# Chime in and diagnose...



## Stephanie. (Jun 10, 2010)

Okay.. I'm gonna run this by you and let me know what you think, and what you would do in this situation.


You are dispatched to a call, to a 62 yom who fell and hit his head on the counter. He never lost consciousness and when you arrive he is sitting up in the floor stating that his stomach and left flank hurt. The first responders take C-Spine, because it was a fall, and you note a small cut on the top of his forehead. The patient is alert and oriented. His vitals look a little something like this...

BP- 80P
RR- 32 bpm
HR- 148
BGL-314
O2- 99%

He has NKDA and not much of a medical history. 
His current medications are; Nicorette and Propecia.

You load him into your rig. Start him on O2 15mL via NR. The paramedic starts a line and hooks him up to saline. The patient then tells you that last night when he was using the restroom (#1) he gets a sharp pain in his abdomen and he drops to his knees. 

You collect another set of vitals which look like this.
BP- 102/74
RR- 28 bpm
HR- 132
O2- 99%


... Chime in.. and let me know what you think.. what you would do? I am not a Paramedic, so I am not sure about any drugs, but I would like to know what everyone thinks, what they would have done.. This one gets a little tricky one we drop them off at the ER..


----------



## exodus (Jun 10, 2010)

O2 is fine, so I wouldn't do the NRB, unless they have a low SpO2 initially, but then i think an NC would be more comfortable for the pt.

How are eyes? Did the pt only feel the pain while excrementing? Or did it keep coming back? How's the colors or texture of the stool? Is he in any pain at the moment? If so, lets get some MS onboard after we assess him.  What is his general appearence? Healthy, proper weight, etc. Does he drink water, or his he a soda drinker?

I'm thinking kidney stones. So just Zofran and MS till we get to the ED.  I'm also gonna grab a 12 lead if he doesn't know if he tripped over something. 

I'm also thinking possibly a syncapole episode from a drop in BP when he stood up.  How does my abdomen look? Is it distended and rigid? Maybe it is a tear somewhere.

His BP coming up in the rig makes sense form the NS bolus you gave him.

That's all for me  *prods you, pssst* O2 is lpm, not ml


----------



## jjesusfreak01 (Jun 10, 2010)

Slight change in pressure with posture position might indicate some sort of shock. The pain in the abdomen could be caused by a septic condition such as a burst appendix. 

My uninformed opinion as a basic student would be give O2, watch for shock, and get to the hospital fast. Could also be cyanide poisoning...


----------



## Stephanie. (Jun 10, 2010)

exodus said:


> O2 is fine, so I wouldn't do the NRB, unless they have a low SpO2 initially, but then i think an NC would be more comfortable for the pt.* We pretty much did NRB because of the respiration rate.*
> 
> How are eyes? Did the pt only feel the pain while excrementing? Or did it keep coming back? How's the colors or texture of the stool? Is he in any pain at the moment? If so, lets get some MS onboard after we assess him.  What is his general appearence? Healthy, proper weight, etc. Does he drink water, or his he a soda drinker?* Patient is fairly healthy for a 62 yo. He recently quit smoking. He also said that the pain in his abdomen and flank are constant. Scale of 1-10 7. His skin is warm and dry and pink. Eyes are PERRLA.*
> 
> ...


 *I knew SOMEONE would catch that.. *


----------



## Stephanie. (Jun 10, 2010)

jjesusfreak01 said:


> Slight change in pressure with posture position might indicate some sort of shock. The pain in the abdomen could be caused by a septic condition such as a burst appendix.
> 
> My uninformed opinion as a basic student would be give O2, watch for shock, and get to the hospital fast. Could also be cyanide poisoning...



*Would it ever occur to you that this should be a flight patient?*


----------



## exodus (Jun 10, 2010)

Hmm. It'd be nice to have capnography to see what their ETCO2 was, probably wouldn't have done too much for this scenario, because probably doesn't relate to the matter at hand. ANYWAYS. I got a really good feeling, something went boom internally.


