Dispatched to assault. Really?!

[Shrimpfriedrice]

Dispatched to an assault.

Onscene crew finds "a little person", female in back of cab. Driver sts she was talking to him a short while ago, paid her fare and was about to exit the cab when she sat back in seat.

Pt awake and unresponsive
Ctc: unremarkable
Little amount of dried blood notesd at corners of mouth
Driver dns seeing and type of tremors.

Pt's pilates instructor on scene.

Pt is 42yo, no dcapbtls throughout.

Go!!!

 

[firecoins]

Take them to hospital

 

[Tigger]

Dispatched to an assault.

Onscene crew finds "a little person", female in back of cab. Driver sts she was talking to him a short while ago, paid her fare and was about to exit the cab when she sat back in seat.

Pt awake and unresponsive
Ctc: unremarkable
Little amount of dried blood notesd at corners of mouth
Driver dns seeing and type of tremors.

Pt's pilates instructor on scene.

Pt is 42yo, no dcapbtls throughout.

Go!!!

How is someone awake and unresponsive?

 

[Shrimpfriedrice]

Apologies! I meant responsive to painful stimuli..
Tried to edit after rereading but i dont have the option anymore

And while ur input is welcomed u may want to look up the difference between unconscious and unresponsive!

 

[Clare]

So she basically has an altered level of consciousness.

What do your investigations reveal? For example ECG, blood sugar, physical exam.

What is dcapbtls?

 

[EpiEMS]

What is dcapbtls?

DCAP-BTLS is a silly mnemonic that "they" try to drill into BLS providers. It stands for Deformities, Contusions, Abrasions, Punctures/Penetration, Burns, Tenderness, Lacerations, Swelling, is intended to remind providers what to check for in trauma patients during a trauma assessment. Not that it's really necessary to have an mnemonic for this stuff.

For the OP, there is a fair number of possible causes for this patient's presentation. What's the patient's BGL? What's a more detailed HEENT exam show? BP?

 

[Aidey]

How is someone awake and unresponsive?

Easy. Eyes open and no one is home. Not uncommon in absence seizures, or the postictal phase.

 

[Shrimpfriedrice]

Vitals:

Hr: 92
R: 18
Bp: unattainable ( 1st and 2nd attempts made by both emts and 1 medic using child cuff ) last attempt made by medic with adult cuff revealed questionable 240/p

Bgl: 86
O2 : 99 while on 15lpm via nrb
+ PERRLA
12 lead no abnormalities

Contact made with pt's mother who sts no pmh, no meds, nkda that she is aware of

 

[Aidey]

Seizures secondary to increased ICP due to her CSF shunt becoming occluded.

 

[NomadicMedic]

Dried blood at her mouth... Did she bite her tongue? And why was she on 15 LPN of o2 on a mask? Was she hypoxic or displaying an obvious increase in work of breathing?

 

[JPINFV]

Assault?

Was there any tennis balls around?

 

[Summit]

Blood came from where?
You suspect super duper htn?
Altered level of consciousness?
Must suspect Suspect postictal after sz 3* CVA 2* super duper htn.

Now get a real BP to adjust that focus?

 

[Veneficus]

Seizures secondary to increased ICP due to her CSF shunt becoming occluded.

You laugh, my first neurosurg assist was an emergent repair of a CSF shunt for a guy who decided to defend his girlfriend's honor and got hit in the head during a bar fight.

He is in a vegetable garden now.

 

[Aidey]

I wasn't laughing, that was a serious guess.

 

[JPINFV]

You laugh, my first neurosurg assist was an emergent repair of a CSF shunt for a guy who decided to defend his girlfriend's honor and got hit in the head during a bar fight.

He is in a vegetable garden now.

Sounds like he was a Sontaran.


/Dr. Who reference.

 

[Aidey]

Sounds like he was a Sontaran.


/Dr. Who reference.

Groan

 

[Shrimpfriedrice]

Dried blood at her mouth... Did she bite her tongue? And why was she on 15 LPN of o2 on a mask? Was she hypoxic or displaying an obvious increase in work of breathing?

Its easy to say why is she on o2 with all the info placed nicely right before you. Now ask yourself someone presents as ams, u have no history, non verbal, no glucometer or pulse oximeter bls. What do u do?

 

[Shrimpfriedrice]

Seizures secondary to increased ICP due to her CSF shunt becoming occluded.

Nice guess, pt brought into er after many attempts to get a bp, reading was 280/150! Pt has massive intracranial hemorrhage after following up next day.

 

[FLdoc2011]

In these sort of cases I would ask for a good neuro exam. And what was her GCS?

 

[Handsome Robb]

Its easy to say why is she on o2 with all the info placed nicely right before you. Now ask yourself someone presents as ams, u have no history, non verbal, no glucometer or pulse oximeter bls. What do u do?

Without signs of hypoxia or respiratory distress you don't give high flow o2, that's for sure. Were there any indications in the physical exam that she was hypoxic/hypoxemic? From what you described it doesn't sound like it. If CVA is high on your list of differentials high flow isn't a very good choice. Hyperoxygenation can cause more harm than good in these patients. There's a reason low flow o2 is the standard for CVA care. The whole "just load the blood up with o2 so there's a chance more o2 will slip past the clot" idea doesn't hold any water.

Not trying to be an *** but in the future you'll get better responses to your scenarios with more detailed information and better structure to them.

I'm having a hard time understanding why it was so difficult to get a BP on this patient... her being a "little person" isn't a good reason. Hypotensive then sure that makes sense, not hypertensive though.