# Hypotensive dialysis transfer



## Brandon O (Nov 28, 2009)

Hi guys. Thought you might enjoy a somewhat less whacky scenario; this one happened to me a few weeks back and am interested in opinions, since I just got a chance to follow up on the dx yesterday. Since it was a while ago, some of the details are sparse or fictional, but you should get the drift.

You're dispatched for a routine transfer from St. Whatever Dialysis back to Misty Greens rehab. Ms. Elderly Renal is one of your frequent fliers, but this is your first time taking her.

On arrival at St. Whatever, staff direct you to the patient's seat and indicate to you that she was recording a run of hypotensive BPs during her run of dialysis. You see them charted on the monitor, like this -- 100/61, 120/78, 96/59, 121/75, 91/61, fluctuating during the course of her treatment, but basically low. They further indicate that Ms. Renal has been very stuporous, barely responsive and communicating little if at all, just puddled in her seat for the majority of her treatment. Neither of these are typical for her, according to staff; "it's not the Ms. Renal I know," you're told.

The patient presents as an elderly black female slumped in her chair, wrapped in blankets. Her eyes are more or less open but she's clearly obtunded, her verbal responses varying from nothing at all to brief, grunted, coherent words. She obeys simple commands.

You notice immediately that the right side of her face seems to be noticeably drooping; asking her to smile, it is more pronounced. She is barely able to lift her arms in front of her, so although her right arm seems to lift less well it is difficult to tell. She squeezes your fingers with fair strength and you can't decide whether it's your imagination that has her right side weaker. You have her repeat a sentence after you (which in appropriate tradition is something like "why the hell is it always raining in Boston?"), and she gets it right but slurs it.

Radial pulses are equal, but very nearly impalpable; you manage to count one at around 100. The last BP from the computer automatic cuff is 91/61, but you're unable to obtain one manually. Respirations are 18 or so. Her hands are perceivably cold, up through her forearms. Pulse oximetry and BG chem are unavailable to you.

The paperwork available to you is just a master copy of your company's dialysis run sheet, which has a PMH including various uninteresting tidbits. You look in particular for history of CVA or baseline hemiparesis, and also for diabetes; you see neither, but these documents have a habit of not being especially exhaustive.

Having expressed its concerns and scribbled some things in Ms. Renal's dialysis book, staff pats you on the back and sends you back to Misty Greens. You load her up and are sitting in the back of your truck. Now what?

I'm particularly interested in what you guys would do, not when viewed through zebra-calibrated retrospectoscopes, but if you actually took this routine transfer tomorrow. This is one of the two major decision-making points so I'll unfold the rest of the story for you later.


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## Onceamedic (Nov 28, 2009)

Altered level of consciousness = transport to nearest *appropriate* facility which in this case is not the nursing home.  This lady needs to go to the hospital, specifically a stroke center.  Try and find out from the patient (as the documentation is incomplete) whether she has deficits from a prior CVA.  Get a FAST score on her (or whatever you use to quantify stroke) and diesel bolus to the hospital.


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## redcrossemt (Nov 28, 2009)

Kaisu said:


> Altered level of consciousness = transport to nearest *appropriate* facility which in this case is not the nursing home.  This lady needs to go to the hospital, specifically a stroke center.  Try and find out from the patient (as the documentation is incomplete) whether she has deficits from a prior CVA.  Get a FAST score on her (or whatever you use to quantify stroke) and diesel bolus to the hospital.



+1

From the story, it sounds like she normally doesn't have the deficits that are now apparent to you. If the patient is alert and oriented, talk to her and figure out if she has had these issues before, express your concerns, and talk her into transport to the nearest appropriate emergency receiving facility, preferably a stroke center.


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## Seaglass (Nov 28, 2009)

Kaisu said:


> Altered level of consciousness = transport to nearest *appropriate* facility which in this case is not the nursing home.  This lady needs to go to the hospital, specifically a stroke center.  Try and find out from the patient (as the documentation is incomplete) whether she has deficits from a prior CVA.  Get a FAST score on her (or whatever you use to quantify stroke) and diesel bolus to the hospital.



