Case: Difficulty in breathing

[Asysin2leads]

You are called to respond to an 82 year old with reportedly difficulty breathing. Wait, a minute, you know, don't the textbooks start out with a little story? Let's make this more interesting. You and your partner are settled in with your plate of perfectly seasoned pasta bolognese, you even went all out and used pancetta rather than bacon and scrounged up some tagliatelle pasta, and the station is still heavy with the aromatics you used in the soffrito. As you tuck your napkin into your shirt, just before the first morsel of pasta hits your mouth, you recieve a call for an 82 year old with difficulty breathing, and you and your partner head out into the dark and stormy night, with the wind howling and the usual suspects lurking about.

After a 10 minute curse word filled response, you arrive to find said 82 year old female sitting upright with family, pale cool, diaphoretic, with slow, shallow respirations, who moans when you speak to her, sitting next to a home glucometer. As per the family, she has a history of asthma and a heart murmur. She had complained of mild difficulty breathing and asked to use her inhaler about 30 minutes prior to calling 911, and now is in the current state. The family seems strangely calm about the whole situation. Physical exam: PERRL, lips pale, skin pale, cool, diaphoretic, respirations shallow, slow, negative accessory muscle use, equal chest expansion, lung sounds difficult to hear, but with mild expiratory wheezing, abdomen soft, non-tender, negative incontinence, pulse present, weak in extremities, negative edema, negative obvious DCAP-BTLS. Pulse: 46 and regular, BP: 62/P, GCS: 5,

SPO2: ??? (pulse ox cannot detect). EKG: Narrow complex bradycardia with no P waves, probably junctional rhythm.

Okay, so the question is, if you decided to say "to hell with procedure and protocol", and your medical control doctor gave you carte blanche, and you could do one thing with this patient, what would you do?

A. Sedate and pace

B. D50 IV.

C. Atropine 0.5mg

D: Eh, make that 1mg Atropine.

E. Sedate and intubate.

F. 500cc fluid challenge. Starling's law, baby!

G. Dopamine 5ug/kg/min titrated to effect

H: Dopamine is for wussies. Gimme epinephrine 2ug/kg/min or give me death.

I. Say "She's 82, lets go finish our pasta"

[brentoli]

Well, you mentioned the glucometer, but I didn't see the BGL?

I am BLS mind you here, this is a canidate for assisted breathing by BVM for me. Give it a try with an OPA, switching to NPA if needed.

I went on a call along these lines at a nursing home, I belive about halfway to the hospital the medic gave her Atropine. Her GCS was probably about a 7 with shallow slow resps and a pulse of about 45.

So blind faith would have me following his course of action, because the only diffrence is the LOC.

Blind faith will screw me too in the end.

[fiznat]

Before any of the above I would like to do the basic stuffs first. O2, Monitor, IV.

Let's put her on 15lpm NRB with a basic airway adjunct if she will tolerate, Attach the monitor (including ETCO2, please?), and bang in an IV real quick.

I'd like to know a few more quick history/assessment things (can do this while doing the basics)

-Patient even been intubated due to asthma?

-Did the MDI help at all? How many did she do?

-Any pain, pressure, discomfort complaints before the change in mental status?

-Recent illness, anything abnormal in this respect?

-Whats that BGL?

-Quick neuro checks (INCLUDING BABINSKI haha)

-Rapid trauma assessment, focus on ABD (?AAA) and distal pulses if palpable (?equal)

-Is this patient a full code?

Probable first line actions:

-Consider patency of the airway at GCS 5. Possible BVM? Think about intubation.

-Shock precautions

-Fluid blous 250cc for starters

...OR are you sticking by the "if you could do only 1 thing" question?

If that is the case, I would really like to know that BGL first. ...Assuming it is normal of the choices above I think I would have to go with pacing. She is profoundly unstable, bradycardic and hypotensive. Although our protocols suggest a "brief trial of medication" prior to pacing (because if you have time to sedate you have time to try atropine), you say we can only pick one so there it is.

