# Scenario - For students



## NomadicMedic (May 6, 2017)

Dispatched for shortness of breath at IHOP. 

You find a 56 year old female sitting in a booth in the restaurant, diaphoretic, pale and a respiratory rate of 40. Hands are cool, almost cold, with poor perfusion. Cap refil  of >4 seconds. 

Her husband says it just happened, with no warning.  They were traveling north on I95 from Orlando, heading to NJ. They're about 300 mies into the trip. 

Tell me what you want, your treatment, differential DX, and what you might expect to have happen while en route to the ED.


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## DesertMedic66 (May 6, 2017)

Lupus


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## NomadicMedic (May 6, 2017)




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## Gurby (May 6, 2017)

Pulmonary embolism.  I take her to the hospital.  I cross my fingers, clench my buttocks and hope she stays alive until we get there.  Maybe I'd take some vitals and ask about her history or something too.


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## DesertMedic66 (May 6, 2017)

Gurby said:


> Pulmonary embolism.  I take her to the hospital.  I cross my fingers, clench my buttocks and hope she stays alive until we get there.  Maybe I'd take some vitals and ask about her history or something too.


Are you a student? Haha


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## GMCmedic (May 6, 2017)

Im studying for FP-C. I think that qualifies me, therefore im going with Sarcoidosis. 

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## Gurby (May 6, 2017)

DesertMedic66 said:


> Are you a student? Haha



School of hard knocks baby.  I'm very "hands on" and I don't take well to book learning.  I'm a go-getter.  You need chutzpah if you're gonna make it in business.  Thinking about differentials is for people who lack confidence and decisiveness IMO.


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## Flying (May 6, 2017)

Gurby said:


> School of hard knocks baby.  I'm very "hands on" and I don't take well to book learning.  I'm a go-getter.  You need chutzpah if you're gonna make it in business.  Thinking about differentials is for people who lack confidence and decisiveness IMO.


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## Old Tracker (May 6, 2017)

I'd want history, any priors? What if any meds is she on? I'd be thinking NS IV asap, I'd also put her on the LifePak and get a 12 lead going.. I'm just a basic and still constantly learning. Any lower on the bradycardia I'm calling for ALS to medicate her and pace her. I have an hour wait for a plane and 90 miles to the nearest hospital.


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## DesertMedic66 (May 7, 2017)

Old Tracker said:


> I'd want history, any priors? What if any meds is she on? I'd be thinking NS IV asap, I'd also put her on the LifePak and get a 12 lead going.. I'm just a basic and still constantly learning. Any lower on the bradycardia I'm calling for ALS to medicate her and pace her. I have an hour wait for a plane and 90 miles to the nearest hospital.


May want to read the OP a little closer. It does not state the patient is bradycardiac. The respiratory rate is 40.


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## DesertMedic66 (May 7, 2017)

For me I would get the normal AMPLE questions with any associated symptoms. Hx of PE, MI, DVT, CVA? Any blood thinners or ASA? Does it feel like she can't take a deep breath in or that she can't get enough oxygen in?

A set of vitals (RR, lung sounds, SpO2, EtCO2, BP, pulse). Get a 12-lead and look for the possibility of a S1Q3T3 (however it's only present in something like 20% of cases), the presence of a tachy rhythm and a RBBB would also help in confirming my Dx for this patient. 

Treatment would be: some O2, IV (bolus depending on pressure), rapid transport to the ED. That's really all I can do here.


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## Old Tracker (May 7, 2017)

Oops, it's late, my bad.


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## VentMonkey (May 7, 2017)

And yet @NomadicMedic said "_for students_".

Lol, just goes to show how hard of a time us more seasoned paramedics have sitting back, watching, and observing.

...carry on.


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## CALEMT (May 7, 2017)

VOMIT... vitals, oxygen, monitor, IV, and transport. With the limited info the first thought that popped into my head is a DVT that developed into a PE. Like Desert said, AMPLE would be a good start.


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## DesertMedic66 (May 7, 2017)

VentMonkey said:


> And yet @NomadicMedic said "_for students_".
> 
> Lol, just goes to show how hard of a time us more seasoned paramedics have sitting back, watching, and observing.
> 
> ...carry on.


Well to be fair I did wait a while before I posted. For me after 8 hours of no one really saying anything it becomes fair game. This patient needs to live!!


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## shelvpower (May 7, 2017)

NomadicMedic said:


> Dispatched for shortness of breath at IHOP.
> 
> You find a 56 year old female sitting in a booth in the restaurant, diaphoretic, pale and a respiratory rate of 40. Hands are cool, almost cold, with poor perfusion. Cap refil  of >4 seconds.
> 
> ...