----------



## MSDeltaFlt (Jun 10, 2010)

Stephanie. said:


> Okay.. I'm gonna run this by you and let me know what you think, and what you would do in this situation.
> 
> 
> You are dispatched to a call, to a *62 yom who fell and hit his head on the counter*. He never lost consciousness and when you arrive he is sitting up in the floor stating that his *stomach and left flank hurt*. The first responders take C-Spine, because it was a fall, and you note a small cut on the top of his forehead. The patient is alert and oriented. His vitals look a little something like this...
> ...


 
Did he fall from a standing position?  Breath sounds?  Trach deviation?  Abd assessment?  Tender?  What kind?  Rebound?  Point tenderness?  Where?  How bad (?/10)?  Pale?  He's tachypneic and tachycardic.  We need more information to make a more informed decision.  

Define "flight criteria".  What are the capabilities in your area?  Why would you even mention flight?


----------



## Stephanie. (Jun 10, 2010)

MSDeltaFlt said:


> Did he fall from a standing position?  Breath sounds?  Trach deviation?  Abd assessment?  Tender?  What kind?  Rebound?  Point tenderness?  Where?  How bad (?/10)?  Pale?  He's tachypneic and tachycardic.  We need more information to make a more informed decision.  *he did fall from a standing position. He said the pain in his stomach caused him to collapse. His abd is rigid and distended. His pain scale is about a 7 and it is his left abdomen and left flank.*
> 
> Define "flight criteria".  What are the capabilities in your area?  Why would you even mention flight?


*Flight is very common in my area, we are rural with mainly volunteer FRs. I am south of Dallas/Fort Worth. Average transport time is at least 30 minutes to any hospital. Most of our flight patients are STEMI, stroke, occasional pedi, and trauma*


----------



## Stephanie. (Jun 10, 2010)

exodus said:


> Hmm. It'd be nice to have capnography to see what their ETCO2 was, probably wouldn't have done too much for this scenario, *Someone once told me that it would be epic to have on every patient though.. lol*because probably doesn't relate to the matter at hand. ANYWAYS. I got a really good feeling, something went boom internally.


*Hmmmm I wonder where you got THAT feeling from. Cheater. LOL  :rods you back::*


----------



## exodus (Jun 10, 2010)

Stephanie. said:


> *Hmmmm I wonder where you got THAT feeling from. Cheater. LOL  :rods you back::*



Hey, I said it before you said it. So I win!


----------



## Stephanie. (Jun 10, 2010)

We dropped the Pt off at the ED, on a later transport we were told by the nurses that the Pts vitals looked a little something like this.

BP: 148/106
RR: 26 bpm
HR: 134
O2: 99%

He was then rushed and flown to a more advanced hospital to be sent to the cath lab.. He coded halfway in flight and wasn't brought back.


Any other guesses?


----------



## Veneficus (Jun 10, 2010)

Stephanie. said:


> We dropped the Pt off at the ED, on a later transport we were told by the nurses that the Pts vitals looked a little something like this.
> 
> BP: 148/106
> RR: 26 bpm
> ...



If I understand your reply. He had lower Abd pain, a distended abd and signs of shock. 

AAA and Pseudo (formerly incorrectly known as dissecting) aneurysm are the glaring differentials.

Acute pancreatitis that ruptures secondary to a gall stone possibly.

Obstructed bowel.

Thrombus/embolus of the celiac, mesenteric or branched arteries.

Ruptured hemorrhoid or esophageal varices.

Liver failure

unconventional MI presentation

ruptured appendix or gut. 

Ruptured ureter

upper GI bleed.

More specific findings than a few sets of vitals and non specific findings would be required.

Was there Caput medusae?

Goss Blood?

rapidly distending abd?

involuntary muscle guarding?

Purpura?

Traumatic injury signs from the fall? bruising?

Family history of aneurysm? 

It seems like there is definately a shock state, that from the outcome seems like it was not aggresively managed.


----------



## Delando (Jun 10, 2010)

exodus said:


> Hey, I said it before you said it. So I win!


rofl



Stephanie. said:


> You load him into your rig. Start him on O2 15mL via NR. The paramedic starts a line and hooks him up to saline. The patient then tells you that last night when he was using the restroom (#1) he gets a sharp pain in his abdomen and he drops to his knees.
> 
> QUOTE]
> 
> hmm...I too agree kidney stones would be your best bet. Was ab pain the cause of this fall as well?


