PE vs psychosis

[krumel]

Hey guys,

I finally got permission to release a case report of a quite interesting case my former service had.

I really would be happy to hear some opinions on this one.

DISCLAIMER: THIS IS NOT AN AUSTRLIAN CASE ALTHOUGH I USED AUSTRALIAN QUALIFICATION NAMES. I simply could not find better names for the real "non-english" qualification of the people involved.

Caller Statement: Young female, breathing difficulties.

An ALS Truck, staffed with one Intensive-Care-Paramedic(10 years total expierence, 5y as graduate paramedic, 1.5y as ICP) and one advanced-care paramedic/EMT(5y expierence, in traning for ICP-paramedic) is dispatched to a remote country hotel. The service operates a "clinical decision model" where only a few guidelines (for resus&trauma) are established, there are no mandatory protocols. The weather is 32° Celsius, no clouds, the next basic care hospital is 22 min away from the scene, the next trauma-center 45minutes.

The travel time to the scene is 17 Minutes. On scene the team is awaited by hotel staff and brought to the third floor of the hotel where they find a approx 30 y/o female sitting on the ground of a hotel room with a normal skin color who is remarkably agitated and extremely hyperventilating.

A verbal approach/ "talk-down" to the patient seems not possible, the patient reacts with increased agitation to that. Therefore getting a direct patient Hx is impossible. The accompanying spouse informs the team that the patient had a recent miscarriage with a highly traumatic curettage 10d ago, no further medical history, allergies or medication is not known. The spouse suspects a psychotic episode as the psychological situation of the patient was degrading during the last days.

The attached pulsoximetry shows 98% SpO2 and a HR of 100, getting a BP is impossible due to the patients movements. The auscultation of the lungs shows no abnormal diagnosis. There is no evidence of a further neurological problem visible, the patient is moving all 4 limbs with similar force, is able to identify persons, the pupils react PERL, the speech appears normal and the patient is speaking complete sentences, although not being orientated to person, situation, location or time. There is no evidence for a intoxication, the spouse was with the patient for the last 24hours and packed the bags of the patient. After further attempts by the spouse and the team to establish verbal contact with the patient failed the decision is made to sedate the patient, as a working diagnosis a presumed psychotic episode following the miscarriage is used.

One arm is fixated and a 18G placed on the forearm without any problems. After securing the IV access and confirming the placement 4mg of Diazepam are administered. After awaiting the onset the patient appears to be a bit less agitated but still confused. Now taking a BP (110/70mmHg) and establishing a 3 Lead ECG (no abnormal diagnosis beside mild sinus tachycardia) is possible. As the patient still appears to be too agitated to securely transport her another 2mg of Diazepam are administered. After the onset of this dose a first attempt to transport the patient is done but due to the confined spaces (extremely small staircase, transport only in the carry canvas) and the fact that the patient is still trying to jump of the carry canvas the attempt is cancelled another 2mg of Diazepam is administered. After the onset of this dose the patient is now sleepy but opening eyes to pain (GCS9), has intact protective reflexes and a SpO2 of 98% on room air, HR90, BP as above. Another auscultation still shows no abnormal diagnosis, the hyperventilation has decreased, the RR is normal. A short palpation shows no abnormalities beside a small haematoma on the elbow.

The patient is now again put on a carry canvas and carried the flights down, with a stop after each flight to recheck the airway and breathing. On the ground floor the patient is brought into recovery position and the airway and breathing is checked again. The patient now has a SpO2 of 95%, takes 8-10 deep breaths per minute and is maintaining her own airway. Now the patient is brought into the ambulance and is there observed by the advanced care paramedic while the intensive care medic is trying to get further medical history from the spouse and inform the receiving hospital, observing the patient thru the open door.

After a few moments the advanced care paramedic notes a change in the skin color of the patient and immediately asks the ICP to join again. The SpO2 is now degrading rapidly, to 80% at the moment. Now a bradyarrythmia is noted with a frequency of 40. The patient is now rolled on her back and ventilated with bag valve mask with is no problem at this stage but within 20 seconds the patient goes straight into asytole.

CPR is started by the ICP from the "over the head" position to allow the ACP to attach defib patches and to call for air-ambulance backup. Directly after this the patient receives the first dose of adrenaline (1mg) IV thru the IV-Line placed before. While doing CPR within the first minute the ICP notes increasing ventilation pressure and tries to place an oropharyngeal airway (Guedel). After two further ventilations (by now the ACP has taken over compressions) light-red blood comes out of the OPA, a minimal airway trauma from the insertion of the OPA is suspected and the OPA is removed. By now a large amount of light red blood is noted and the airway is first cleared manually and then my electrical suction.