A set of vitals ASAP as well as an AMPLE history.  
Any adventitious lung sounds? 



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## NomadicMedic (May 7, 2017)

This is a scenario for new providers. Please let the new folks have at it. 

HR: 120, sinus tach. No ectopy. 
Resp: 44, no adventitious breath sounds. 
SpO2 on room air: 84
ETCO2: 14

No significant history, no meds. No allergies. 
Last ate 4 hours ago. 

STUDENTS: what is happening, why is it happening, what can you do to improve the patient's condition?

What are three differential diagnoses?


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## Old Tracker (May 7, 2017)

She needs O2, what's her level of consciousness? BGL?


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## VFlutter (May 7, 2017)

A lot of cool patho with the potential diagnosis. 

Anything you want to look for on the EKG to increase your index of suspension?


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## CWATT (May 9, 2017)

What's the Pt's BP?  Any pain?

1.  PE
(Low ETCO2 is throwing me off here - if V/Q mismatch, I would expect high ETCO2 + low SPO2)

2.  Thoracic or Aortic Dissection
(Symoathetic response for absolute hypovolemic state; no hemoglobin to transport O2 and low CO2 b/c transported via bicarbonate buffer system, so blown off c/ tachypnea).

3.  Ruptured Ectopic Pregnancy 
(I know, I know - 56yrs old.  Still possible though...)


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## AcuteBlueWaffle (May 9, 2017)

Excuse me for my probably under-educated response, but i'm going to take a stab at it

She's clearly having a sympathetic response.
BP? pain? BGL? Does/has she felt weak/sick at all? LOC?

1. PE (sudden onset,  low O2, tachypnea/tachycardia *BUT no cyanosis?*)
2. MI (sudden onset, low O2, pale, cool, clammy, tachypnea/tachycardia, >40 age) 
3. Some sort of internal bleeding. curious to see further assessment  

I'd put on a 15lpm NRB and *GO*


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## VentMonkey (May 9, 2017)

AcuteBlueWaffle said:


> Excuse me for my probably under-educated response, but i'm going to take a stab at it


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## AcuteBlueWaffle (May 9, 2017)

After I slept on it, I'm thinking MI. 

1) She's in cardiogenic shock and can't pump well enough peripherally, thus causing the increased cap refill.
2) The sympathetic NS is activated with her lack of oxygen to her heart.
3) women tend to have more "silent" MIs and she might not have pain per say, but will feel have N/V or just a general weakness. 
4) it was sudden and unprevoked 

Also, along with high flow O2, I'm giving 324 my of aspirin to help with platelets not clotting as well


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## VFlutter (May 9, 2017)

Can patients with PE go into shock? What kind?


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## AcuteBlueWaffle (May 9, 2017)

Obstructive shock. 
But what I'm confused about is normally (i thought), patients get cyanosis because they aren't getting oxygen rich blood in PEs because of the obstruction.

I guess I just need help with how to distinguish which route to go. Other than rales/crackles in the lungs (PE), don't PEs and MIs have very very similar presentations? 

Also, I'm treating the patient with blankets to keep warm


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## NomadicMedic (May 9, 2017)

I love that @Chase is kicking in some stuff here.

 Here's a few more tidbits for you. 

 She's fully conscious and alert, but incredibly anxious, says she's complaining of chest tightness.  This is very obviously not a hypoglycemia scenario, but for those who want to blood sugar, it is 98. 

On a NRB at 15lpm her SpO2 is 99%. Respiratory rate is still around 40, etCO2 is still 12. Capnography waveform is non obstructed.


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## AcuteBlueWaffle (May 9, 2017)

Ok, my best educated guess is an MI with until convinced otherwise.

Out of curiosity, what does the ETCO2 below the average (35-45) mean? I can't seem to figure it out.

Did she change in appearance with the o2?


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## CWATT (May 9, 2017)

I figured out my error -

"End tidal partial pressure of CO2 (ETCO2) is a physiological surrogate for vascular obstruction from PE. Pulmonary thromboembolism results in dead space ventilation and therefore prevents meaningful gas exchange in the subtended lung unit, yielding an alveolar CO2 content as low as zero mmHg. As a result, carbon dioxide content measured at end expiration, which represents admixture of all alveolar gas, drops in proportion to dead space ventilation" 

http://erj.ersjournals.com/content/erj/early/2009/08/28/09031936.00084709.full.pdf


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## VFlutter (May 9, 2017)

Awesome job doing the research to find the answer. ETCO2 is huge topic itself but it's important to remember that it is just as much a marker of perfusion as it is ventilation. Don't get caught chasing the number trying to correct it thinking it's a ventilation issue as your patient is circling the drain. 

