting something I was trying to edit before posting! How do his pupils look/react? Is it a possible overdose? Did he eat or drink anything out of the normal (maybe early allergic reaction)? Pupils are equal, round, and reactive to light and accommodation. Pt's last PO intake was a ham sandwich, a small bag of potato chips, and a can of diet soda, pretty much his normal shift. Pt works 2nd shift (3pm-11pm) and was just heading to work. Pt denies eating or drinking anything out of normal for him for the past day or so, denies any insect bites/stings or other possible allergens. You note no swelling, hives, or itching. We know immediately that the presentation doesn't match the vitals. This guys could be in trouble, so lets look at other possible causes. Of course he could just be playing with some dope he's hiding from his wife. I'm going to lift him from the car, no walking for now. Take the automated cuff from the fireman and cut off the friggin' hose off and get a new set of vitals on my own. We are going to need a better history than we've gotten so far. Is he compliant on his meds? Does he have the bottles on him? Lets verify that the remaining pills match the dosage/prescription date. I want an IV on him right away, I'll ask my partner to do that. Pupils? You state a rhythm strip shows no cardiomyopathy, yet a rhythm strip wouldn't show such things. Did you mean a 12 lead? If not, then he needs one right away. What is his pulse quality? I guarantee you that there is something that this guy isn't telling us regarding this situation...we need to figure out what it is. Dwayne Dwayne, the pt is lifted from the car on the stretcher and placed immediately into the ambulance. There are no law enforcement present that he would feel the need to lie to (of course, I know they lie to us too), and he adamantly denies any recent illicit drug or alcohol use. A new set of vitals is obtained. Manual BP is 128/86, HR is 77 in a NSR. RR 20, easy and unlabored. SpO2 is 98% on room air. He continues to tell you the same story of events: he just left home, was driving along, turned to look in the rearview mirror and felt that very mild "pop," no more severe than an insect bite. Shortly thereafter symptoms began, which are still the same. Upon assessing the neck you feel no point tenderness along the spine, normal range of motion, no evidence of a bite or sting, he does c/o 2/10 pain to the left posterior of the neck, but you can see nothing wrong upon visual inspection. Pt states he is compliant with his meds, does not have them with him. He does state he hasn't been to his primary doctor in over a year. Pupils are normal. Your partner placed a 16ga IV in his left AC with a liter bag of 0.9% NS running at KVO. As for the rhythm strip, I stated II thought) that those things that you can diagnose from a rhythm strip weren't there. But when you do the 12-Lead, you see no T wave inversions, no ST-segment elevation/depression in any lead. QRSd is 80mS, PRI is 150mS, QTc is 420mS, and R-axis is 10 degrees. Poor R wave progression noted in V1-V4 but nothing acute seen anywhere. Because this doesn't line up with what you're seeing, as he really looks like he's not doing so well, you go ahead and do a right-sided 12-lead as well, but you see nothing in V3R or V4R. Pulse quality is normal strength with a regular rhythm corresponding with the cardiac monitor. As far as you can tell the patient is being open and honest with you in all regards. It might be a panic attack If he is that severely nauseous, put an IV in and give him some ondansetron He has no history of anxiety or panic attacks and denies any recent stressors that might trigger one, however, it doesn't rule it out. He rates his nausea as a 4/10, doesn't feel like he is going to vomit. You have IV access, would you like to push the ondansetron? You have an approximate 5 minute transport time. Imma go old school here but, here it goes. Airway? is it patent? Breathing?- RR, Lung sounds, depth and quality? Circulation- Pulse, strength quality and regularity, major bleeds perfusion? Place the patient on a nonrebreather 15 lpm Reassess vitals do full workup, pupils, skin tenting, grips, can i get a temperature in farinheit please? im not good in celsius, EKG followed by 12 lead, BGL, stroke test also get a good look over of the vehicles, such as pill bottles, wallet with a file of life, medical id braclelets, any information that can lead you to any kind of conclusion. Rapid transport with two IVs running on TKO for now just in case Airway is patent. RR 20, breath sounds are clear/equal in all fields. Symmetrical chest movement, normal depth, easy and unlabored. Pulse is of normal quality with a regular rate. No abnormalities. Pt denies any recent trauma, GI bleeding, etc. No evidence of a hole in your patient's skin is seen anywhere. No bruising seen, abdomen is soft, non-tender, and non-distended. Pt is now on high-flow O2 via NRB. 3rd set of vitals - BP 123/84, HR 80, RR 20, SpO2 100% on high-flow. GCS continues to be a 15, although he is slightly lethargic. Skin turgor normal, pupils as above. Grips are equal, pronator drift test negative, no facial drooping, speech is regular and not slurred. 37.0 is normal temp in Celsius, so corresponding Fahrenheit temp is around 97.6. EKG's as above, BGL is 130 mg/dl. Vehicle is in good condition, late model foreign sedan. No apparent damage, pt denies a collision, stated that when this began he pulled over into the parking lot you are currently in. No further medical information can be found. You begin transport and place a second, 18ga IV, saline lock, in his right forearm. Any thoughts? Anything else you'd like to know or do?
Kiwiology Posted July 16, 2011 Posted July 16, 2011 Yes, lets him give some ondansetron. Transport time should not be a factor to decide medication administration! If he heard a "pop" in his neck then perhaps he nunngered something with his sympathetic nervous system causing massive cholernergic discharge? .... or is that a false positive?
DwayneEMTP Posted July 16, 2011 Posted July 16, 2011 (edited) Let put a C-collar on him, no board as the cost benefit isn't there. I know the ER is likely to laugh/bitch at me for having a patient with a collar and no board, but I want to remind him not to move his neck. It sounds like he's damaged his C-spine in some way and though the benefit of the collar is questionable at best it will help him remember to stay still. I did think CNS decompensation from the initial mention of the 'pop' but the vitals don't seem to speak to that. No tachycardia, B/P holding well. I went back to see if these values were maybe being controlled chemically but didn't see anything that would lend itself to that. Perhaps there was a previously undiagnosed osteopathy, or a damaged ligament or tendon caused swelling that is intruding into spaces reserved for the spinal column/nerves. Not sure. Though I'm a pretty big advocate of relieving the discomfort of patients I'm not going to give an anti-emetic at this time. Not because we're so close to the ER, but because I don't really have any idea what's going on with this guy and I don't want to steal symptoms from the ER. The severity, quality, and possibly other descriptions of the nausea that might not mean anything to me but might mean something to the physician. Now, should the nausea increase and I believe that vomiting may be eminent, compromising C-spine management, then I may be forced to treat it. If we were, say, an hour out I would call the Doc and consult. But at this point I won't likely even get him on the phone before I'll be going through the ER doors. Otherwise I have no idea what's going on. I'm going to transport with the current interventions in place unless something changes that should push me into a certain direction. Awesome, intelligently presented scenario man....thanks for taking the time to do it. I wish I had better ideas... Dwayne Edited to correct a spelling error only. Edited July 16, 2011 by DwayneEMTP
Recommended Posts