----------



## mycrofft (Jun 11, 2010)

*Dissecting aortal aneurysm or allied disaster.*

PS: I'm ignorant (and obsolete), what is "HR" if not heart rate? But BPM (beats per minute) is also posted. Or is that "Breaths per  minute"? Or is HR the electrocrdiographic rate while BPM is a palpated or pulseox pulse rate?
Bowel sounds for gut pain is pretty good to do, especially since, if in this case it was an aneurysm, you might have heard the bruit as the blood swished past the site. Palpaton would have been good to localize it; but, bad if you jabbed into the dissection.


----------



## mycrofft (Jun 11, 2010)

*Renal calculi leading to code?*

Well, anyone could have calculi casuing pain and another more lethal condition.


----------



## MonkeySquasher (Jun 11, 2010)

Stephanie. said:


> We dropped the Pt off at the ED, on a later transport we were told by the nurses that the Pts vitals looked a little something like this.
> 
> BP: 148/106
> RR: 26 bpm
> ...



I have a feeling you're asking for one of two reasons.  A), you're curious as to what could have caused it, or B.) you wonder if there was more you could have done to change the outcome.

The answer to B.) is almost certainly No.  This guy's problem was definitely something surgical, and there's nothing else that could have been done in the field to fix it.

As for possible Dx...  I think only an autopsy could say the actual cause of death.  But from what you're describing, I'm going to agree with everyone else, something tore open/off and he bled out internally.


----------



## Veneficus (Jun 11, 2010)

mycrofft said:


> Well, anyone could have calculi casuing pain and another more lethal condition.



Ureters are very vascular, a ruptured one can create significant bleeding.


----------



## Simusid (Jun 11, 2010)

Veneficus said:


> Goss Blood?



I don't recognize this sign and google fails me.   Can you explain in terms that a lowly B would understand?


----------



## mycrofft (Jun 11, 2010)

*"Gross blood" or "grossly bloody"*

Substitute "obviously" for "grossly". In stool or a clear fluid like urine or CSF, there may be blood you need guiac (Hemoccult) to detect, or blood which is obvious.

Yeah, a ureter will bleed pretty good but the pt would have an acute peritoneal or retroperitoneal thing going on (shocky, constant pain, guarding) with free blood and maybe urine in there, no? 

A simlar case near me: obese man in a mobile home making a sandwich, heard something fall down in the kitchen behind him, felt a sharp pain in his flank to his gut and he went down. Got up, pain there but ok enough for him to get wedged into his customary lounger, then called for 911.

A small caliber bullet had punched through the wall (the sound like something falling down), entered his flank, missed all the vital goodies and lodged almost midline after nicking the peritoneum. Had to do dressing changes for one long time, they had to debride the entire bullet track and most of it was through slow-healing adipose tissue.


----------



## Veneficus (Jun 11, 2010)

mycrofft said:


> Substitute "obviously" for "grossly". In stool or a clear fluid like urine or CSF, there may be blood you need guiac (Hemoccult) to detect, or blood which is obvious.




I speak medicine my friend  

Gross: able to be seen with the naked eye. Like Gross anatomy. (opposed to microscopic anatomy)

If you need guiac, it is not gross.






mycrofft said:


> Yeah, a ureter will bleed pretty good but the pt would have an acute peritoneal or retroperitoneal thing going on (shocky, constant pain, guarding) with free blood and maybe urine in there, no?



For sure, but "last night" is plenty of time for an acute peritonitis, less likely than a retroperitoneal event due to the ureter location. The peritoneal pain is often from expansion though, so a compression from retroperit. may not cause constant pain. Guarding is inoluntary and that specific finding I did not see as part of the exam here.

One of my earliest calls was for a guy who was cutting down a tree in his yard the day prior, woke up with "unbearable back pain" called 911. On physical exam he had ecchymosis that looked like a massive Grey Turner's sign. Shipped from ED straight to surgery for a small rupture in the myocardium. No pain until the next moring following event.


----------



## MrBrown (Jun 11, 2010)

Damn Vene you make my medical knowledge look like crap, guess thats why I'm not rolling round in an orange jumpsuit yet.

My professional opinion is that this patient is pretty crook :unsure:


----------



## Veneficus (Jun 11, 2010)

MrBrown said:


> Damn Vene you make my medical knowledge look like crap, guess thats why I'm not rolling round in an orange jumpsuit yet.
> 
> My professional opinion is that this patient is pretty crook :unsure:



You are far too kind.

