Bieber Posted May 25, 2012 Posted May 25, 2012 Since everyone thought it was me who posted that ECG thread in the other forum the other day, I've been feeling obligated to post a scenario. Nothing overly complex, but fun. You and your paramedic partner respond with a BLS fire squad to a local nursing home for a patient complaining of difficulty breathing. You arrive on scene and head inside where you are directed to the patient's room. You are advised that the patient began having trouble breathing twenty minutes ago and are immediately told that he is a DNR. The patient himself is an 82 y/o patient who is laying almost flat in bed (x2 pillows under his head) who is obviously in severe distress. Patient's breathing is labored with intercostal retractions and nasal flaring preset. His fingers are cyanotic. You have a 25 minute transport time to the nearest hospital. Go! Addendum: Never fear, there will be some strips in this thread as well!
DwayneEMTP Posted May 25, 2012 Posted May 25, 2012 Let's have basic vitals, then O2, sit him up straight if possible, send someone for a copy of the DNR. Not going to ask for everything so that others can participate too... Thanks Biebs...we've been needing some scenarios...
Bieber Posted May 25, 2012 Author Posted May 25, 2012 You got it, Dwayne. HR: 134, regular RR: 24 labored SpO2: 83% on 10 lpm O2 via NRB BP: 186/102 Any other vitals you'd like? Someone's going to get the DNR... It'll be here shortly! (Well... maybe, you know how nursing homes can be.) No change in status on sitting the patient up.
DFIB Posted May 25, 2012 Posted May 25, 2012 What does he look like? Tall? Thin? Does he appear malnourished? SAMPLE history? Lung sounds? JVD? Trachea inline?
Happiness Posted May 25, 2012 Posted May 25, 2012 Same questions as above. Also what time is this call comming in, did he eat just before this event. 1
Bieber Posted May 25, 2012 Author Posted May 25, 2012 What does he look like? Tall? Thin? Does he appear malnourished? SAMPLE history? Lung sounds? JVD? Trachea inline? He's about 5'6" 130 lbs. He appears to be in moderate health. S - Dyspnea, increased work of breathing. A - NKDA M - Levothyroxine, spiriva, furosemide, coumadin, lisinopril. P - DVT (lower extremity), COPD, CHF, HTN. L - Unknown. E - Patient was sleeping when he suddenly woke up short of breath. Lung sounds are severely diminished (little to no auscutatable airflow). Trachea is midline with JVD present. Happi, the call came out at around 2330 with time of symptom onset was approximately 2310. Also, success! A valid DNR has presented itself! It is up to date and valid.
nypamedic43 Posted May 25, 2012 Posted May 25, 2012 (edited) Extremity edema? And is the O2 helping the cyanosis? Also the lungs are diminished....what sounds? Wheezes, ronchi, rales? Edited to ask for lung "sounds" Edited May 25, 2012 by nypamedic43
Bieber Posted May 25, 2012 Author Posted May 25, 2012 Surprisingly no! No real peripheral edema. O2 doesn't seem to be doing much; patient's sats are still about 83% with no change in his cyanosis.
systemet Posted May 25, 2012 Posted May 25, 2012 (edited) I'm going to use my crystal ball combined with an extreme distrust of nursing facilities and profound cynicism. The patient has a recent nursing-home acquired pneumonia that's caused an acute exacerbation of his CHF, manifesiting as dyspnea misdiagnosed by nursing staff as agitation, treated with po benzodiazepines and supine positioning x 30 minutes ago? Any improvement with Fowler's and O2? Level of consciousness? Accessory muscle use? Does he appear to be tiring with a RR of only 24/min? Signs of volume overload? Ascites? Sacral / pedal edema? Heart sounds? Any assymetry of chest rise? 12-lead ECG? IV access and bG. HX of recent illness / surgery / fall / catheterisation? Any recent disease outbreaks in the nursing facility? Recent med changes? Edited May 25, 2012 by systemet
Bieber Posted May 25, 2012 Author Posted May 25, 2012 Any improvement with Fowler's and O2? None. Level of consciousness? Accessory muscle use? Does he appear to be tiring with a RR of only 24/min? Verbal, GCS: 3, 4, 6. Accessory muscle use is present and he seems to be holding his own--for now--but he's really working at it. Signs of volume overload? Ascites? Sacral / pedal edema? Heart sounds? No real signs of volume overload. You're unable to auscultate heart tones over the sound of the patient's breathing. Any assymetry of chest rise? Chest wall movement is equal bilaterally. 12-lead ECG? Ah, you're a step ahead of what I was. I'll give you the 4-lead and we'll say the 12-lead is non-diagnostic with right axis deviation. IV access and bG. You go in for one of the massive veins on the patient's hand with a manly 18 and... pop! Sucker blows. Coumadin cleanup, aisle systemet. HX of recent illness / surgery / fall / catheterisation? Any recent disease outbreaks in the nursing facility? Checking your tablet, you see the patient was transported back at the start of April but no one knows what for. No recent falls, surgery, or catheterizations. Recent med changes? None.
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