+2. While she might usually be a routine transfer, she's now an emergency call. We're going to the stroke center. 



			
				redcrossemt said:
			
		

> If the patient is alert and oriented, talk to her and figure out if she has had these issues before, express your concerns, and talk her into transport to the nearest appropriate emergency receiving facility, preferably a stroke center.



Of course I'd try to obtain her consent, but the scenario reads like we may not need be needing it. In some cases, we can take altered patients even if they're correctly responding to the A&O questions. Would be my medic's call (as well as PD's, her physician's, medical control's, her legal guardian's, etc. as applicable), though, not mine.


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## Brandon O (Nov 28, 2009)

Nice analysis, guys.

The especially interesting part of this one, for me, is what both of you hit on. The entire crux of this run hinges upon the available history. If I knew for a fact that everything I was looking at was this patient's baseline, or within a reasonable range thereof, there would be no emergency and we'd toddle back to her facility with yawns all around. Conversely if I knew for sure that none of it was typical for her, or could be explained by any unexciting etiology, I'd be tearing out of there and calling a stroke alert. But since I didn't know anything for sure, it was a stinker.

Dialysis patients are regularly sick as hell, and if you hit the big red button every time one of them looks bad you're going to have a very tiring week. On the other hand... they're sick as hell, which means they're in a real position to deteriorate or undergo acute downturns while in your care, so you can't just play taxi driver.

I'll share the next page in a bit.


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## medicdan (Nov 28, 2009)

+3. Ultimately you may get pushed around by the staff at the clinic, and encouraged that it's nothing, but ultimately it's your choice. It's likely I have seen this patient (or their rough equivalent) before, and played it different ways. At some point, you should trust the dialysis staff, they know the baseline better then anyone else.  Patients like this come in looking terrible, and out tired but happy, or come in happy, out exhausted and mad at their tech. 

Depending on your proximity to the hospital, and/or SNF, you may consider just going back to the SNF and talking to the RN. These patients are hospitalized often enough, so finding out the facility of choice is important, but so is talking to someone who really knows the baseline, as the RN and CNA most likely do. 

If you are unsure, give the Field Supervisor-du-jour a call. What do your manual vitals say? What does your gut say? Is the patient stable enough to go back to the SNF? Go back to the basics (ABCs). What is (or could be) killing the patient first? 

Hope this helps. Unfortunately, these cases are extremely ambigious, and personal judgement plays a big role. I guess it boils down to "How comfortable do YOU feel with this partient, and what is in their best interest?


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## firecoins (Nov 28, 2009)

+4  Call medics and meet up with them.


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## sbp7993 (Nov 28, 2009)

+5 I would definitely transport this patient to the nearest hospital. The blood pressure is off, the slurring of the speech and the unequal lifting of the arms would cause me to suspect a stroke, she was cold, i mean the list goes on and on.


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## rescue99 (Nov 28, 2009)

Brandon Oto said:


> Nice analysis, guys.
> 
> The especially interesting part of this one, for me, is what both of you hit on. The entire crux of this run hinges upon the available history. If I knew for a fact that everything I was looking at was this patient's baseline, or within a reasonable range thereof, there would be no emergency and we'd toddle back to her facility with yawns all around. Conversely if I knew for sure that none of it was typical for her, or could be explained by any unexciting etiology, I'd be tearing out of there and calling a stroke alert. But since I didn't know anything for sure, it was a stinker.
> 
> ...



Any labs on this patient?


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## Brandon O (Nov 29, 2009)

rescue99 said:


> Any labs on this patient?



Yeah, I banged out an ABG after I checked the pupils...

Nah, what you see is what you got. So far, anyway.


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## redcrossemt (Nov 29, 2009)

emt.dan said:


> Depending on your proximity to the hospital, and/or SNF, you may consider just going back to the SNF and talking to the RN. These patients are hospitalized often enough, so finding out the facility of choice is important, but so is talking to someone who really knows the baseline, as the RN and CNA most likely do.