I'd rather have one of the green or red jumpsuits though


----------



## jjesusfreak01 (Jun 11, 2010)

Stephanie. said:


> *Would it ever occur to you that this should be a flight patient?*



Maybe, but not where I live (Wake County NC). Here, flight will be reserved for extrications and extremely complex cases that will need very advanced care. You can get to a level 1 trauma center (Wakemed Raleigh) in 15 minutes by ground, a hyperbaric facility in 20-25 by ground (and thats traveling out of the county), and all of the major hospitals in the area have diagnostic cath labs. WakeMed Raleigh (located right in the middle of the county) has an interventional lab. 

I can possibly see a burn patient being flown out to UNCs Jaycee Burn Center or something like that, but unless something happens at the borders of our county, or outside them, there are few reasons to consider lifelight. 

So far, in my limited experience (2 ride alongs), our longest time to scene has been around 10 minutes (with traffic, no L&S), the average has been <5 min, and our travel to hospital is less than 10 minutes. 

I do know that the lifelight choppers at UNC ran constantly when I was there, so I would imagine that they probably service a very large area outside of their county.

Back to the issue at hand...yeah sure probably not a bad idea to fly him if it would be quicker than driving.


----------



## Stephanie. (Jun 12, 2010)

MonkeySquasher said:


> I have a feeling you're asking for one of two reasons.  A), you're curious as to what could have caused it, or B.) you wonder if there was more you could have done to change the outcome.
> 
> The answer to B.) is almost certainly No.  This guy's problem was definitely something surgical, and there's nothing else that could have been done in the field to fix it.
> 
> As for possible Dx...  I think only an autopsy could say the actual cause of death.  But from what you're describing, I'm going to agree with everyone else, something tore open/off and he bled out internally.



B is correct.  It did turn out to be a AAA. The only reason I was asking was because we had to sit through a class and realize that we could have flown him. But with all the signs and symptoms that were initially revealed, anyone and damn near everyone thinks it would be a kidney stone. That was my guess. Just justifying that I didn't make the wrong decision. That, and if I were to fly him- then what says I shouldn't fly all my pts with abdominal pain? 
Its a woulda, coulda, shoulda situation...


----------



## MrBrown (Jun 12, 2010)

I don't know about there, but here kidney stones do not cause hypotension and tachycardia.

BP- 80P
RR- 32 bpm
HR- 148
BGL-314

Those initial vital signs to me say that this patient is pretty sick.


----------



## Aidey (Jun 12, 2010)

^^^ Not necessarily. 

To all appearances this man had a syncopal episode, and those vitals immediately after aren't surprising. It would be concerning if the patients vitals stayed that way, but this patient's vitals improved, which is what I would also expect in a syncopal episode.


----------



## Veneficus (Jun 12, 2010)

Aidey said:


> ^^^ Not necessarily.
> 
> To all appearances this man had a syncopal episode, and those vitals immediately after aren't surprising. It would be concerning if the patients vitals stayed that way, but this patient's vitals improved, which is what I would also expect in a syncopal episode.



A syncopal episode is always pathologic, even in older people. 

Some are aware of the underlying pathology, are managing it, and occasionally need assistance.

Pain is always pathologic, it is the body's response to injurious stimuli.

In my simple mind:
No history + new pain and syncope = ED

Which is what the responders did and cannot be faulted. it seems they were operating presuming a less severe Dx, but what would it really have changed? Even if they called for the Helo earlier, it may not have arrived earlier. Even if it saved 20 minutes, can we say that a patient would still be alive because the pt would have gone straight to emergent surgery and not stopped in the ED for confirmation of DX? 

Would the EMS providers have had any treatment options of benefit if they did know? (more on this in the bottom)

The reason EMS has had to incorperate transport destination protocols is because of these very circumstnces.

If you want to lay blame down, why didn't the local hospital recognize it earlier and be more agrresive in treatment?

There are a few reasonable explanations that precludes fault for the ED as well.

1. They knew what they had but didn't have anything they needed to help. Like a surgeon, an available OR, and ICU, massive blood transfusion, autotransfusion, etc. 

