What do you think was wrong with this patient

[Inthecity]

A 28 year old patient, 3 days past an emergency c section. Good health before this episode, in good shape for the most part and no history of medical problems. She was having trouble breathing and gasping for air, shaking hard, heart rate of 225 and a temperature of 104.5. Another medic considered her to be stable but given this information is this a stable patient? I will tell you in a bit what the problem turned out to be.

[Kiwiology]

A 28 year old patient, 3 days past an emergency c section. Good health before this episode, in good shape for the most part and no history of medical problems. She was having trouble breathing and gasping for air, shaking hard, heart rate of 225 and a temperature of 104.5. Another medic considered her to be stable but given this information is this a stable patient? I will tell you in a bit what the problem turned out to be.

No this patient is not "stable"; based solely on your information she is right now what we call status two or potentially life threatening problem

It could be any one of 400 things but right now my suspicion is high for a post-operative infection (specifically pneumonia/RTI) or another surgical complication could be anything from the sniffles to a bloody great DeBakey clamp left inside her.

General impression? (by which I mean well perfused etc or does she look "crook" (sick) i.e. shut down?)

What is her obstetric history? why did she have the c-section?

When did this fever start; did it just "turn up" or did it come on gradually? has she taken anything for it?

What has precipitated the SOB? has she been coughing up any sputum (if so what colour) or anything else?

How do her lungs sound?

What is meant by "shaking" i.e. any seizure activity (I'm thinking it's just because she is in the latter stage of fever and is feeling "cold")

How does her surgical wound look? is it pink and nicely sutured up or is it oozing and smelly and discoloured?

Observations including SpO₂?

I'd be inclined on transporting to a hospital with gynae capability even if we have to get the Consultant out of bed.

[Inthecity]

Extremely sick looking. Pale and very sweaty and shaking violently and saying she could not breathe but not a seizure.. .Very coherent though. C section due to severe pre elampsia and HELLP syndrome. The fever just started up quickly. She did not even know that she had a fever, it came on very fast. Lungs clear. Wound looks fine and not infected at that site. So you said 2 life threatening problems, what are the 2?

[Kiwiology]

We use a numerical scale between zero and four to describe the threat to life the patient has.

Status codes ... reflect the potential for threat to life rather than purely how abnormal the patient's vital signs and physiology are. The ... approach requires Ambulance Officers to make an assessment of the patient's problem or injuries, combine this with their vital signs and then allocate a status code based on threat to life. This gives them more leeway for common sense than the ... purely physiology based approach.

Status 0 is dead; status 1 is immediate life threat; status 2 is potential life threat; status 3 is unlikely life threat and status 4 is no life threat

What are the patients vital signs including SPO2? what is her work of breathing?

I want to call this lady status one but she doesn't quite seem to be sick enough

If indicated by SPO₂ I'd put her on some oxygen, put a drip in (doesn't have to be a big one) and look at moving towards hospital

Is there somebody to look after baby at home? i.e. dad or auntie or neighbour? I want to begin to get her moving toward hospital if she is this crook

[Eydawn]

I'm guessing she's both septic AND threw a PE. Both common complications post-surgical, and would explain the gasping for air and high fever... I would really like to know her BP, and if she's been d/c'd on any medications and if she's been compliant with those meds, given that she was diagnosed with HELLP. I am curious as to whether she actually had pre-eclamptic signs, or was just exhibiting more of the HELLP spectrum... it's all moved around so fast nobody can keep them straight anymore, but I'd like to know if her disease state affected her BP or her liver more, essentially...

What's her vaginal discharge like? Any indication of birth material retention? (Rare, but could occur, even with a C-section).

What's the monitor look like? Neurological status?

Wendy

CO EMT-B

[Kiwiology]

Any indication of birth material retention? (Rare, but could occur, even with a C-section).

I initially considered this as well but discounted it because of the whole c-section thing; I think I might have been a bit premature in doing so perhaps

If she had POC retained she'd easily turn septic; most likely she has severe sepsis rather than septic shock; *puts ceftriaxone back in hip pouch, one day friend... one day

I am still keen to call this lady status one (super crook^TM) but I have not quite convinced myself that she has an immediate threat to life

Edited March 19, 2012 by kiwimedic

[Eydawn]

Hullo? She's sinus tach (assuming till strip is provided) in the 200's and severely SOB... I'd call that immediate threat to life, there... especially being post-surgical and at very high risk for PE not only due to surgery, but because pregnancy and labor mess with clotting factors...

Wendy

CO EMT-B

[Kiwiology]

Ambulance Status Codes

The status codes .. reflect the potential for threat to life rather than purely how abnormal the patient's vital signs and physiology are.

The new approach requires Ambulance Officers to make an assessment of the patient's problem or injuries, combine this with their vital signs and then allocate a status code based on threat to life. This gives ... more leeway for common sense than the .. purely physiology based approach.

• Status one patients have an immediate threat to life. Examples would include any of the following - obstructed airway or airway needing intervention to prevent obstruction, severe stridor, severe respiratory distress, shock unresponsive to fluid loading, multisystem trauma with very abnormal vital signs, post cardiac arrest with coma, cardiogenic shock, coma with GCS less than or equal to nine.
  

• Status two patients have a potential threat to life. Examples would include any of the following - moderate stridor, moderate respiratory distress, shock responsive to fluid loading, anyone meeting our pre-hospital definition of major trauma but with normal or near normal vital signs, post cardiac arrest but awake, cardiac chest pain unrelieved by nitrates and oxygen alone, abnormal GCS but greater than nine.
  

On reflective thought, our local hospital does not have a Radiologist on duty after 5pm (must call one in from home to get a CT scan) and the surgical service is probably provided by the Surgical House Officer with an on-call Registrar (who is likely on-site asleep in the call room). The Emergency Department will be (now as it's > 10pm) staffed by a House Officer who is probably going to have kittens when we take this lady through the doors.

Based on the immediate facilities available (we have 24 hour theatre, anaesthesia, diagnostic microbiology, ICU, radiology and obstetrics/gynae but several Consultants will have to be woken) I will call this lady status one and place an early RT call to the hospital (before leaving scene) that they need to wake people up.

Happy now?

Edited March 19, 2012 by kiwimedic

[Pavehawk]

My first thought based on history and the limited presentation is that she is in a rare, but documented, post HELLP C-section shock syndrome which is mimicing the PE (though PE is not a bad guess either along with sepsis). She should be treated aggressively for shock and watched for trending response. IV antibiotics would NOT be out of line here due to the high fever but really need some more information i.e. ABD exam, BP/FiO2/Capnography, POC lab work if available 12 lead (she seems a bit fast for sinus tach I would want to Diff dx for Afib/Aflut/AVNRT/AVRT/AT) and a CXR /CT once in the ED

Bottom line... she is sick (perhaps with more then one pathology; some folks don't catch a break) and needs to be in hospital. Field care is supportaive in nature. I would certainly like to see her transported to a hospital that has GYN and Surg capabilities ASAP.

How did she do?

[Eydawn]

OK. I got another one. Did she by any chance need blood products while she was in the hospital? Because... (Zebra music please)... I just learned about a condition called TRALI- Transfucion Related Acute Lung Injury, whose seminal symptoms are dyspnea, hypotension and fever...

I know it's a wild hair, but DID she get blood products? Could this be our zebra?

Wendy

CO EMT-B