Good thought! You could try calling the SNF and speaking to the patient's nurse or a CNA that knows the patient well.

If no one can give you a good baseline, or it's obvious that this is not baseline behavior, you need to transport to an emergency department.


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## Onceamedic (Nov 29, 2009)

Brandon Oto said:


> They further indicate that Ms. Renal has been very stuporous, barely responsive and communicating little if at all, just puddled in her seat for the majority of her treatment. Neither of these are typical for her, according to staff; "it's not the Ms. Renal I know," you're told.



Asked and answered.  The altered LOC is reason enough to go the ED.  Establishing a baseline for symptoms of CVA is a bonus.


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## Brandon O (Nov 29, 2009)

Thanks guys. You see the issue, of course.

I was going to tell you more about what unfolded and tease this out a little longer as a scenario, but what the hell; I'll just share the actual events.

Although I was very uneasy about it all, we decided to transport back to Ms. Renal's rehab. When it came down to it, without any knowledge of her medical history and current situation except spotty paperwork, I wasn't comfortable wheeling off to the ED with no story in hand except "er... she seems wrong, gov'nor." As I suggested before, what I really wanted to know was her history of stroke and diabetes. The patient herself was far too obtunded to be a useful historian.

The one piece of this I didn't mention is that the dialysis tech was swearing she had been in this condition since she came in. That was well over three hours ago, since she completed her full session. In other words, if we're going to talk about stroke, fibrinolytics ain't going to happen anyway; the deadline isn't exactly looming, it's already past.

The facility wasn't next door, but it wasn't a long transport -- call it 10 minutes -- and I monitored her like a hawk the entire time. I remained unable to obtain a BP, and as we bumped down the road I found myself unable to palpate a radial or brachial pulse any longer. I managed to get one apically, no major changes.

We show up at Misty Greens Rehab, wheel her past the desk, and tell the loitering nurses about the hypotension. They say they'll have a look. I ask them about the hemiparesis. One of them glares at me -- "I KNOW you didn't bring her here with her face drooping." They say she's not diabetic, no history of stroke. They also claim that she was doing fine when she went out for dialysis this morning. I'm ready to haul her out of there but they have me take her to her room.

I stay with her, grimly. After a bit an LPN floats through with a vitals trolley and puts an automatic BP cuff on Ms. Renal. It's backwards and doesn't record. An RN shows up, chases off the LPN, and puts it on properly. We get a pressure of 71/49.

Eyes wide, she wanders off. The staff drag their feet and call the facility MD, who decides that, well, shucks, I guess she'll go to the hospital. They then proceed to putter around, getting together referral paperwork with painstaking slowness.

I'm perched at Ms. Renal's side, reevaluating her continuously. At this point I've got her on O2 by cannula, 4 liters (IIRC); I don't know what's going on but oxygenation seems like a nice thing to have. Her hands are still cold, now up through her arms and shoulders. I fluctuate between thinking she has an obvious strength deficit between her two hands/arms and thinking I'm imagining it; her lower extremities seem fine, anyway.

I'm continually on the brink of just grabbing her and hauling her off. The facility staff seem to be teasing me, making sure to include in the paperwork every detail of her current care, including the fact -- admittedly interesting -- that she hasn't been eating the past couple days.

They finally get everything together (at which point I've already got her back on the stretcher, packaged to go and waiting by the door), and we take off, in classic wait-and-hurry-up fashion. I point my partner at the requested hospital, which is a stroke center and pretty much everything else you could ask for. Flipping through the paperwork I note that she's on thinners (aspirin, coumadin); at this point my cleverest guess is a hemorrhagic stroke, but that makes almost no sense.

At triage, we hook her up to the usual wires and I get a pressure I can't remember -- low -- and a sat of something like 49. Undoubtedly incorrect due to poor perfusion. She's admitted directly to one of the trauma rooms and the team starts to fuss over her; I give a somewhat-chaotic report as best I can and leave them to it, attempting to bring some sort of narrative thread to the paperwork in the hallway. I hear them unsuccessfully attempting IVs and watch a portable X-ray get wheeled in.