2. They knew what they had and could not get transport any faster. It is no different than EMS. You can't just teleport people to better facilities. If you have a serious medical even out in the country, you are probably going to die or be severely disabled. It is a hazard of living there. Many rural people I know are aware of and accept such risk because they value the other aspects more.

In medicine, experience counts. Low volume providers who do not see serious patients on a frequent basis are unlikely to accurately identify sick vs not sick. I have met surgeons in smaller hospitals who haven't seen a trauma patient since their 3rd year of residency. 

Even in the ED the providers (aka physicians) may not be familiar with severe pathologies for a variety of reasons. If they haven't seen a AAA in years it can be as hard to identify as a paramedic trying to grade and stage cancer based on patient presentation.

It is a learning experience for all involved. Anyone who claims such things have never happened to them is either very new and will at some point, didn't realize it did, or their truthfullness may be in doubt. 

If the US medics recognized there was a AAA and it was high enough to put on a set of MAST pants (if they even had them) and pneumatically clamp the aorta, I would have had crow for lunch based on my critisism of the ability of EMS to recognize when/how to use the device.


----------



## Aidey (Jun 13, 2010)

I think you may have misunderstood what I meant. 

The syncopal episode is significant, it is the vitals that are not as significant unless they stay that way. Basically what I was getting at is that temporary hypotension and tachycardia are not unusual after a syncopal episode.


----------



## Smash (Jun 13, 2010)

Veneficus said:


> A syncopal episode is always pathologic, even in older people.
> 
> In my simple mind:
> No history + new pain and syncope = ED



I like the way your simple minds work.  It seems like I have to have the discussion on a daily basis: "Syncope's aren't normal, we're taking this 80 year old to hospital" and then have to put up with the grumbling because the obs are normal.
That or "Anyone who is 80 and has called us for abdo pain goes to hospital"
or any one of a number of variations on that theme.


----------



## dmiracco (Jun 13, 2010)

Flying him for the presentation that you gave i wouldnt have and it really doesnt match a kidney stone at all. Did you ever get BP on both the arms?


----------



## Aidey (Jun 14, 2010)

Why do you say it doesn't match a kidney stone at all?


----------



## DrParasite (Jun 14, 2010)

Stephanie. said:


> BP: 148/106
> RR: 26 bpm
> HR: 134
> O2: 99%
> ...


I was thinking AAA until I saw this BP: 148/106?  I think I have seen one confirmed AAA, and he was pretty hypotensive the entire way to the hospital.  to have his pressure spike like that seems odd to me (assuming it was always taken on the same arm).

btw, the patient I had we transported to a level 1 trauma center, squeezing as much fluid as we could into him to get his BP somewhat stable.  he even made it to the hospital alive (after a 25 minute trip).  a 20 second exam by the ER attending confirmed the paramedics suspicion of AAA, and off he went to surgery.  and we were informed that he died on the table, despite us doing everything right.

Don't worry, you did what anyone else in your position would have done.


----------



## Veneficus (Jun 14, 2010)

*pardon me*



DrParasite said:


> squeezing as much fluid as we could into him to get his BP somewhat stable..



I am not really sure this helped. Can you tell me why you did that?


----------



## dmiracco (Jun 14, 2010)

Perhaps a little initially but not so much for me personally. The decomp shock presentation is clearly representative of more than just kidney stones. Also typically kidney stones by itself usually wouldnt cause someone to fall without defending it or bracing it. Remember that typically an abdomen can hold up to a liter and a half without showing outward signs, rigidity, discoloration, etc. So if you have a rigid and distended abdomen I would be thinking that we have lost alot of blood in the abdominal cavity. 
Hemm pancreatitis, bowel perforation, AAA, lower GI bleed, splenic rupture, you get the point. 
Hemodynamics typically dont change that much with a kidney stone or appendicitis. 
Did the patient see blood in urine? Any associated fever lately? BP and pulses in all extremities, any difference? Associated back/retroperitoneal pain? Shoulder pain or does the patient feel like they have to take a dump?
Lots of etiologies are differential diagnosis by hands on assessment and proper questions.
Sometimes the best thing we can do is take the patient to the hospital. 
I was not there so I am not going to arm chair it but hopefully you and your partner can learn something from this patient. 
Also for the true AAA we are not going to be able to do anything with it, you just hope you have enough time to get to a surgeon. 
Good luck.


