# Unknown Problem Run



## firemedic0227 (May 6, 2013)

Called to a sick person call the other day. The engine company beats us there, I walk in and ask the Captain what's going on (He's a medic also). He looks up at me and says, I have no clue what's going on, we don't have much to go on. I see a middle aged woman laying in the hallway of her residence. She is only moaning every time we move her and not responsive. I look down at the patient and noticed she has swelling on her left side from her chin down to her left foot none on the right side. She has JVD on the left side only. No known medical history and husband's story is not reliable. Basically he said the PT wasn't feeling well on friday night so he layed her on the couch. Saturday she wasn't feeling well so he left her on the couch, Sunday same thing. He went to pick up the PT to take her to the bathroom but couldn't carry her all the way so he left her in the hallway at 0300 Monday AM and called 911 at 0715. She had no bowl movements and passed no urine during any of this time. Vital signs were normal,breathing was rapid but sats were 94% on a non rebreather, eyes were equal and reactive, ECG showed NSR with no Ectopy. IV was started Patient was taken Code 3 to the Hospital. While enroute to the hospital we notice that her sats were going down and that her arms were starting to get cyanotic. Myself and the other medic noticed that she had stopped breathing but was still NSR on the monitor. Started bagging her and sats come up and she starts breathing on her own again. BGL was 84 also. The Patient was transferred to the ED.

You guys have any idea what's going on with this patient? (After talking to the doctor after another patient later I finally figure out whats going on)


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## SpecialK (May 7, 2013)

Was she lying with her left side lower than right? I am thinking if it was only left sided edema than there it might be some sort of gravitational interstitial expansion thing going on.

A bit of dehydration from being sick is going to cause the level of coma found in this patient.  

My main thinking would be a stroke? or if not some sort of massive intracranial catastrophe ... not sure why but thats just what comes to mind at the moment.


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## rmabrey (May 8, 2013)

Ok bare with me here, Im just kind of pulling this out of nowhere.

But first off what was her BP?

And did the swelling go down(redistribute when she was moved to the cot?

Potentially thinking edema due to fluid build up, and metabolic acidosis causing AMS. Sats dropped when fluid shifted.

A stretch I know. Probably much simpler but I got nothing else


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## MountainMedic (May 9, 2013)

Headscratcher. But what do you guys think the underlying pathology is? I'd like more info, obviously - did the pt ever have any complaints other than AMS/lethargy? CVA doesn't make sense based on progression. I'm thinking possibly UTI to start, perhaps with rhabdomyolysis around when the husband called. Rhabdo would result in metabolic acidosis, explaining the resp alkalosis here. 

I know rhabdo is more common with crush injury, but I've seen it once when an older pt was on his floor without moving for 6 hrs. He was close to unresponsive and went into cardiac arrest shortly after our arrival at the ER. 

I'm not gonna get hung up on unilateral JVD when I have no idea what it signifies (vascular anomaly?). Huh. What did it wind up being? Don't have time to run a full DDx right now...


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## 000 (May 9, 2013)

Maybe major fluid retention due to blood pressure meds?

or if overweight or unhealthy, it could be a major DVT issue or vein blockage?

just off top of my head.


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## VFlutter (May 9, 2013)

MountainMedic said:


> Headscratcher. But what do you guys think the underlying pathology is? I'd like more info, obviously - did the pt ever have any complaints other than AMS/lethargy? CVA doesn't make sense based on progression. I'm thinking possibly UTI to start, perhaps with rhabdomyolysis around when the husband called. Rhabdo would result in metabolic acidosis, explaining the resp alkalosis here.
> 
> I know rhabdo is more common with crush injury, but I've seen it once when an older pt was on his floor without moving for 6 hrs. He was close to unresponsive and went into cardiac arrest shortly after our arrival at the ER.



+1 on the Rhabdo. I had a patient on the floor for only a couple hours who had a CK of 50K with pretty substantial AKI. With an underlying infection or disease process added to the equation you can get very sick very fast. Respiratory failure was probably due to exhaustion from being tachypneic for days.


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## Sublime (May 10, 2013)

Vitals? What was her skin color / temperature? Could you describe the swelling a bit more? How swollen was she / any pitting edema / redness?


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## Handsome Robb (May 10, 2013)

Without knowing anything else it sounds like sepsis. What were her vitals.

Third spacing fluid and it all ended up on one side due to her positioning, just like dependent lucidity. 

That's my bet.


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## chaz90 (May 10, 2013)

Robb said:


> just like dependent lucidity.



I love phone auto corrects. I can just imagine documenting a DOA with dependent lucidity


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## Handsome Robb (May 10, 2013)

chaz90 said:


> I love phone auto corrects. I can just imagine documenting a DOA with dependent lucidity



Damn iPhone! Didn't even see that.


