# What do you think?



## dastri (Dec 26, 2011)

Guys ill start out saying that I am new to the forum and new to EMS in general. I just got my EMT-B card and have limited experience in Medicine so work with me please i only want to learn!^_^  This is something that happened about a month ago so my memory is kinda dodgy but anyway here goes: 
Dispatched to a 40ish pt "feeling bad".
Arrival pt is lying supine near the doorway with vomit next to him. He was sweating profusely and complained of dizziness when he opened his eyes. He then vomited again. Pt helped get up and sit down. Said he was his mom's caretaker. Said he ate a burger a few hours ago and he sat down at the computer and then he said he started to feel really dizzy and fell of his chair. 
Vitals: B/P= 184/104 (around don't remember exactly)
Pulse: around 90
Skin felt normal to the touch.
Resp: Normal range, non labored.
Eyes: Pinpoint
Lung Sounds: Clear
Transported to Overlook hospital in Summit NJ.
Any idea what this could be? When i did my clinicals my nurse said it was probably drugs. I will try to answer any ?s to my best ability. Sorry if it they will be limited!


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## Remeber343 (Dec 26, 2011)

Vertigo possibly?  Did it increase with movement?  The dizziness that is.


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## dastri (Dec 26, 2011)

He didn't complain of it getting worse or better when we lifted him into a chair or when he was moved on the stretcher.


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## STXmedic (Dec 26, 2011)

Way too many possibilities without significantly more information. Drugs, bacterial, MI, or anything else under the sun that causes N/V.


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## EMSLaw (Dec 26, 2011)

And of course, since this was dispatched as a 'sick person' job, there was no help from your local ALS, right?  

I would have liked to know a BGL.  And respirations.  From a basic perspective, though, there isn't much to do here.  O2 and transport.  

It could be anything.  The possibilities are vast, though with only marginal hypertension (unmedicated?  You didn't say), I wouldn't be thinking cardiac right off.  It could have been a bad hamburger.  Who knows.


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## dastri (Dec 26, 2011)

Yup No ALS support. Also jersey does not allow EMT-bs to take BGLs what a great state! Other than that i dont remember any medications and md history. Sorry I told you my memory is dodgy. Anyway thanks for the Info guys!


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## mycrofft (Dec 27, 2011)

*Bilateral pinpoint pupils, vomiting, HTN, vertigo...*

http://www.merckmanuals.com/professional/neurologic_disorders/stroke_cva/intracerebral_hemorrhage.html
What did the guinea pig yell into the megaphone?






Or opiates.


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## Localmotion34 (Dec 27, 2011)

A CVA would be what I was thinking, or at least something that can cause brain abnormalities of occulomotor function.

"Eyes: Pinpoint"

That is (generally) a third nerve cranial abnormality, whether arising from the midbrain or pons (pontine pupils), which indirectly affect the occulomotor centers of the midbrain.  I would lean more to the level of the pons because his blood pressure was off, and he was sweating.  Lots of fibers and nuclei in the pons that affect the sympathetic regulation/stasis of the body.  Additionally, vertigo/dizziness can arise from disruption of the eighth cranial nerve, which interestingly, has its nuclei in the pons.  

Occulomotor abnormalites should be considered a high priority for BLS.  Sort of like saying:

"_Sudden onset headache with altered vision is an aneurysm UNTIL PROVEN OTHERWISE_".  

In either of those patients, when they get to the ER, they will do bloods/labs/cultures no matter what, so metabolic and pathogenic causes will be found if they exist.  However, if you point out to the nurses/docs there are occulomotor abnormalities or _classic_ signs of a CVA/cranial nerve deficit, the patient is much more likely to get transferred quickly to a neurovascular interventionalist if the facility has one.  

The moral of the story being that if you see an abnormality of the occulomotor nerve, there may be much, much more going on than you realize.


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