----------



## Smash (Jun 14, 2010)

Cholelithiasis is perhaps the most common misdiagnosis for abdominal aneurysm.  The bifurcations to the renal arteries are one of the most common sites for dissection to occur, and the symptoms can initally be identical to renal calculi.  A rather significant volume of blood can be lost in the retroperitoneal cavity as well.  It is worth remembering that renal calculi is typically (not always, but typically) a disease of white males in their 30s and 40s.  Be concerned about anyone over that age group complaining of what sounds like renal colic.

The old saw about unequal blood pressures may be of very little use.  It is very common for there to be some variation in blood pressure between the arms, even in normal patients.  For there to be a difference in blood pressure due to a thoracic aneurysm, the aneurysm would have to arise from the ascending aorta or aortic arch and impact upon one or other of the subclavian arteries; it would therefore most likely present with different symptoms than the case described.

I have to echo Veneficus with concern regarding the aggressive adminstration of crystalloids to an uncontrolled hemorrhage.  I thought that discussion had been had ad nauseam: aggressive crystalloid resuscitation of uncontrolled hemorrhage is bad.  Very bad.  Very, very bad.


----------



## Aidey (Jun 14, 2010)

dmiracco said:


> Perhaps a little initially but not so much for me personally. The decomp shock presentation is clearly representative of more than just kidney stones. Also typically kidney stones by itself usually wouldnt cause someone to fall without defending it or bracing it. Remember that typically an abdomen can hold up to a liter and a half without showing outward signs, rigidity, discoloration, etc. So if you have a rigid and distended abdomen I would be thinking that we have lost alot of blood in the abdominal cavity.
> Hemm pancreatitis, bowel perforation, AAA, lower GI bleed, splenic rupture, you get the point.
> Hemodynamics typically dont change that much with a kidney stone or appendicitis.
> Did the patient see blood in urine? Any associated fever lately? BP and pulses in all extremities, any difference? Associated back/retroperitoneal pain? Shoulder pain or does the patient feel like they have to take a dump?
> ...



She never actually said the abd was distended though. She said "maybe...maybe not". Given that it is perfectly reasonable for the DD to include kidney stones. 

I don't think it's out of the realm of reality for the pain from passing a kidney stone to cause a syncopal episode.


----------



## dmiracco (Jun 14, 2010)

I said perhaps a DD but not me personally. Anything is possable as is my big toe hurts and I fell and hit my head. Not all AAA will have a difference in BP and not all different BP in arms indicates AAA clearly however its one of many assessment tools you have that could help in your DD. 
No different than all wheezing is not asthma and asthma doesnt always wheeze you have to assess and question the patient than utilizing your education and experience come up wuth an educated diagnosis for treatment.
This case essentially is a moo point and anybody wouldnt be wrong in considering a kidney stone however I wouldnt have considered that to be the culprit.


----------



## Veneficus (Jun 14, 2010)

Smash said:


> The old saw about unequal blood pressures may be of very little use.  It is very common for there to be some variation in blood pressure between the arms, even in normal patients.  For there to be a difference in blood pressure due to a thoracic aneurysm, the aneurysm would have to arise from the ascending aorta or aortic arch and impact upon one or other of the subclavian arteries; it would therefore most likely present with different symptoms than the case described..



Is this some kind of failed shortcut for an Ankle/brachial index?

The A/B indix is very useful but as the name says, it is measuring the difference between the arm and the leg, not both arms.

Also keep in mind that an A/B ndex is not specific, all it tells you is there is some kind of vascular compromise somewhere.

especially in older people, they could have multiple chronic vascular compromises so I am not sure in a case like this if you could call the results indicative of acute pathology.


----------



## Veneficus (Jun 14, 2010)

Aidey said:


> She never actually said the abd was distended though. She said "maybe...maybe not". Given that it is perfectly reasonable for the DD to include kidney stones.
> 
> I don't think it's out of the realm of reality for the pain from passing a kidney stone to cause a syncopal episode.



There is more than one type of kidney stone. The Struvite stones can be seen in older people.

