Dyspnea

[Bieber]

Good morning!

It is midnight when you and your paramedic partner are dispatched to a patient complaining of shortness of breath. The patient is coming from a local rehab facility, fourth floor. You find your patient, a 70 year old obese female lying supine on their bed with very labored respirations audible from outside the room. The patient is staring straight up at the ceiling and does not respond to your presence. From the door you can see that they are very pale with cyanosis around the lips. Staff mysteriously disappears after directing you to the room, thankfully someone has left the paperwork on the counter.

Go!

[island emt]

First thing: Sit Shamu up and put her on some O's

Then do your assessment and send someone to track down her medical records.

Then call for a Hoyer crane to put her on your oversized stretcher.

Hope the dump has an elevator big enough to safely take shamu to the ground floor.

[Bieber]

Patient has been sat up! Still not responding. Medical records are in the room, what information would you like to have?

Airway - Patent, no vomitus or obstruction.

Breathing - Shallow respirations, very labored and rapid at about 35 resps/min, lung sounds are diminished with barely audible rales in all fields. Perioral and peripheral cyanosis present.

Circulation - Skin is cool, pale, diaphoretic. No trauma or bleeding. Pulse is difficult to locate due to size of the patient.

Initial GCS 3 (1/1/1).

[DartmouthDave]

Hello,

First, I would like to get some more assistance. An other ambulance and drum up some staff if you can. I think we will be needing them.

Do we know the code status of this patient?

When was she last seen well?

Basic medical history? COPD? Asthma? CHF?

With a clear airway we can lean away from an allergic reaction, Ludwig Angina, Reinke edema, or a penut

With course lungs it could be COPDE, pneumonia, CHF, or the standard PE.

Dose she still have a pulse?

Her GCS is worrysome as well.

Time to get moving. I would insert an OPA and a NPA and attempt two-person BVW with some PEEP. With a slow and steady rate.

Getting a line would be nice as well. Put her on the monitor as well.

Of course, this will be hard with just two people and MIA rehab staff. =)

[Bieber]

You've got it, another ambulance is en route.

Patient is full code.

Staff says they think she was okay yesterday, but they're not sure.

Basic history of COPD and CHF.

Pulse is dubious. VERY dubious. Nobody's been able to definitively find one yet.

Patient gags when the OPA is inserted, however she tolerates the NPA. No resistance to bagging.

[mobey]

Prolly gonna be a Cardiogenic shock (Low pressure pulm edema)

Throw the pads on for a lead 2 interpretation, 12 lead can wait. I just need rate & rhythm for now

Try for a BP, if we can't get one, depending on rhythm, we will get Dopamine up right away.

I'm happy with npa/BVM for now, we can keep the PEEP valve nearby, but I need a BP before we do anything else.

Forgot to ask: How far to hospital?

Is there an emerg department? cardiology?

[Bieber]

Lead 2 shows a regular complex rhythm with a QRS of 150 ms, no discernible P waves, and a rate of about 210.

Finally, you're able to obtain a blood pressure of 84/58. Patient is being ventilated via BVM without difficulty, SpO2 is about 85%.

Nearest hospital is about 10 minutes away, full services.

[mobey]

Ahhh... well that changes things!!

Lets throw the leads on with those pads and sync!

I'll cardiovert with my new zoll x series please! I doubt it will work with all the adipose tissue.... but start at 120j Biphasic to make the auditors happy

Does she have a temp?

[Bieber]

Pads are on and monitor is synched! Before we shock, is there any reason you can think of why we would want to delay or defer cardioversion of this patient at this time? (Not a trick question.)

[MariB]

What kind of rehab? Cardiac? Injury to limb? What's going on with that? Alcohol?