zzyzx Posted October 13, 2006 Author Posted October 13, 2006 You've never worked with this EMT before, but you knew not to trust him when you saw him pull into work today in a lifted Hyundai with a bumper sticker reading "My Phone Number is 911." Ok, so you want to give him sugar since he's a diabetic with ALOC and a low blood sugar. However, you can't get a line (much to your partner's delight), so you give him 1 mg of glucagon IM. You load the patient up and begin transport to the hospital, which is only five minutes away. You understand that the glucagon won't take effect until after your arrival, so you don't expect any change in the patient's mentation, if hypoglycemia really is the cause of his ALOC. Just before you arrive at the ER, you do get a line and give him half an amp of dextrose. Funnny, but this doesn't wake him up at all. Per someone's suggestion, you give him a fluid challenge. (His lungs are clear.) To answer one of your question, his pupils are reactive but sluggish. Anything else you want to do before you arrive at the ER???????
zzyzx Posted October 13, 2006 Author Posted October 13, 2006 One other bit of info: you found the patient incontinent.
Thunderchild145 Posted October 13, 2006 Posted October 13, 2006 Yea, due to the incontinance I'd almost certainly say stroke/TIA. Due to interventions we can rule out Beta blocker overdose and hypoglycemia. What did the neuro exam tell us? Quick check of pupils, "doll's eye" movement, break open an ammonia amp and wave it under the pt's nose, that type of stuff.
zzyzx Posted October 13, 2006 Author Posted October 13, 2006 Ok, so per your suggestions, you suspect stroke and do some supportive treatments. He has a gag and just to keep things simple let's say you can't do nasal intubations in your protocols, so you put in an NPA. You have him on O2 and watch his breathing, and you're giving a fluid challenge. He's still sinus brady on the monitor, and his BP is around 90 palpated. Anything else you want to do???????? Any other suggestions as to what's wrong with this guy?????? There's something very important that's been left out here....and you're in for a suprise when you drop this patient off. I'll post the ER diagnosis when I get back on Monday.
Asysin2leads Posted October 13, 2006 Posted October 13, 2006 I guess my only question would be does this guy present as being septic for any reason? A prior similar instance leads me to still strongly suspect a stroke, or a new onset of seizures, though if the guy was postictal, he probably would have woken up by now. Okay, I want to know more about this guy's head injury. His blood pressure is low, but that doesn't mean the AMS/Bradycardia aren't signs of a whack on the noggin. At this point the EMT's semi should be stopping at a local truck stop before that long trip to Phoenix.
medic001918 Posted October 13, 2006 Posted October 13, 2006 I guess my only question would be does this guy present as being septic for any reason? A prior similar instance leads me to still strongly suspect a stroke, or a new onset of seizures, though if the guy was postictal, he probably would have woken up by now. Okay, I want to know more about this guy's head injury. His blood pressure is low, but that doesn't mean the AMS/Bradycardia aren't signs of a whack on the noggin. At this point the EMT's semi should be stopping at a local truck stop before that long trip to Phoenix. I'm going to agree. The patient should be treated for hypoglycemia. The hypoglycemia could be from burning off sugars secondary to seizure activity. The suspected seizure activity can be casued by a stroke/TIA as has already been mentioned. I also have to agree that my EMT partner and I would be having some words after this call about when it's appropriate to question patient care and how to bring it up. The duck tape idea isn't half bad. Consider myself as adding to the contribution to ship him somewhere else. Shane NREMT-P
brock8024 Posted October 15, 2006 Posted October 15, 2006 Well I think this is a funny scenarios due to the fact that two or three people have asked for a 12 lead, but it was never said what it showed. 1)Ok he was found in his pj's, he is 82 so when did gramps normally get up out of bed? 2)When was the last time he was seen in his normal state of mind? 3)Sinus brady on the monitor but what does our 12 lead show. 4)The blood was clotted so that means he could have been laying there for a while. 5)He is skinny and barrel chested which means COPD, but we all knew that 6)His Blood Pressure is low but what is normal for him? 7)FSBS of 60 could just mean that he has not had breakfast. 8)So he urinated and or defecated on himself that could be many things, Like I said how long has he been laying in the floor. 9)He has a AMS but that could be from poor cardiac output or hitting his head. 10)Does he have any pedal edema? 11)He has what sounds like a GCS of about 7 or so giving him the benefit of doubt. 12)When did he have his CABG? I am thinking that this guy might be having a Inferior and Right Sided AMI. This could acount for the hypotension, rate, and the AMS. Right venticle infarct means decreased pre-load which leads to decrease cardiac output. Like I said his FSBS could be from just not eating yet. The urination or defecation from just laying in the floor for a while. The lac to the head secondary to the fall from the AMI. I have not seen many 82 year old smokers that have COPD that breath 10 times a min and have a normal tidal vol. Most are working at it to breath while they puff on that cig. TX- Bag pt with BVM IV and give fluid challenge. If I could not get anything in the arms, I would be looking at the neck. I would consider some type of vasoconstrictor, possible Dopamine or something. I want to help his heart work easier not harder. Monitor with 12 Lead Drop a Nasal ETT down. He might have a gag reflex but I have been told you can intubate someone nasally while they are still awake. This is all I can think off. Personally I think he clogged off one of his new bypass vessels and is in caridogenic shock.
zzyzx Posted October 15, 2006 Author Posted October 15, 2006 Thanks for all your interest in this scenario. I realized I did make one mistake that I will have to correct. I said earlier that his pulse ox reading showed 93. However, on this patient you probably wouldn't get a pulse ox reading because his fingers are cold. Per some of your suggestions, you bag the patient. To clarify, his pupils are equal and responsive but sluggish and dilated. He opens his eyes to painful stimuli, he withdraws to pain, and he moans. Per some suggestions, a 12-lead was done and it shows sinus bradycardia with occasional unifocal PVC's. Per another suggestion, you ask the son how long his father has been lying there, but the son says he doesn't know. He talked to his father sometime the day before. Per suggestions, you have considered that he is hypoglycemic (but giving him sugar has not had any effect), that he has suffered a stroke or head injury, or that he's had an MI (though the 12-lead shows only bradycardia with a few PVC's). Per other suggestions, you are also giving him a fluid challenge. The patient is c-spined and you are ready to take him into the ER. Are there any other treatments you'd like to perform? I'll post the conclusion to this scenario on Tuesday.
JCicco345 Posted October 15, 2006 Posted October 15, 2006 Quick question and this may sound stupid but I would've thought to go with pacing, or atleast consider it due to the unstable bradycardia. Well i quess the question is, if you have the patient where you are suspecting cva and they happen to be unstable and bradycardic, do you treat the brady like you normally would ????? I'm just trying to put all this info from school into practice. Thanks in advance. o2, monitor, IV with fluid challenge (250cc), consider pacing (maybe call med control).
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