Some time later, I head back in to get a signature for my PCR. The nurse handling things signs me off, telling me we did great by noticing something was wrong and bringing her in. Their current thoughts are that dialysis simply took too much fluid out of her, which clashes with the claim of their tech that she had been in her current condition from the moment she came in the door -- but never mind.

***

This was all a few weeks back. A couple of days ago, I took a run transferring Ms. Renal from a local ED back to Misty Greens. I was excited to get the chance to poke through her chart and see what came of our little episode, as well as see the lady herself.

She was far more together than I remembered, conversational and alert, although her speech was indeed slurred. Ironically, this time she'd been in the ER because one of our crews had taken her from dialysis and again noted her as hypotensive. The outcome was that the renal consult had decided her current pressure (something like 97/69) was her baseline now and it wasn't going to get much better. She's soldiering on; tough old lady.

In any case, I got hold of her chart, and discovered that following my own run three weeks prior, she'd been diagnosed with... drum roll please...

1. Urosepsis
2. Hypoglycemia

Yes, folks, the woman was diabetic. In retrospect, this probably should have been obvious no matter what I was told; she's a friggin' dialysis patient, after all. So she hadn't been eating and was low. Why neither the dialysis center nor Misty Greens had figured this out is beyond me, but then, most things are.

As for the sepsis, the odds of my nailing that one were minimal. She was admitted to the ICU and spent some time there with vancomycin and the rest.

In any case, if there's a lesson here, it's probably not a diagnostic one, since the diagnoses here were gnarly and not even super relevant in the end. But it's interesting to look at how the information both available and missing played a major role in how things played out, particularly with the fragile nature of a patient like this. In the textbook, someone like Ms. Renal would be an outright emergency... but in the textbook we aren't making dialysis transfers, and in the end of the day I have to give the benefit of the doubt to the personnel and facilities who see this person everyday and who have greater training and resources than I do. Nevertheless, it's a tricky situation, because although I'm taking the patient between two locations, BOTH of which should know more than me, NEITHER of them really feel like it's their problem... so it's easy to fall through the cracks.

Hope this was interesting for some. Happy to answer any questions, although I may not remember many of the details.


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## MrBrown (Nov 29, 2009)

Take her to the hospital


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## Aidey (Nov 30, 2009)

Just an FYI, hemodialysis can make a pt hypoglycemic also. She may have left the facility acting fine, with a borderline sugar, and after they started her treatment it dropped low enough she was obtunded.

What is strange is that with so many (50%+ roughly) of dialysis patients being diabetics the facility should have at least one glucometer on hand.


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## redcrossemt (Nov 30, 2009)

Also, the body's metabolism shoots up (at least for a while) in any sort of sepsis... Nutritional support is important, and hypoglycemia is often seen.


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## medicdan (Nov 30, 2009)

Brandon--

Thanks for the great writeup. Unfortunately, cases like this happen more often then any of us would like to admit. It argues for much more training for "Just EMTs" on the care and assessment of dialysis patients (arguably the sickest barely-stable patients we ever see). it argues for giving you field tools such as glucometry, and empowerment for the clinic or SNF to listen when you say, "something looks wrong", or the ability to call a supervisor and say "something's wrong". 
Where can you go from here? What will you do differently, if given the same patient again?


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## Akulahawk (Nov 30, 2009)

That was a pretty good write up! As presented in your write up, I wouldn't have taken her back to the SNF, I'd have gone to the ER with her. The fact that the dialysis staff was saying that she's "not normal" perks my ears up. The droopy face, slurred speech, altered level of consciousness and so on, puts CVA on the high index of suspicion list. Dialysis or not, she's not supposed to be cold. Cold and hypotensive (even if relative for her) can put sepsis on that list too.

Trust your gut. Sometimes the "oh CRAP" reaction is the correct one.