[Asysin2leads]

Before any of the above I would like to do the basic stuffs first. O2, Monitor, IV.

Let's put her on 15lpm NRB with a basic airway adjunct if she will tolerate, Attach the monitor (including ETCO2, please?), and bang in an IV real quick.

Done, done, done. She is making fish faces beneath the NRB, but she tolerates the OPA. As previously stated, she shows a narrow complex bradycardia sans P waves on the monitor. IV is in like flynn with a 250 cc 0.9% NS @ KVO. For the purposes of this scenario, your department is too busy selling T-shirts and making homoerotic calendars to bother buying the ambulance drivers ETCO2 detectors, aside from the plastic doohickeys for the BVM that look like they were found in a box of Frosted Flakes, and ditto for the glucometers. You're on your own, chief.

I'd like to know a few more quick history/assessment things (can do this while doing the basics)

-Patient even been intubated due to asthma?

Negative.

-Did the MDI help at all? How many did she do?

Negative.

-Any pain, pressure, discomfort complaints before the change in mental status?

Negative.

-Recent illness, anything abnormal in this respect?

Negative,

-Whats that BGL?

See above.

-Quick neuro checks (INCLUDING BABINSKI haha)

Yeah, they're all good and stuff. In fact, they're better than good.

-Rapid trauma assessment, focus on ABD (?AAA) and distal pulses if palpable (?equal)

[fiznat]

lol

What about my pacing?

[canuckEMT]

Ok, Grandma is an unstable bradycardia so I would try the old 500 cc bolus while preparing to pace with no sedation as she is hypotensive. If this was usuccessful I would attempt the dopamine starting @ 5mcg/kg/min.

Of course there is room to switch the dope and pacing given the info of the previous post (hee hee). Another thing I would check would be a temp and any Hx of illness recently, cough?

The way the family is acting kinda raises a red flag as well.

Could we do a 12 lead on her? What does it show, also do we have any meds or a list for her?

[Doczilla]

You are called to respond to an 82 year old with reportedly difficulty breathing. Wait, a minute, you know, don't the textbooks start out with a little story? Let's make this more interesting. You and your partner are settled in with your plate of perfectly seasoned pasta bolognese, you even went all out and used pancetta rather than bacon and scrounged up some tagliatelle pasta, and the station is still heavy with the aromatics you used in the soffrito. As you tuck your napkin into your shirt, just before the first morsel of pasta hits your mouth...

Don't know what's going on with the patient, but now I'm hungry as hell.

'zilla

[vs-eh?]

Sorry, what medications is she on?

Bilateral BP please...

Take her BGL with her glucometer. I realize FDNY does not have them (why on earth), but use her's before treating anything else (ABC aside). Treat hypoglycemia if indicated.

On the surface it would appear the classic case of the inferior MI with right ventricular involvement. But it probably isn't...

Sorry, she is a GCS of 5 but gross neuro assessment is "better than good"? Hmmm... I assume that was her initial GCS? What is it as you are talking to her/assessing her?

Big one's to me are CVA/TIA, MI, hypoglycemia, or OD (beta blocker, Ca++ blocker, or cholinesterase inhibitor - I've seen this believe it or not).

Since it's probably not the obvious as presented I'll go with OD and you could have used a "reversal" medication/treatment instead of pacing.

[vs-eh?]

oh and gud post asys. 8)

PS - This is to get my post count up, so I can get into chat! *crosses fingers*

[HellsBells]

Keeping in mind that I'm only a BLS guy here,

My first thought was to try a Combivent Neb, Followed by IV access, with a good old 250ml bolus.

If there is no joy from the Neb, OPA, BVM interventions if needed.

I'd also like to see a 12 lead on this Lady, leaving any further interventions to my highly skilled Paramedic partner.

Now as for a BGL, why can't we get one from her home monitor? Is it broken, or just Paramedic proof?