mobey Posted December 19, 2012 Posted December 19, 2012 Well it's not an "S" word, but I'm going to take the safe route and treat him like a ruptured AAA. Hold off the fluids, and start Dopamine. I like Ketamine for this guy for pain, and will also use it to intubate if his GCS drops off. Depending on where we are, we better start thinking about air transfer. Was this bloody diarrhea? Oh ya.... don't palpate the abdomen! I would like to know if it is ridged though?
fakingpatience Posted December 19, 2012 Posted December 19, 2012 Is his skin still flushed and warm? You said his RR decreased, is that because he is getting tired of breathing/ lethargic, or is relaxing? What is the pulse ox? Here is my thinking "aloud" Types of shock: Hypovolemic: Possibly, but where is he bleeding into? Skin should be pale/ cool/ clammy Neurogenic: Doesn't quite fit with his initially elevated HR, but possible. Unlikely traumatic, but possibly a bleed? Cardiogenic: 12 lead is clear, but could possibly be NSTEMI or other. Don't really think pericardial tamponade, no hx or s/s/for that. No s/s of CHF Anaphylactic: Could possibly be a severe reactions, without respiratory compromise, however what is he reacting to? Fits with the sudden onset, tachycardia, hypotension, sudden diarrhea + vomiting Septic shock: Doesn't' fit the sudden onset. He is slightly febrile though I'd be tempted to give him epi at this point. Would help with the refractory hypotension, and if cause is anaphylactic could assist there also.
mobey Posted December 19, 2012 Posted December 19, 2012 Lung sounds are clear. . Doubt it is allergic reaction with this finding
HarryM Posted December 19, 2012 Author Posted December 19, 2012 (edited) His RR decreased because he is getting lethargic. His skin remains flushed and warm to touch even with drop in BP. There is absolutely nothing abnormal with stools or emesis. Abdo pain is not worsened with palpation or percussion and as above there is no rigidity, guarding, distension etc. Fake patience (especially) and fab you are both on the right track with your posts. What treatments would you now give? Do you want me to reveal? Edited December 19, 2012 by HarryM
fab Posted December 19, 2012 Posted December 19, 2012 (edited) Please do so, it's been a great scenario so far. To be honest what I would do is keep on guessing and rush to hospital, intubate at some stage and rush again. Anaphylaxis? Edit: Anterior wall infarction? Paralytic ileus with massive toxine spread? Probably deteriorating too quickly... Edited December 19, 2012 by fab
HarryM Posted December 19, 2012 Author Posted December 19, 2012 (edited) For those who guessed anaphylaxis you are 100% correct. The patient was stung by a bee (only the second time he has been stung) between his thumb and forefinger whilst running. He didn't notice the inital sting due to endorphins released during exercise and subsequent abdo pain fully masked any ongoing pain. He has a moderate welt on his left hand from the sting. If you picked this up early and given 0.5mg IM adrenaline on scene and a further dose enroute the patient recovers quickly. If you picked it up after deteriorating then an IV adrenaline infusion would have been required. In this actual case the crew did not pick anaphylaxis and even in ED it was not picked up on and treated immediately. Learnings: People assume anaphylaxis will always result in respiratory compromise and severe stridor. This is not the case, particularly with venoms or IV drugs where the allergen does not enter the respiratory system and is introduced directly to the blood stream. Anaphylaxis is defined as involving any two of the following systems: respiratory, circulatory, integumentary and GI. So always have this in the back of your mind if the anaphylaxis is not immediately obvious. The best pain relief here would have been ketamine due to its stimulation of the sympathetic nervous system. However opiates would have posed little risk as systemic histamine release had already occured and morphine/fentanyl will not have a huge effect in releasing more histamine. How can you tell? This patient was in shock and we should have seen a fight or flight response during the compensation phase. So it was abnormal to see hypotension and tachycardia when we should have seen hypertension and tachycardia during compensation then decreasing BP and HR when he started decompensatng. He also should have had cold, clammy peripheries as he shut down and blood flow was directed to vital organs. However his skin remained red (due to histamine release) and flushed and warm to touch. Fluid loading did not help the patient as the fluid just leaked straight back out of the blood vessels. I'm not saying I would have picked it up personally, but I thought this was a very interesting case. I took a lot away from it and it's made me think about anaphylaxis more often and have it in the back of my mind. Edited December 19, 2012 by HarryM
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