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## bunkie (Nov 30, 2009)

Brandon Oto said:


> Yes, folks, the woman was diabetic. In retrospect, this probably should have been obvious no matter what I was told; she's a friggin' dialysis patient, after all.



Not all dialysis pt's are diabetic. Something to keep in mind.


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## Brandon O (Nov 30, 2009)

Thanks guys.

Truth be told, although I can see the possibility of doing certain things differently, I'm not certain that I would do them, even in retrospect. This call ran on assessment, not treatment; for the latter the only thing I can imagine is maybe throwing her on oxygen sooner, perhaps by NRB. If the assessment had been there, I suppose I could have given glucose, but frankly I wouldn't have trusted her airway.

The biggest piece that was missing was the diabetic one. In one way or another I should have been able to confirm she was diabetic, or at least suspect it so strongly as to make no odds; with that knowledge, I could have probably demanded that either facility take a BG chem. Again, would my treatment have changed? Maybe, maybe not -- but the way I look at it, the goal should always be the best possible understanding of what's going on. At least that way you don't feel as dumb.

The main decisions here were decisions of transport. So the REAL choice I could have made differently would have been to grab her and burn diesel, either shortly after our arrival at dialysis, or shortly after arriving at the SNF. And I can easily see someone making those choices. But here again, I don't necessarily think I went the wrong way, given the information available. In a way I was able to dodge the issue, because the only really critical scenario on the table was the possibility of CVA, and as I mentioned, given the onset of symptoms 3+ hours before, the time for tPA had come and gone regardless. So with close monitoring I did not feel like we were at the level of danger where we couldn't take the time to keep the regular caregivers (you know, the folks who know her background, provide a higher level of care, and oh yeah, pay our bills) in the loop.

But like I said, it could have gone either way, and I wouldn't call anyone wrong for doing it differently.

Akula: is low body temp a particular flag for sepsis? I'd just have put that down as one more sign of shock. As a matter of fact, isn't septic shock considered distributive -- i.e. if anything shouldn't I expect to see HOT skin due to vasodilation?


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## redcrossemt (Nov 30, 2009)

Brandon Oto said:


> Akula: is low body temp a particular flag for sepsis? I'd just have put that down as one more sign of shock. As a matter of fact, isn't septic shock considered distributive -- i.e. if anything shouldn't I expect to see HOT skin due to vasodilation?



I'm not Akula, but sepsis typically starts with hyperthermia (read fever) due to increased metabolism and the body's immune response to the pathogen. Later in sepsis, cardiac output begins to fall and the patient becomes "shocky" -- peripheral perfusion decreases and the patient can become cool to the touch.

In the differential for sepsis, look for a patient who is:

- Hyper- or hypothermic
- Altered mental status
- Tachypneic 
- Tachycardic
- Elevated WBC (if available to you)

Hypotension is the hallmark finding in septic shock. You can have sepsis without the shock though... Again, look for the above signs.


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## Akulahawk (Nov 30, 2009)

Brandon Oto said:


> Thanks guys.
> 
> Truth be told, although I can see the possibility of doing certain things differently, I'm not certain that I would do them, even in retrospect. This call ran on assessment, not treatment; for the latter the only thing I can imagine is maybe throwing her on oxygen sooner, perhaps by NRB. If the assessment had been there, I suppose I could have given glucose, but frankly I wouldn't have trusted her airway.
> 
> ...


The quick & dirty explanation: The elderly don't respond quite the same way we do to infection. They sometimes don't have the ability to increase their body temperature in an attempt to kill off infections like we do in our younger years. Throw in the fact that their limbs don't get the blood flow that they normally do get thanks to systemic vasodilation from sepsis, they can get cold pretty fast. 

Your assessment showed something was wrong. The Dialysis staff said something was wrong. Even though the "window" for thrombolytics may have passed, she would still need to be seen at an ED instead of going initially to the SNF, where they also said something was wrong. Given the reports that she'd been that way since arrival 3+ hours ago at the clinic, I wouldn't have called a Stroke Alert, but she'd have been treated as if she was a stroke victim and as if she was in shock. 

