# Tunnel vision strikes again?



## Amber Lance (Feb 16, 2014)

Call for a 22 y/o female c/o vomiting. Arrive to find pt sitting on couch, unable to sit still, with a bucket containing about 1/2 Liter of vomited stomach fluid (bile, etc. - no food). 

Pt states she had one beer and one shot the night before on an empty stomach and has not been able to stop vomiting today. She denies allergies or previous medical history.

Vital signs: Pulse 74 strong and regular, SpO2 96% on room air, BP 100/80, temp 97.9, pupils PERRL at 3mm.

Go! h34r:


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## Emtsgv (Feb 16, 2014)

Amber Lance said:


> Call for a 22 y/o female c/o vomiting. Arrive to find pt sitting on couch, unable to sit still, with a bucket containing about 1/2 Liter of vomited stomach fluid (bile, etc. - no food).
> 
> Pt states she had one beer and one shot the night before on an empty stomach and has not been able to stop vomiting today. She denies allergies or previous medical history.
> 
> ...





easy i call for ALS and eat my dinner while i wait


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## Amber Lance (Feb 16, 2014)

Why ALS?


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## Akulahawk (Feb 16, 2014)

What's the patient had to eat/drink in the past 24 hours besides EtOH? Any recent travel? Dizziness/lightheadedness? Recent abdominal pain, tenderness, distention?


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## Angel (Feb 16, 2014)

Recent illness (family, friends. tis the season)? Why hasn't she been eating? I second the abdominal assessment and if shes had diarrhea and HAVE to ask about LMP to rule that out. what are skin signs? bp is on the lowish side

and I also want to know what else shes been eating/drinking ie Anything besides alcohol
shes been vomiting for how long? and hasn't taken anything for it?  

has this ever happened before, if so when? was it diagnosed and how was it treated

what do we feel when we palpate her abd

This might be a dumb question but why is she unable to sit still...id expect her to be lethargic


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## Kevinf (Feb 16, 2014)

The amount of alcohol is negligible, though it could have upset a pre-existing condition with her liver I suppose.

BP is well within normal limits if she is a smaller female, ask is that normal for her.

Pt is afebrile, so while infection isn't ruled out it's lower on my list though I'll consider it more strongly if she says she is somewhat hypotensive (or doesn't know her normal BP). 

What is her CBG?

Any other unusual outward signs? Bug bites? Unexplained lesions? (agree with a need for Abd and other assessment)

How do the lungs sound? How's the heart sound?

Any edema?

What was your impression of her mental status in general? Who called?

For non-stop vomiting she's still going to the hospital regardless


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## mycrofft (Feb 16, 2014)

PAin? Abodominal exam?

Alcohol abuse (drinking without eating is not a good piece of lifestyle), think liver, gallbladder, pancreas.
(Pancreas…not a word you read here that often).

Comfort, trip to hospital, support VSs.


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## Amber Lance (Feb 16, 2014)

Pt complains of severe stomach pain, and also says "everything hurts." 
She called 911 herself and is unable to give any other information as she is becoming increasingly drowsy. She loses consciousness and is unresponsive to verbal and painful stimuli (sternum rub). She spontaneously regains consciousness about 20 seconds later but is still difficult to communicate with due to drowsiness. HR has decreased to 52, all other vital signs remain the same.

ALS arrives and assumes patient care, pushes Zofran and transports (about a 45 minute transport time). Patient is able to stand and walk a few steps to the gurney.

A few hours later we found out she had a seizure at the hospital. They had noted a prolonged QT interval on the 12-lead.

I wish we'd had a chance to do a more thorough assessment. The seizure really threw us off and left us wondering what was actually going on.

My thoughts: 
-Poisoning (maybe some type of pesticide?)
-Alcohol withdrawal (she only said how much she had last night, not how much she normally drinks)
-Possibly some type of meningitis (I have been suspicious for some time now that our thermometer is jacked and reads really low), although no complaints of headache or stiff neck
-Gastroenteritis plus a severe electrolyte imbalance from the vomiting
-There's always the possibility that the vomiting and the seizure were two unrelated events, although that seems unlikely given that she had no history of seizures.

Anyone have any insight?


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## VFlutter (Feb 16, 2014)

Hyponatremia/Hypocalcemia.


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## mycrofft (Feb 16, 2014)

Honestly, are there (m)any abdominal complaints you can do much for except pain relief and an IV JIC (just in case) before the hospital?


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## Amber Lance (Feb 16, 2014)

I suppose it's not so much a question of what else could we have done (because, as basics, there's not much). I mean, we should have gotten a better assessment, but I don't know that it would have changed our handling of the situation much.
At this point, it's an effort to understand what may have happened so that I can hopefully go into future calls like this with a more open mind and lower the risk of missing something really important.


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## mycrofft (Feb 16, 2014)

To repeat my anatomy instructor's statement, "The abdomen is a dark and mysterious place full of danger" or words to that effect.


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## teedubbyaw (Feb 16, 2014)

Chase said:


> Hyponatremia/Hypocalcemia.




What I'd guess. She'd have gotten a NS bolus, zofran, and transport.


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## VFlutter (Feb 16, 2014)

teedubbyaw said:


> What I'd guess. She'd have gotten a NS bolus, zofran, and transport.



