# 90yof - csf?



## TreySpooner65 (Jan 13, 2012)

Here is the scenerio:

I work as an EMT as an IL facility, licensed as an AL facility.

Resident walks into my office and asks us to check her ear. "If feels like moisture is leaking from it." So I inspected her ear. Indeed fluid was leaking; clear with an orange/pink tint. Large stain on her collar and shoulder from fluid. No battle signs. Other ear was dry and normal. No other complaints from patient. Eyes were _*not*_ PEARL. Left was normal, reactive. Right was constricted and non reactive. Heart rate was 115. No other complaints. A/Ox4.

What would you do?


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## TbArbie (Jan 13, 2012)

Well from what I have learned, I would apply a loose dressing by the ear to collect the leaking fluid, 15l 02 , cspine precautions to cover myself, transport...it sounds like a spontaneous csf leak which could have to do with something wrong in the sub arachnoid space


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## Remeber343 (Jan 13, 2012)

First I would ask what happened prior. Then I would see if there was a past history of this. I would then grab a piece of gauze and so that inaccurate halo test. I would also ask her if she has a glass eye or if her eyes are normally unequal. I wouldn't think it would just leak out all willy nilly. It could be just a small perforation in the ear drum or something.  I would also ask her if she had any other complaints, headache/n/v.  Anything else that is bother her. 



TbArbie said:


> 15l 02 , cspine precautions to cover myself



Just curious, why the 15l o2? And why C-Spine?


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## DrankTheKoolaid (Jan 13, 2012)

*re*

Get a history and Vs.  Snicker as partner asked to do the novelty Halo test (though i always wanted to do it to a patient also early in my career) as i instead test it for glucose.  Spinal precautions are not only not indicated but would actually be contraindicated with this patient causing increased ICP and faster leakage ICF if indeed it was.  Standard treatment while enroute to ED.  High fowlers position for transport, Vs, CM, IV for the incoming blood patch if she does infact have a csf leak and gets the typical headache.  O2 is not indicated.  Other then that have a nice chit chat while en route to ED.


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## TreySpooner65 (Jan 13, 2012)

Remeber343 said:


> First I would ask what happened prior. Then I would see if there was a past history of this. I would then grab a piece of gauze and so that inaccurate halo test. I would also ask her if she has a glass eye or if her eyes are normally unequal. I wouldn't think it would just leak out all willy nilly. It could be just a small perforation in the ear drum or something.  I would also ask her if she had any other complaints, headache/n/v.  Anything else that is bother her.



Halo test was inconclusive.

No headache, nausea, or vomiting. Patient has mild cognitive impairment. Denied any trauma/fall or further pain. 

History of A-Fib. No other pertenant history. No ocular devices. Eyes are normally PEARL.

Keep in mind I do not work on an ambulance and we do not send off every patient to the ER. In this situation would you have initiated transport to ER?


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## DrankTheKoolaid (Jan 13, 2012)

Yes, especially if the suspect fluid bgl is ~ half (f)bgl.  And even if she flat refused ambulance transport i would spend plenty of time to convince her and or other caregivers to get her to a MD for further evaluation


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## mycrofft (Jan 13, 2012)

Baseline pupils and which ear was it?
Orangish clear fluid could be a draining sebaceous gland or even en early staph infection.
Second the no O2 indicated by these factors. Why an IV?


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## TreySpooner65 (Jan 13, 2012)

mycrofft said:


> Baseline pupils and which ear was it?
> Orangish clear fluid could be a draining sebaceous gland or even en early staph infection.
> Second the no O2 indicated by these factors. Why an IV?



Right ear, and right eye.


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## mycrofft (Jan 14, 2012)

ANd large stain, so too big for abscess etc.. Get an otoscpe.


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## DrankTheKoolaid (Jan 14, 2012)

mycrofft said:


> Baseline pupils and which ear was it?
> Orangish clear fluid could be a draining sebaceous gland or even en early staph infection.
> Second the no O2 indicated by these factors. Why an IV?



Planning ahead for the labs i would draw blood for along with access for a (blood patch) which is the treatment for the headache patients get when they lose to much csf from lumbar punctures / csf drainage.


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## Remeber343 (Jan 14, 2012)

Im not thinking it's csf though. Could be a few things. Could be cause by a puncture from a q tip or whatever else they could fathom sticking in their ear. Could be swimmers ear, some sort of otaorrhea. The pupil change is interesting though...  And she said no signs of trauma but how good of a historian can she be?


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## TreySpooner65 (Jan 14, 2012)

We did initiate transport to ER for that patient. Would you like me to tell you what the resolution was?