Aside from heading to the SNF to begin with, it sounds like you did OK. I would think that a call like this would be a good one to learn from.


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## Akulahawk (Nov 30, 2009)

redcrossemt said:


> I'm not Akula, but sepsis typically starts with hyperthermia (read fever) due to increased metabolism and the body's immune response to the pathogen. Later in sepsis, cardiac output begins to fall and the patient becomes "shocky" -- peripheral perfusion decreases and the patient can become cool to the touch.
> 
> In the differential for sepsis, look for a patient who is:
> 
> ...



Redcrossemt covered that part of things pretty well. The elderly sometimes can't or don't increase their body temp like younger people, so that puts them further behind the hypothermia curve... Once the sepsis progresses to a shock state, they can cool off really quickly.


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## Brandon O (Dec 1, 2009)

Thanks again guys.

One other thought is that my assessment was significantly hindered by the unavailability of a manual BP. I don't think this was a personal failing; I tried it in the motionless rig with everything ideal and there just wasn't one to be had. Low BP, poor distal perfusion. But if there's a vital sign I would've liked to have been totally on top of this was it, so that made things much more difficult. Anyone have any suggestions for dealing with this kind of thing? Never thought I'd be wishing for a good old Lifepak with NIBP, but I don't have computerized ears...


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## Aidey (Dec 1, 2009)

Dealing with it in a dialysis patient is going to be different from dealing with it in a non dialysis patient.

With dialysis patients they may have old or "dead" fistulas and grafts in their arms that aren't used any more. Once an access has been declared unusable, doctors will sometimes allow for BPs to be taken on that arm again. So if the pt has a current access in their L arm, and an old access in their R arm you may end up doing their BP on their R arm. The locations of the vasculature may be different because of the fistula surgery so auscultating at the AC may not work. You can try finding where you can feel a pulse and auscultate over that, or palpate or auscultate over the radial pulse point. 

You may also want to practice doing BPs on the wrist using the radial pulse, and on the distal calf using the posterior tibial pulse. These locations can also come in handy on patients with decorticate posturing, or patients with things like cerebral palsy who have severe contractures that make it difficult to access their upper arm. 

In a patient like the one you had, she was elderly and hypotensive which both work against you. Also she is a diabetic, at if she is on dialysis chances are she may not have taken care of her diabetes as well as she could have. Chronic high sugars can cause damage to the blood vessels adding another potential complication to trying to do a BP on this patient. 

In some cases you just may not be able to get a BP, even under perfect conditions.


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## rhan101277 (Dec 1, 2009)

It is clear she has altered mental status,  I would ask her appropriate questions such as.  Do you know your name?  Where are you? What year is it? Who is President? then a simple math question like what is 2+2.  Of course some elderly nursing home folks won't be able to do this simple math, but that is just what I do.

I would elicit a history from staff and try to find out what medications she was currently on.  If not contraindications and these signs continue to point toward a CVA or TIA, I would administer 324mg chewable aspirin if patient can swallow if not I would just monitor and transport.

I wouldn't start fluids because I think that this is permissive hypotension and I will don't want to dislodge something or further aggravate the issue if this is a bleed.  Administering aspirin should reduce platelet aggregation and keep more of these from popping up.  

I would start a saline lock and flush, get the fluids ready and monitor in-route.


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## Akulahawk (Dec 1, 2009)

rhan101277 said:


> It is clear she has altered mental status,  I would ask her appropriate questions such as.  Do you know your name?  Where are you? What year is it? Who is President? then a simple math question like what is 2+2.  Of course some elderly nursing home folks won't be able to do this simple math, but that is just what I do.
> 
> I would elicit a history from staff and try to find out what medications she was currently on.  If not contraindications and these signs continue to point toward a CVA or TIA, I would administer 324mg chewable aspirin if patient can swallow if not I would just monitor and transport.
> 
> ...


Permissive hypotension is something you'll find in Trauma, not so much in Medical. As a basic, your options are pretty narrow. Basically, provide O2 and either call ALS or provide transport to the nearest stroke center, depending upon your local protocols regarding transports. 

