Dizzy and Diaphoretic

[usmc_chris]

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.

Well, I'll give a few hints. I'll tell everybody what it's not. Its not a cardiac event, and it's not an anxiety attack. It is not a c-spine problem, in the actual call I didn't even think of immobilizing for a few reasons. One, I'm a big fan of NOT backboarding people, because of some of the literature I've been reading about worse outcomes following immobilization. Also, there was a lack of any kind of mechanism. Finally, we didn't get the story about the "pop" in his neck until well on the way to the hospital.

We also did not treat the nausea as vomiting wasn't imminent. Also, we only carry Promethazine, and I didn't really want to sedate him anymore than he already was from being generally lethargic. We did call ahead to let them know what was going on, in that we had absolutely no freaking clue what was going on but he had that "pre-code-looking" look to him.

So, vitals remain "stable" through the transport. You bypass the triage line based on your prearrival report, going directly to a room. At this point, he is starting to be a little weaker on the left side, however no facial droop, no slurred speech. The ED doc meets you at the room and is initially thinking of an atypical CVA presentation. He allows you to follow him and the pt to CT, as as soon as a 3rd IV is placed and labs/cultures drawn, off he goes, he's only in the room for about 5 minutes.

Head CT w/o contrast is unremarkable, head and neck CT w/ contrast shows nothing per the ED doc and the radiologist brought in to assess the CT.

So, what else might it be? Any ideas?

And don't feel bad Dwayne, my partner and I had no clue whatsoever what was going on either. I only know because we followed up about 2 hours later with the hospital. Not telling yet though!

[DwayneEMTP]

...Also, there was a lack of any kind of mechanism. Finally, we didn't get the story about the "pop" in his neck until well on the way to the hospital...

Here I disagree. There was no external mechanism possibly, but turning his neck may have been all the mechanism necessary to create a traumatic injury. Like coughing in a "spontaneous pneumo." (I've always thought of that as an oxymoron). Coughing is still the mechanism, right? Despite no external trauma being delivered.

Not busting your balls brother, just throwing that out there for discussion in case the debate may have some educational value.

And I hate longboards. There is not data to support them, at least non that I've ever been exposed to, and tons to use to hate em with. I never use one without a quartered blanket on it which, when I was working the streets, meant about 50% of the time garnered scorn from the non physician ER staff and about 90% of the time from my coworkers as 'not real immobilization.' I finally just quit having the argument and let em bitch. I never once, that I can remember, got a complaint from a Doc for it.

Still no idea what is going on but I'm leaning towards an electrolyte imbalance maybe. The pop...maybe inner ear? No friggin' idea really.

Dwayne

[usmc_chris]

Fair enough about the possibility of a mechanism, however he more than meets our "selective immobilization protocol." Of course, there's people I don't board that technically don't meet the "letter" of the protocol, but after all they're guidelines, right? At least that's what the preface to ours says. We make the best clinical decision we can based on risk/benefit we can for each individual patient.

I completely agree with you on hating long boards though.

While I didn't see his lab values, based on the final diagnosis, I think it is safe to assume that his electrolytes were relatively normal.

The "pop" is the key to the final diagnosis (well, various tests were used to confirm it, but in hindsight, from a pre-hospital perspective, it's all we have). It is in fact what started everything. And it isn't his inner ear.

Any other ideas?

[FireEMT2009]

Dwayne I think you just gave me the answer.

The ear is the one of the center pieces for equillibrium and balance. The pop he could have heard was the popping of the ear that deals with equilibrium. That would cause the nausea and not feeling well and the near code look might also be from the problem.

Jus in case that isn't the answer, has he been scuba diving in the last day or so? I'm thinking it might be the Bends.

[usmc_chris]

Sorry it's been a while, I'm in Bridgeport, CA at the Marine Corps Mountain Warfare Training Center for my 2 week Annual Training for the Reserves, with limited internet access.

It wasn't actually his ear. No recent scuba diving. It turned out that he dissected his left carotid artery. When we picked him up it was a small hole, but it could have easily turned into a much bigger hole and bigger problem. Overall a very interesting case.

[Eydawn]

Man, I wish I had seen this thread before you gave the answer. That's totally where my brain went with the funny move and the "pop" and immediate diaphoresis/pallor. My brain went "uh oh. Vascular compromise." I would have listened for bruit on both sides. I also would have probably placed a C collar to minimize movement in case the vascular compromise was secondary to a busted something or other that could shift around and make things worse.

I would not have given the odansetron. Too many unknown variables. I don't know enough about odansetron to give it when there's potential for this to be a neuro-based issue. If he pukes on me, so be it. 4/10 isn't bucket-worthy... anything above a 6 is where I'm shoving receptacles at you...

What did they do to tx, do you know? Did it self-correct, or did he need some kind of graft/stent treatment?

Wendy

CO EMT-B

[DFIB]

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.

Edited because I missed the diagnosis. Deleted coments.

Edited August 1, 2011 by DFIB

[sparklebaby]

[Happiness]

What part of his neck did he feel the pop. The back, sides or front.

[usmc_chris]

I missed this question, sorry. It was on the left side of his neck.