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## Remeber343 (Jan 14, 2012)

Sure what was the dx?


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## TreySpooner65 (Jan 14, 2012)

Pt was discharged from ER 2 hours later with a dx of an ear infection <_<

To me (granted, I'm just an EMT-B), that doesn't account for the pupils.


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## TbArbie (Jan 14, 2012)

Remeber343 said:


> First I would ask what happened prior. Then I would see if there was a past history of this. I would then grab a piece of gauze and so that inaccurate halo test. I would also ask her if she has a glass eye or if her eyes are normally unequal. I wouldn't think it would just leak out all willy nilly. It could be just a small perforation in the ear drum or something.  I would also ask her if she had any other complaints, headache/n/v.  Anything else that is bother her.
> 
> 
> 
> Just curious, why the 15l o2? And why C-Spine?



O2 for comfort measures, and c-spine incase there had been past trauma and the pt doesn't remember or doesn't want to say.


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## NomadicMedic (Jan 14, 2012)

TbArbie said:


> O2 for comfort measures, and c-spine incase there had been past trauma and the pt doesn't remember or doesn't want to say.



Hmm. Most people aren't very comfortable with oxygen drying out their nares or a mask blasting in their face. How about you only use O2 for patients that clinically require it?


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## TbArbie (Jan 14, 2012)

n7lxi said:


> Hmm. Most people aren't very comfortable with oxygen drying out their nares or a mask blasting in their face. How about you only use O2 for patients that clinically require it?



Very true, I was taught always to administer o2


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## Remeber343 (Jan 14, 2012)

Typically, if they had some sort of traumatic injury that would cause csf to be present, you would either be able to visual the bruising. She is fairly old and frail. Also, if you palp around her head it could also reveal  signs of a fx causing the fluid.


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## Remeber343 (Jan 14, 2012)

TbArbie said:


> Very true, I was taught always to administer o2



And why the o2 though? I mean I know they taught you to do that, but what here would cause you to believe the patient needed to have o2?  Just curious.


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## epipusher (Jan 14, 2012)

TbArbie said:


> Very true, I was taught always to administer o2



are you by any chance a firefighter?


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## STXmedic (Jan 14, 2012)

epipusher said:


> are you by any chance a firefighter?



I'm betting just out of class.


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## TbArbie (Jan 14, 2012)

PoeticInjustice said:


> I'm betting just out of class.



hahaha no im not a ff, and yes im just out of class, im taken my written feb 1st


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## Remeber343 (Jan 14, 2012)

Ah well congrats!  It's definitely an exciting career path.


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## TbArbie (Jan 14, 2012)

Remeber343 said:


> Ah well congrats!  It's definitely an exciting career path.



thank you, im very proud of myself because wasnt easy!


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## Sublime (Jan 14, 2012)

TbArbie said:


> thank you, im very proud of myself because wasnt easy!



Congrats man. I know they teach in EMT school that everyone gets o2 and that it doesn't hurt anything, but thats actually not true. I don't think it's a well known fact in ems because of how we are taught, and I have seen many medics who give everyone o2. 

The truth is that over oxygenating can cause production of free radicals and can cause more damage during reperfusion. Im not saying it would of hurt that lady, in this case, but it certainly wouldn't help her. O2 for comfort is a bad practice. I would encourage you to research the subject some more and see what else you can learn and then pass it on. 

Don't take this into consideration on the NREMT though, I am strictly speaking for real life scenarios. Good luck on the written portion by the way.


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## MedicPatriot (Jan 14, 2012)

That is something I believe needs medical evaluation. It may be less serious but it could also be something bad, especially with the pupils the way they are.

After reading the diagnosis, thats what I would have figured but still it is good to always think of the worst case scenario.


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## NYMedic828 (Jan 14, 2012)

Always nice to be able to confirm with a glucometer if it may in fact be CSF.

I personally, can't say i've ever seen CSF in person even with all the traumatic jobs i've been on. For me it would be very assessment based to rule out whether it was fluid from some form of infection or minor injury or if it was truly CSF.

I am not understanding why giving o2 would make sense for the patient either. If the patient is satting at roughly 100% on RA and have no reason for ischemia to the brain like AMS or other symptoms, their level of oxygen bound hemoglobin headed to the brain isn't getting any higher with or without o2.


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## TbArbie (Jan 14, 2012)

First off i want to say thank you for your responses, 02 is a big debate i guess, and i think it all depends on the teacher also but it is nice to have an outside voice from different medics & emts who have experience. I will check it out thank you.


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