As a medic, I'm going to be pursuing a few things. Here in Sacramento,though my options aren't much better, I'd probably be running several protocols on this patient. One flows right into the next. I'd run the "decreased sensorium" and "Shock" protocols simultaneously as low BGL can mimic CVA exactly and hypotension/shock can cause ALOC. Either way the large bore IV allows for admin of D50 and fluid as needed under either protocol. If the signs and symptoms of CVA persist, then I'll start following the CVA protocol. Either way, this patient needs to go to the ED, so transport as early as practicable. 

Sacramento's protocols... leave much to be desired, but at least I can run multiple protocols as needed instead of being "forced" to follow a single one from the get-go. 

Also, out here, <4 hours from onset of symptoms and +CPSS and a normal BGL = stroke alert.


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## redcrossemt (Dec 1, 2009)

rhan101277 said:


> I would elicit a history from staff and try to find out what medications she was currently on.  If not contraindications and these signs continue to point toward a CVA or TIA, I would administer 324mg chewable aspirin if patient can swallow if not I would just monitor and transport.



Do you give aspirin for stroke symptoms in your system? How do you know it's not a hemorrhagic stroke without CT?



rhan101277 said:


> I wouldn't start fluids because I think that this is permissive hypotension and I will don't want to dislodge something or further aggravate the issue if this is a bleed.



In the ALS realm, we decided the patient had hypoglycemia, so we would want to give some amount of dextrose, and then reassess the stroke-like symptoms. With this patient, I bet most of the symptoms went away with correction of her hypoglycemia. The other problem was poor perfusion and cool extremities. If she continued to perfuse poorly after correction of her hypoglycemia, I would start careful fluid boluses. As I said before, AMS with hypothermia and tachycardia would raise my suspicions of sepsis... which definitely needs fluids.

Also, if it is a bleed with increased intracranial pressure, we need to consider that when figuring out what kind of Mean Arterial Pressure (MAP) we need to keep perfusing the brain. Cerebral perfusion pressure (CPP) = MAP - ICP. So, as the ICP goes up, we need to increase the MAP, or the brain will no longer be perfused (as well). The body typically regulates this well... which is why you often see high blood pressures with increased ICP. Even in trauma, we give more fluids/blood with increased ICP then we do without, to keep the MAP and therefore the CPP up. If you allow "permissive" hypotension in these patients, you may help to stop their bleeding, but their brain is sitting there without blood flow...


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## rhan101277 (Dec 2, 2009)

redcrossemt said:


> Do you give aspirin for stroke symptoms in your system? How do you know it's not a hemorrhagic stroke without CT?
> 
> 
> 
> ...



Well its a fine line I think.  While I am still learning and not even a paramedic.  Now that I think about it most strokes have high blood pressure associated with them and this scenario didn't.  No we don't allow aspirin in stroke protocol, don't know why I put in there, sleepy ?? :wacko:

On any call though it is good to always think outside the box and not focus on one protocol.  I definitely don't want to become a cookbook medic


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## Smash (Dec 2, 2009)

Permissive hypotension is only a penetrating trauma thing at the moment, although I have had some interesting discussions with Ken Mattox and some other luminaries of the surgical scene, and it would not surprise me if research wasn't carried out into permissive hypotension in blunt trauma as well.  It's all about controlled versus not-controlled bleeding and bleeding into some cavities from blunt trauma may not be controlled at all.

This doesn't apply to traumatic brain injury however, as redcross has pointed out it is all about ICP, CPP and also cerebral blood flow (CBF).  You can have high pressure with low flow depending on what the vessels are doing in the head (which is why we aim for a narrow window of EtCO2 after RSI in TBI)

Sepsis (which is Systemic Inflammatory Response Syndrome [SIRS] in the presence of a known or strongly suspected pathogen) is a clinical diagnosis.  If a patient has 2 or more of the following:  
Temperature >38C or less than 36C, 
Heart rate > 90, 
Resp rate > 20 (or PaCO2 <32mmHg)
White cell count abnormalities (high, low or lots of band cells - not that we will know this in the field unless it is an IFT)

then they have SIRS.  These figures are from the surviving sepsis campaign guidelines for early goal directed therapy, whcih I think was published in NEJM off the top of my head.