The Struvite stones are indicative of infection, which in addition to kidney stone adds sepsis and renal failure to your differential. even if not at the sepsis level yet, infections that reach the urinary bladder can become life long infections.

A urethral tear from one of these can not only cause severe bleeding, but spill renal metabolites into the retroperitoneal space.

Even if the Pt. had a history of kidney stones, with the potential sequele, including azotemia from a stone blocking the ureter at the renal pelvis, I would consider this patient emergent until proven otherwise. There are just too many bad things that could be wrong.

Since aneurysms can "leak" before rupturing and I have seen patients who have "leaked" for as long as 9 days (with pain) waiting for a PCP appointment before rupture, I encourage everyone to be highly suspicious for AAAs in the elderly population with recent onset of abd pain.


----------



## Smash (Jun 14, 2010)

Veneficus said:


> Is this some kind of failed shortcut for an Ankle/brachial index?
> 
> The A/B indix is very useful but as the name says, it is measuring the difference between the arm and the leg, not both arms.
> 
> ...



I suspect that the ABPI is possibly the genesis of this, but it's hard to say. It is a relatively common "ambulance-ism" that patients with an aneurysm somewhere in the thorax will present with unequal blood pressures. The degree of difference required to be significant is seldom quantified, nor does there seem to be much grasp on the pathology that would be required to give rise to a difference as I usually hear it with reference to abdominal aneurysm.


----------



## Veneficus (Jun 14, 2010)

Smash said:


> I suspect that the ABPI is possibly the genesis of this, but it's hard to say. It is a relatively common "ambulance-ism" that patients with an aneurysm somewhere in the thorax will present with unequal blood pressures. The degree of difference required to be significant is seldom quantified, nor does there seem to be much grasp on the pathology that would be required to give rise to a difference as I usually hear it with reference to abdominal aneurysm.



I never heard of "difference in pressure in the arms" prior to this. But in a quick analysis of how it would work and if anyone should care, this is what I think.

The most common locations for aneurysms are the abdomen and the circle of willis. If this helps look for a thoracic aneurysm, it may not meet the time/benefit test.

In a pseudoaneurysm, the most common location is the acending aorta. It is possible that the infiltration of the media could block the brachiocephalic or subclavian. But that is not reliable as arteriosclerotic occlusion could do the same.  (which is more likely in the limb artery than in the aorta anyway.) It doesn't account for anatomical variances or coarction of limb vasculature either.

All in all it sounds nonsensitive and nonspecific. Waste of time.


----------



## DrParasite (Jun 14, 2010)

Veneficus said:


> I am not really sure this helped. Can you tell me why you did that?


wasn't my call, so I can't tell you for sure.

I am guessing, and this is only a guess, but with his pressure so low that he was passing out every time he sat up (60/40, etc), they want to try to raise his pressure to help him stay conscious.

but that's just a guess


----------



## Veneficus (Jun 14, 2010)

DrParasite said:


> wasn't my call, so I can't tell you for sure.
> 
> I am guessing, and this is only a guess, but with his pressure so low that he was passing out every time he sat up (60/40, etc), they want to try to raise his pressure to help him stay conscious.
> 
> but that's just a guess



That is a fair response, but I would rather have an unconscious person not bleeding from the aorta than a conscious one that was.

Just a preference of mine.


----------



## PrincessAnika (Jul 3, 2010)

just reading OP - kidney stone
going back to read the rest of the posts now...lol\

eta - wow.


----------



## MrBrown (Jul 3, 2010)

Veneficus said:


> The most common locations for aneurysms are the abdomen and the circle of willis...



Hmmm lets see, abdomen vs. circle of willis ..... abdomen vs. circle of willis .... I choose abdomen.


----------



## 8jimi8 (Jul 3, 2010)

sure i'll chose death over stroke any day.


----------



## MrBrown (Jul 3, 2010)

8jimi8 said:


> sure i'll chose death over stroke any day.



Nah man you got it all wrong, the hospital is just down the road from my house ... come to think of it so is the ambulance station and the HEMS base


----------



## 8jimi8 (Jul 3, 2010)

MrBrown said:


> Nah man you got it all wrong, the hospital is just down the road from my house ... come to think of it so is the ambulance station and the HEMS base



look... you don't have to die to get close to one of those jumpsuits...


----------