Another 30 seconds later the ventilatory situation degrades again and another huge amount of bloody fluid has to be removed from the airway, the patient at this stage lost approx 400ml of fluid thru the airway. Now the patient is intubated conventionally with ongoing CPR and without any problems.(7.5 ETT). Deep endotracheal suction produces another 100ml of bloody fluid and (increasingly foam), the capnography still shows 35mmHg. The auscultation shows wet rales on all four quadrants. The SpO2 under compression gives a value of 88% back.

After the second adrenaline the patient goes into ROSC with a slightly tachycardic sinus rhythm. A good peripheral pressure of 130 to 90 mmHg can be taken, the ventilation is continued and a PEEP of 5 is started. After another 20-30 seconds the patients starts breathing against the tube and to bite on the tube. After another 40 seconds the patient goes into bradycardia (HR of 30) for about 30 seconds, after that directly into asystole. CPR is resumed and another 1mg of adrenaline is given. The ventilation has to be stopped soon as the airway again is again soiled with a massive amount of foam and fluid, almost 1l of fluid are now taken out of the airway. After another 90 seconds the patient goes into ROSC again, the situation is similar to the previous ROSC. The attempt to battle to onset of the bradycardia with continuous adrenaline administration and atropine IV failed, the patient goes into asystole after a short time. Within the next 3 minutes of CPR another 2mg of adrenalines are given (2x1mg), the airway is cleared two times of smaller amount of foam/fluid and a exjug is placed. Following this the patient again goes into ROSC for another 60 seconds. After the onset of the bradycardia pacing is attempted and remains successful for about 1.5 minutes (with good peripheral pressures) before the reaction is degrading and even increased energy does not show any results. CPR is now continued again. At this stage during CPR the patient has good peripheral pulses with a SpO2 of 87% and a CO2 of 30mmHg. Within the next 4 minutes the air ambulance doctor takes over the lead. He increases the PEEP pressure to 15. Further adrenaline is given, the airway is again cleaned from smaller amounts of fluid a few times. To reduce the chance of equipment failure the monitor is changed to the monitor of the air ambulance as the good SpO2 and especially CO2 parameters appear not logical. A further "all body examination" is done with no results. A few smaller episode occur but after further 30 Minutes of resus the patient is declared dead on scene.

As the dead is treated as suspicious the dead is investigated by the authorities. The coroner's report later on states that more than 50 small size pulmonary emboli where found in the patients lung with another huge embolus in the uterus. Further investigation of the treatment by the local control boards and the coroner where done but no obvious mistake can be found. The use of intra-arrest- lysis is discussed but two different coronial experts state that even if administered (lysis was not available at any stage) when arriving at scene the patient would have nil chance of survival.

[Arctickat]

Wow, that's a hell of a call. I've been with a couple of PE flashovers like that, hate 'em. No indication of drug abuse? Did the CO₂ and the SPO₂ on the second monitor match the first one?

[Kiwiology]

Damn bro that is fucking mental insane in the brainbox seriously!

Honestly I wouldn't have done anything differently nor suspected a PE

[krumel]

Arctickat: Yes, in general yes...Where two different monitors-brands (LP12 vs. the new propaq) but in general yes. Initially absolutely no indication of a drug abuse (spouse statement that he had her under "observation" for 24h, packed her bags, considering the fact that the hotel is isolated, quite posh & more for a older customer range it seemed unlikely that she bought something on scene, especially as she had no money...and considering the fact that drugs are not that well known in that part of the world). Complete and comprehensive drug screening was done during post mortem..

But:One of the few points the board criticized was that the fast drug screening kit (would have been available) was not used, especially in the pre-arrest time.

[Arctickat]

How does your kit work? Mine needs a urine sample, from the looks of thinks here I doubt you would have gotten one of those.

[island emt]

Quote"The accompanying spouse informs the team that the patient had a recent miscarriage with a highly traumatic curettage 10d ago, no further medical history, allergies or medication is not known. "

That statement right there gives a clue to the possibility of a PE.

Not usually the first thing to cross ones thought process, but it might make me see zebras,instead of elephants.

It would seem to me that she had been on the downhill slide for several days after the miscarraige and had finally thrown the clot causing the PE. The amount of fluid you suctioned was confirmation of it finally letting go.

Tough case and more than likely the outcome would have been the same if she was in the hospital.

[paramedicmike]

Agree with IslandEMT. Tough call all around. Having seen this myself I know that it can be difficult to figure out as it's unfolding. It's a little easier to consider PE as a differential the second time around. The resolution of the call, however, doesn't always change even if you figure out what's going on.

[krumel]

Hey Island,

"traumatic" was meant in the psychological meaning... Sorry about this confusion.

I think the team was midlead by the following factors:

- The patient was not cyanotic nor had bad SpO2 or expanded jugs

- The patient was mobile for days

- The time-frame for a typical post-curretage PE is normally much shorter

and of course the effect of a highly agitated patient sometimes has.

[island emt]

Krumel: Understood. Any D+C can lead to these types of complications, no matter how carefully the procedure is done..