I remember coding a young woman who suddenly collapsed without notice (smoker/obese/birth control) and going through multiple colorimetric and waveform ETCO2 devices trying to confirm the ET tube but not getting any results, knowing it placed correctly . Turned out she had a massive totally occlusive saddle PE.


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## CALEMT (May 9, 2017)

AcuteBlueWaffle said:


> Out of curiosity, what does the ETCO2 below the average (35-45) mean? I can't seem to figure it out.



Inadequate ventilation. A low capnography reading indicates hyperventilation and the blowing off of CO2 causing a homeostasis to be out of whack. Low CO2 readings are indications of the body becoming alkalotic because CO2 is acidic in nature. Take the acid away and the blood will become more basic. Same concept works vice versa. Hypoventilation (high capnography readings) indicates CO2 retention which in return blood will be more acidotic.


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## captaindepth (May 9, 2017)

CALEMT said:


> Inadequate ventilation.



*Inadequate respiration** ..... for this case.

Ventilation is just the movement of gasses in and out of the lungs, respiration is the actual gas exchange (O2 and CO2) of said gasses moving in and out of the lungs. P.E. is a great example of this. Lung sounds are clear with good movement of air throughout all fields but a low SpO2 and ETCO2 due to the decrease in perfusion and ability for gas exchange.


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## Tigger (May 9, 2017)

NomadicMedic said:


> I love that @Chase is kicking in some stuff here.
> 
> Here's a few more tidbits for you.
> 
> ...


I think promptly ruling out hyperglycemia with tachypneic patients is still a good idea, though her mentation makes this less likely.


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## Old Tracker (May 9, 2017)

Great thread. I just learned a metric ton of good stuff.


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## ParkMedic (May 15, 2017)

Mas!  Mas! Por favor.


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## E tank (May 15, 2017)

CALEMT said:


> Inadequate ventilation. A low capnography reading indicates hyperventilation and the blowing off of CO2 causing a homeostasis to be out of whack.



Or a drastically reduced amount of blood (read: CO2) making it thru the lungs...


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## Jackson dunn (May 21, 2017)

I'm new. Sounds like respiratory failure to me. High flow oxygen via bvm?


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## StCEMT (May 21, 2017)

Jackson dunn said:


> I'm new. Sounds like respiratory failure to me. High flow oxygen via bvm?
> 
> 
> Sent from my iPhone using Tapatalk


Respiratory failure caused by what? (This is just to brainstorm ideas based on what you see)


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## Jackson dunn (May 21, 2017)

StCEMT said:


> Respiratory failure caused by what? (This is just to brainstorm ideas based on what you see)



Explain please!


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## NomadicMedic (May 21, 2017)

Jackson dunn said:


> Explain please!
> 
> 
> Sent from my iPhone using Tapatalk



Why is this patient experiencing shortness of breath? Is A BVM the right choice?


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## Jackson dunn (May 21, 2017)

Thanks. Makes sense now.


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## StCEMT (May 21, 2017)

Jackson dunn said:


> Explain please!
> 
> 
> Sent from my iPhone using Tapatalk


Expand on your thoughts. Respiratory distress/failure has a cause. What do you think the cause is? And to echo Nomad, what is your reasoning for the BVM?

This is a good place to learn from others, throw stuff out there and learn from folks like Nomad who have been at this for a while.


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## Jackson dunn (May 21, 2017)

Awesome. Thanks guys! I'm definitely glad to have this as a learning tool.


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## NomadicMedic (May 21, 2017)

Jackson dunn said:


> Awesome. Thanks guys! I'm definitely glad to have this as a learning tool.
> 
> 
> Sent from my iPhone using Tapatalk



Good. So, what do you think?


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## Jackson dunn (May 21, 2017)

Reading earlier posts on this thread, p.e. Makes more sense to me. Age, smoker, birth control.The resp rate accompanied by delayed cap refill made me jump to o2 via bvm. I was thinking inadequate tidal volume. 


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## Tiff Las Vegas (May 25, 2017)

You would use a BVM to help slow the fast respirations, you need to pace her. Into a better rate.