Agree with a NS bolus but I would be cautious with IV fluids until labs are obtained. If this patient is truly hyponatremic enough to have seizures then they need to be corrected precisely over days. You should not have have a problem unless you have a long transport time and decide to dump multiple liters. 

Central Pontine Myelinolysis :excl:


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## teedubbyaw (Feb 17, 2014)

Always learning something new. Thanks, Chase.


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## mycrofft (Feb 17, 2014)

Chase said:


> Agree with a NS bolus but I would be cautious with IV fluids until labs are obtained. If this patient is truly hyponatremic enough to have seizures then they need to be corrected precisely over days. You should not have have a problem unless you have a long transport time and decide to dump multiple liters.
> 
> Central Pontine Myelinolysis :excl:



Transport time: the zone where you can save a life, or do pointless things which need to be documented, or make the receiving facility's evening more complicated than they expected it to be. Or worse.


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## chaz90 (Feb 17, 2014)

mycrofft said:


> Transport time: the zone where you can save a life, or do pointless things which need to be documented, or make the receiving facility's evening more complicated than they expected it to be. Or worse.



Probably true for every other part of medicine too. Replace "Transport Time" with "Time in ED" and "receiving facility" with "floor."


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## usalsfyre (Feb 17, 2014)

Chase said:


> Hyponatremia/Hypocalcemia.



How in the flaming hades are you figuring that?

If anything I'd be more suspicious for a hypernatremia from volume contraction. I'm betting more along the lines of substance withdrawl/ingestion.


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## mycrofft (Feb 17, 2014)

chaz90 said:


> Probably true for every other part of medicine too. Replace "Transport Time" with "Time in ED" and "receiving facility" with "floor."



Potentially, but in the field you don't have the benefit or excuse of recent diagnostics (lab tests, X-rays) and attention from definitive practitioners (doctors) so you either follow a protocol, or you wildcat it. The is why protocols can be maddening, to try to think of stuff which may benefit the pt, while reining back the tech's need to feel they are doing something.

On the floor, the danger is crummy service, bad staffing ratios, germs, etc. In the ED your worst enemy besides being forgotten or lost in transport, is being left waiting without treatment.


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## Ewok Jerky (Feb 21, 2014)

medical history?
diabetes?
lithium toxicity?
pregnant?
any abdominal pain?

the differential is pretty large. I would like a CBC and BMP to start, maybe some imaging. hard to tell if the seizure is related or secondary to electrolyte imbalance from vomiting.

as far as prehospital goes, start a line, zofran, deisal.


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## Carlos Danger (Feb 21, 2014)

mycrofft said:


> To repeat my anatomy instructor's statement, "The abdomen is a dark and mysterious place full of danger" or words to that effect.



Especially in a young female.....


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## Carlos Danger (Feb 21, 2014)

usalsfyre said:


> How in the flaming hades are you figuring that?
> 
> If anything I'd be more suspicious for a hypernatremia from volume contraction. I'm betting more along the lines of substance withdrawl/ingestion.



Vomiting can cause hyponatremia. Nausea, lethargy, and seizures are certainly symptoms of it.

Could be from a glucocorticoid deficiency, excessive alcohol consumption without eating (you know the rule....you need to at least double whatever number of drinks they admit to), or any number of other causes.

Or it could be something entirely different.


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## Handsome Robb (Feb 23, 2014)

I don't think these all that volume depleted from one day of vomiting, especially with those vitals. If she's hyponatremic secondary to vomiting she would also be hypovolemic she should be compensating and she's not. She's young, doesn't seem to have any medical Hx unless I missed it somewhere so it's not like her compensatory mechanisms are suppressed (ie beta blockade) or something of the sort. 

Did we ever get answers to last menstrual cycle? Any spotting/bleeding? G/P/A? Sexually active? If she is is she monogamous or polygamous? If she's polygamous or if her monogamous partner has she been tested recently? Not many STDs would fit here but questions that need to be asked. 

She was complaining of pain as well was she not? Did we hear any more about that pain? OPQRST? Vomiting then pain or pain then vomiting?

Did she go on the monitor?

How's her fluid intake been? She hasn't eaten and that can cause abdominal pain and nausea, I know I get real nauseous when I haven't eaten in a long time, add a hangover to it and you're in for a day. "I only had one shot and one beer." Alright fine, but people lie so we do need to consider that. 

Any elicit drug use? Specifically opiates? Opiate withdrawal can cause N/V/D and abdominal pain. Generally you'd see an increased sympathetic tone though with that one.


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## Handsome Robb (Feb 23, 2014)

Also, you said she had a period of unresponsiveness. How was her respiratory effort during this time? What time of the day was this after the "drinking last night"? The reason I ask is GHB ingestions can present with suppressed vitals, lethargy/ALOC and have periods of completely unresponsiveness sometimes accompanied by apnea/bradypnea. Even a small amount of ETOH in conjunction with GHB can have profound effects even hours after the facts in some cases depending on the amount ingested.

I missed it too, where are we? College dorm? Dorm food? Gastroenteritis has to be an option as well. Any melena or blood in her stool? Any family history of GI problems? 

No food at all correct? Any sugar or anything? Glucose tolerance tests can cause abd pain and N/V, sugary meal could have the same effect, especially if she's been evaluated recently. With her mentation I'm not 100% going to believe every word she said. 

What type of seizure did she have in the ER? Her brief unconsciousness could have been a seizure without tonic-clonic movements.


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