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## wanderingmedic (May 10, 2013)

How did it end? What did the doc say was going on?!?


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## teedubbyaw (May 10, 2013)

Sub'd


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## firemedic0227 (May 11, 2013)

Sorry guys, it was a busy week for me. I'll try to answer all the questions at once. BP was 140ish/90ish. Skin was warm to the touch but not diaphoretic. Besides her rapid breathing to begin with to not breathing very well while enroute to the hospital all other vitals were normal, BGL was 85ish. The woman was not overweight either. 

Later on in the day after bringing another patient to the ER we asked the ER doc what was going on with our patient. He stated "she's a train wreck, she has liver failure due to excessive ASA intake which then led to her going into kidney failure, and at some point had a mild heart attack." Which all makes sense why she was swollen on one side of her body which happens to be the side that her husband lefter her lay for a long time before calling 911.


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## EMT B (May 16, 2013)

How does this lead to the unilateral swelling? Pathophys never was my strong subject


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## Handsome Robb (May 16, 2013)

EMT B said:


> How does this lead to the unilateral swelling? Pathophys never was my strong subject



She's retaining fluid due to the renal failure and it has to go somewhere so it goes into the interstitial space which would generally cause bilateral peripheral edema but since she's laying on her side gravity pulls all the interstitial fluid to that side causing unilateral edema.


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## EMT B (May 16, 2013)

If she is in renal failure and has fluid backup, wouldn't you see a more elevated blood glucose level due to SIRS/Sepsis?


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## VFlutter (May 16, 2013)

EMT B said:


> If she is in renal failure and has fluid backup, wouldn't you see a more elevated blood glucose level due to SIRS/Sepsis?



Huh? Renal failure/fluid retention and SIRS/Sepsis are two independent disease processes. 

But yes, you will typically see hyperglycemia in sepsis or most systemic disease processes for that matter.


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## EMT B (May 16, 2013)

Wont toxic fluid backup casue a systemic inflamitory response if not sepsis?


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## VFlutter (May 16, 2013)

EMT B said:


> Wont toxic fluid backup casue a systemic inflamitory response if not sepsis?



Nope. Sepsis is an immune/inflammatory response to an invasive infection not an build up of intrinsic waste. Metabolic acidosis, hyperkalemia, elevated BUN/Cr, Etc will not cause sepsis and should not cause SIRS unless there is some necrosis or infarction going on.


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## Handsome Robb (May 16, 2013)

Chase said:


> Nope. Sepsis is an immune/inflammatory response to an invasive infection not an build up of intrinsic waste. Metabolic acidosis, hyperkalemia, elevated BUN/Cr, Etc will not cause sepsis and should not cause SIRS unless there is some necrosis or infarction going on.



Ya what he said.


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## Melclin (May 17, 2013)

Chase said:


> +1 on the Rhabdo. I had a patient on the floor for only a couple hours who had a CK of 50K with pretty substantial AKI. With an underlying infection or disease process added to the equation you can get very sick very fast. Respiratory failure was probably due to exhaustion from being tachypneic for days.



Pretty much this. Pt is sick with one of any number of diseases, contributes to generalized weakness, dehydration from poor ability to care for self/resp rate/illness. Pt lays on floor for a while. Further dehyration, worsening illness, +/-rhabdo. The "mild heart attack" was interesting. Don't kidney failure pts have some minor troponin rise fairly routinely?

But there wasn't really a great deal to go on. Just a heads up for future cases, we'll need a little more detail and structure if you want a genuine attempt at us figuring it out.


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## VFlutter (May 17, 2013)

Melclin said:


> The "mild heart attack" was interesting. Don't kidney failure pts have some minor troponin rise fairly routinely?



You will have minor troponin elevation with renal failure and pretty significant elevation with Rhabdo. In the presence of Rhabdo you can not really make a NSTEMI diagnosis based off enzymes alone so there may have been some EKG or Echo abnormalities. With all that was going on hypercoagation would not be suprising.


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## EMT B (May 17, 2013)

what about the renal failure causes troponin release?


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## Melclin (May 18, 2013)

Chase said:


> You will have minor troponin elevation with renal failure and pretty significant elevation with Rhabdo. In the presence of Rhabdo you can not really make a NSTEMI diagnosis based off enzymes alone so there may have been some EKG or Echo abnormalities. With all that was going on hypercoagation would not be suprising.



Yeah, that was my understanding, but I'm certainly no expert.

Some ECG/echo changes? Around my way it seems more likely someone just saw a troponinrise and assumed nSTEMI. Wouldn't be the first time


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