SIRS can occur from a wide range of things like infection from bacterai, viruses or fungi, burns, trauma, pancreatitis, all sorts of things.  The most common cause though is infection, and urosepsis is the most common type (followed by chest infection/pneumonia)  It is also the second biggest killer in hospital, and can be quite subtle and thus not always easy to pick, particularly (as has been pointed out) in the elderly and the immunosuppressed.

Severe sepsis is the above criteria, plus signs of systemic hypoperfusion, such as hypotension, oliguria, altered mental status or organ dysfunction.

Septic shock is the same criteria, unresponsive to fluid resuscitation.

SIRS/Sepsis is a very complex interplay between the inflammatory cascade and the complement system and much of it is poorly understood.  It is not the pathogen that causes the problems per se, but rather the host response to the pathogen.

One of the key pathological features in sepsis is that of microvascular dysfunction and leaky capillaries.  These patients lose an enormous amount of fluid to third spacing and require very aggressive fluid resuscitation to normalise perfusion (which is one of the first steps in treating them).  They also start making very large amounts of very poor quality urine, so as well as relative loss through fluid shifts, they have absolute fluid loss from the kidneys as well.  The microvascular dysfunction will also lead to cold, shut down peripheries and the characteristic mottling of the skin that is seen in sepsis.

Myocardial dysfunction is often occuring in these patients as well, with something (probably NO) depressing myocardial function (stunning the myocardium) which exacerbates the shock state.  If they patient survives, this myocardial stunning resolves itself without any long term cardiac issues, hence the term stunning or hibernation that is used.

Now, just to be a little more tricky, there can be two different shock states seen in these patients.  One, cold shock, is reasonably obvious, has been discussed and is also generally late and bad as I think akulahawk and redcross pointed out.  However the patient may also have what is known as warm shock, whcih is where things get a little trickier in identifying what is going on.  Warm shock is a hyperdynamic shock state:  that is the cardiac output remains normal or even elevated, however due to hugely increased metabolic demand, perfusion remains inadequate.  There is a mismatch between supply and demand so that even though supply is normal or even raised, demand still outstrips it, and the organs remain poorly perfused.

These patients can present warm or normothermic (particularly in the patients who cannot mount a good fever such as the old, young or immunosuppressed) with flushed skin, bounding pulses and possibly normal blood pressures.  However you need to take a good look at the diastolic BP.  A wide pulse pressure (low diastolic) may be a clue that the patient is on their way to cardiovascular collapse, cold shock, and the coroner.

Where I work treatment would be (depending on the cirumstances, distance to hospital so on and so forth):  Supplemental O2, possibly intubation (RSI)depending on the patients condition (we want to ensure adequate O2 delivery, and we also want to minimize workload and O2 demand), large bore IV access; aggressive fluid resuscitation; inotropic support if fluid resus alone does not improve perfusion.  If we start inotropes (epinepherine/norepinepherine) we will also give low dose IV steroids as adrenal insufficiency is very common in these patients and the fact that we need to give exagenous catecholamines suggests that the endogenous ones aren't working so good no more.  We may also give a 3rd generation cephalasporin like cefataxine of ceftriaxone, particularly if we suspect meningococcal sepsis, however we would weigh up the need to identify the pathogen in hospital with the need to acheive bacteriostasis before hand.  With meningiococcal sepsis it doesn't matter if we are on the doorstep of the hospital, they get the antibugs.

Right, that's my typing done for the next 4 months.  Hope I haven't bored you all to tears


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## redcrossemt (Dec 3, 2009)

Smash said:


> Right, that's my typing done for the next 4 months.  Hope I haven't bored you all to tears



You explained it about as well as anyone could have in that few words.


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