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## VentMonkey (May 25, 2017)

Tiff Las Vegas said:


> You would use a BVM to help slow the fast respirations, *you need to pace her. Into a better rate*.


By "pace" I imagine you're referring to synchronizing the patients ventilations with yours (BVM).

If so, how and why do you want to do this? Is this really necessary? What if this is a compensatory mechanism on behalf of the patients body mechanics based off of their underlying condition? Is it still feasible and conducive to a positive outcome (our ultimate goal)? 

Short of complete and total paralysis, or allowing the patient to hypoventilate into near apnea, I don't know how realistically effective it is to think we can slow the fast respiratory rate with _our_ ventilations. So again, please explain...


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## NomadicMedic (May 25, 2017)

Just FYI, she had no history of smoking or birth control use. 



Jackson dunn said:


> Reading earlier posts on this thread, p.e. Makes more sense to me. Age, smoker, birth control.The resp rate accompanied by delayed cap refill made me jump to o2 via bvm. I was thinking inadequate tidal volume.
> 
> 
> Sent from my iPhone using Tapatalk


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## CALEMT (May 25, 2017)

VentMonkey said:


> By "pace" I imagine you're referring to synchronizing the patients ventilations with yours (BVM).



I'm pretty sure the post was implying TCP.


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## StCEMT (May 25, 2017)

CALEMT said:


> I'm pretty sure the post was implying TCP.


CAL: Alright ma'am, every time this shocks you, I need you to take a breath.


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## VentMonkey (May 25, 2017)

CALEMT said:


> I'm pretty sure the post was implying TCP.





StCEMT said:


> CAL: Alright ma'am, every time this shocks you, I need you to take a breath.


Right, so perhaps she needs to clarify, and/ or use proper terminology. 

When I think pace I think TCP as well, but the way she responded leads me to believe her treatment indicates aggressive BLS airway management via timing BVM ventilations with the patients (something I find less, and less conducive to actually protecting the patients airway).

Again, I'll allow her to clarify remembering this is for students so I was throwing some questions regarding her choice of patient, and airway management her way.


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## StCEMT (May 25, 2017)

I knew what was meant (ventilation timing), I remember being told about that in EMT school. That being said, I have never personally done it.


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## VentMonkey (May 25, 2017)

StCEMT said:


> I knew what was meant (ventilation timing), I remember being told about that in EMT school. That being said, I have never personally done it.


So I just had a pretty good discussion today with an RT at our base about the advantages of PCV vs. a more "vent-controlled" mode (e.g., A/C and SIMV) in, say, metabolically deranged patients.

Without derailing too much, and taking away from the valued approach students bring, I would like to see, and know what the rationale would be for a basic (BLS) approach to aggressively managing said patients airway, and why or why not.

At every prehospital-level a provider can do a lot of harm, so why not learn and discuss rationale here?


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## CWATT (May 25, 2017)

VentMonkey said:


> ...why do you want to do this? Is this really necessary? What if this is a compensatory mechanism on behalf of the patients body mechanics based off of their underlying condition? Is it still feasible and conducive to a positive outcome (our ultimate goal)?



Another question to ask yourself is: what conditions cause tachypnea?  Which of these requires manual BVM and why?


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## NomadicMedic (May 25, 2017)

Quick sidebar: this was something Mike taught in my Paramedic class. http://www.emsworld.com/article/10319947/assisting-ventilations


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## VentMonkey (May 25, 2017)

CWATT said:


> Another question to ask yourself is: what conditions cause tachypnea?  Which of these requires manual BVM and why?


A better question is:

Is this solely tachypnea, or is there _hypoventilation_ present as well?


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## StCEMT (May 25, 2017)

@VentMonkey I think the idea is that it makes them consciously focus on their breathing and then in turn helping them slow down.


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## VentMonkey (May 25, 2017)

StCEMT said:


> @VentMonkey I think the idea is that it makes them consciously focus on their breathing and then in turn helping them slow down.


If they're "conscious" enough to focus on their breathing there's no need to aggressively protect their airway, period. Passive oxygenation, and/ or coaching techniques work just fine.

Knowing when to be proactive vs. reactive is often not really covered in a ~120 hour course.

Basically they're either aware that they're actively, and purposefully hyperventilating, or they aren't. The latter should put your clinical  feelers up. 

Again, differentials, and experience can sharpen this approach, but without it you may fall into the "they're full of sh-t" trap all too common with newer providers.


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## StCEMT (May 25, 2017)

VentMonkey said:


> Knowing when to be proactive vs. reactive is often not really covered in a ~120 hour course.


This.


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