Call from today

[JCicco345]

I view the posts on here daily, however i don't post very often. I did a call today and i was looking for some opinions of what was going on with her, and what else if anything could have been done for her. I am a paramedic student so i've been trying to look into the deeper pathophysiologies of what is actually going on with the patient. Anyways, we are a BLS truck, we responded to an assisted living for a fall. Arrived to find a 96 year old female, supine on the bathroom floor, she is caox3 with some periodic confusion. She had no obvious injuries, denied pain, was pale central and peripheral, her hands were really pale and her nail beds cyanotic with refill times of 6-8 seconds. She knew that she was on the floor and unable to get up, but was unable to explain how she got there. C-spine precautions taken. Patient had also been incontinent of bladder and bowels prior to arrival. So we load her up quick and i went to get my vitals, i was unable to palpate the radial pulses, explains the pale extremities with the delayed refill. I tried for a brachial, carotid, both with no luck, also no luck with auscultating for a blood pressure, couldn't even see the needle jump (i know that is somewhat inaccurate anyways but i was trying to get something). I asked my partner to give me a hand for a second and he couldn't get any of them either. Attempted auscultation of the apical pulse, with some weak/faint heart sounds, however with her respirations it made it hard to get a rate. So she had already been on 15 liters via NRB mask, and by the time we got to the hospital had pinked up a little centrally. Still unable to get a pulse. After a few minutes in the ER, someone got a femoral pulse. But here's the weird part, she got hooked up to all their little toys and showed a rate of 88 with a pressure of 112/60. So i don't see how we couldn't come up with anything ? Ever had that many problems with vitals on a patient ? Thanks in advance for any opinions.

[Timmy]

What was her HX? Any meds?

Roughly about how long had she been lying there for?

Sounds like she’s in shock or a tad hypothermic.

I hate it when you can’t get a pulse lol!

[JCicco345]

Oh i meant to put how long she had been there, she said she walked into her bathrooom at 8 am or so and this was 1:30pm so 5-5 1/2 hrs.

Unknown Hx (asthma, cardiac)

Only meds we found were for asthma, and then some nitro (which she hadn't used today at all)

Also once in the ER based on her lung sounds the MD sent her to get a cxr, he was going with pneumonia, however i dont know what happened with that. But with shock i wouldn't really expect her vitals to be that stable, if she'd been septic she probably would've been a little hypotensive.

[JPINFV]

Don't ya love the paperwork at assisted living places? Half filled out, hand written forms that's been copied a bajillion times.

Anything else on the secondary (unequal grips, clubbing, edema, etc)?

Lung sounds?

Did you request an ALS intercept?

[JCicco345]

Secondary was unremarkable, her grips were weak but equal, no slurred speech, a little lethergic, but nothing major. I not great with lung sounds but the bases had some fluid but it wasn't much just enough to hear a little junk. I considered ALS but it would've just been a chase, the closest hospital was like 5 minutes away.

[JPINFV]

I considered ALS but it would've just been a chase, the closest hospital was like 5 minutes away.

Fair enough. That's the same situation that I'm in most of the time.

[Asysin2leads]

Sounds like a classic vasovagal reaction, she was in the bathroom, she vasovagaled, went down onto the floor, had a low BP initially which came back up when you got to the hospital. That would be my guess, but this definitely someone who you needs to be monitored for transport.

[BushyFromOz]

Would pericarditis be an option here?

[Doczilla]

Doesn't sound so much like vasovagal to me. One key thing about vasovagal is that it is transient. I wouldn't expect her to be in the bathroom with a low BP for 5 hours if that were the case unless she vagaled down again just prior to your arrival.

It is possible that the oxygen helped her BP as well. It sounds as though she might have been a bit hypoxic based on the cyanosis, and with your therapy, that improved. The possible causes of her hypotension are many and varied, but with hypoxia and crappy lung sounds, that narrows the field a bit. If her pressure was better at the hospital, then she's obviously not yet in septic shock, but she may be headed that way. Your exam findings sound consistent with hypotension, so there's probably nothing wrong with your BP technique. I certainly agree with not waiting for ALS on this one, particularly considering your distance from the hospital.

Also, as a general rule, asthma is not that common in this population. Other lung diseases (COPD) are, and that's generally what the inhalers are for. Asthma is a specific disease marked by airway hyperreactivity, excess mucus production, and hypertrophy of bronchial muscles (which enhances the reactivity). This is similar to but a narrower category than what we refer to as Reactive Airway Disease, a broad term to define people who have bronchospasm (wheezes) in response to certain stimuli. For example, emphysema patients can get bronchospasm that can be life-threatening, but it is not asthma.

'zilla