# Dispatched: Unknown Incident



## ceej (Aug 30, 2009)

Hello all, couldn't remember the name I used to post under. Here's a case study presented to me by an ER doc:

Diagnose the patient, provide your interventions. Ask and you shall receive.

Your crew: EMT-P (You), EMT-B x 2. Fire is also on scene with a fly car with 3 EMT-B's.

Tones drop for a 40 yom unresponsive. His 13 year old daughter calls because she can't rouse him. He's drank a 12 pack of beer over the last hour and a half. Daughter says he has a condition but is not able to verbalize what it is or what it affects. This is a relatively rural area, so dispatch sent a FD fly car out and they will beat you to the scene. They are BLS non-transport.

Pt is in obvious respiratory distress. You find him prone on the hard kitchen floor having fallen and hit his face on the counter on the way down.

A - Airway is being partially obstructed by broken teeth and blood. He bit his tongue on the way down and it is swelling fast.

B - 4/min and shallow when you find him.

C - Pulse is 89 and strong.

S - Appears to be in respiratory distress, first vitals are below.

A - Sulfa, NSAIDs.

M - Daughter can't vocalize; you find Lipitor, Prednisone, Albuterol and Coreg. You find a glucagon kit, but cannot locate any other medications related to Diabetes.

P - She says daddy has been taken by the paramedics before because of his heart.

L - He finished off his 12 pack about an hour ago.

E - He was getting up off the couch to make himself a sandwich when the daughter heard the crash.

O - Daughter called when she couldn't wake him up, it took you 18 minutes to get there. Onset is believed to be within the last 25 minutes.

P - Unknown

Q - Unknown

R - Unknown

T - Unknown







Vitals:
Unresponsive, cannot be aroused.
Skin is wet and cool.
BP: 140/98
Pulse: 89
RR: 4/min and shallow.
Pupils: ERRL

Clearing the airway and tubing will cost you 3 minutes.
CSpine + LBB will cost you 2 minutes.
Combitube will cost you 2 minutes.

Hospitals:
Level III Trauma Center: 22 minutes hot. (Out of the city)
Level I Trauma Center: 21 minutes hot. (Out of the city)
ER with no trauma classification: 13 minutes hot (Into the city)

Other considerations:
It's 4:30PM on a Friday and traffic is BAD. You might consider adding 15-20 minutes to your hot run times if you decide to go out of the city...

Hints:
Zebras have stripes.

Good luck!


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## enjoynz (Aug 30, 2009)

Was a blood sugar reading done for this patient? If so, what was it?

Enjoynz


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## ceej (Aug 30, 2009)

enjoynz said:


> Was a blood sugar reading done for this patient? If so, what was it?
> 
> Enjoynz



You check blood glucose, 237 mg/dl.


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## ceej (Aug 30, 2009)

ceej said:


> You check blood glucose, 237 mg/dl.



Respirations are also now 30/min and deep.


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## enjoynz (Aug 30, 2009)

As I'm not a medic...I'll leave the scenario for those that are. Just I noticed that there was not a Blood sugar reading on the first post.
One is normally taken as part of protocol(In NZ) with a collapse.
If I was to do anymore with this pt.  Of course I'd be looking at maintaining the airway first.

Thank you!
Enjoynz


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## Sasha (Aug 30, 2009)

> Clearing the airway and tubing will cost you 3 minutes.
> CSpine + LBB will cost you 2 minutes.
> Combitube will cost you 2 minutes.
> 
> ...



Can we get C-Spine and intubation going while we get HEMS on it's way?


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## Brandon O (Aug 30, 2009)

Just wanna say I went through this (modified for BLS) with the OP and it's a doozy. If anyone handles this one without fumbling you should get an award.


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## ceej (Aug 30, 2009)

Sasha said:


> Can we get C-Spine and intubation going while we get HEMS on it's way?



Cspine and LBB are done.

Intubation failed times 3 attempts. Too much blood and too many broken teeth obstructing the airway.

Would you like to break out the Mcgills and try to clear it? It'll cost you another 4 minutes.

Edit: Helicopter takes 25 minutes to get here and it's 10 minutes to nearest viable LZ. HEMS is moving.


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## MrBrown (Aug 31, 2009)

At a quick look ECG looks like LVH ... check out V1, V2 and V3 but that's not my main concern.

If I had to venture a guess I'd say it's a drunk guy who fell down but with the BGL of 237 mgdl (13.8mmol/l for us) he's hyperglycemic as ... the resps are puzzling 4/min would fit with the collapse and some serious CNS depression (I know a dozen cheap beers will probably do that) but 30/min and deep have me leaning toward DKA.

Suction the airway as best I can, drop an OPA for the time being, throw him on a scoop and load into the truck.

Once onboard I'd drop an LMA and get going towards the LZ to get the chopper.


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## emtbill (Aug 31, 2009)

12 lead shows a right axis deviation with a posterior fascicle block, which is not normal in any patient. I think he had a syncopal episode from a dysrhythmia per cardiac history. I would like to know his EtCO2 as well as heart and lung sounds, and SpO2. A neurological event is another possibility. Ventilatory support is indicated, and I would be aggressive with it. Right now this is looking like a supportive care patient.


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## Ridryder911 (Aug 31, 2009)

I don't understand this "cost you" b.s. I have what 6 EMT's and it will take me 2 minutes to combitube? B.S. someone (your physician) needs to be educated in airway management and as well as other prehospital care. Majority of which can be performed while enroute (including ETI) and to place cervical collar on takes two minutes again.. geez are the mentally challenged? 

Good scenario but let's be realistic, okay?

R/r 911


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## ceej (Aug 31, 2009)

Lung sounds are clear.

Heart sounds are significantly stronger on the right side.

This system isn't set up for Capnography, SpO2 is 99% since the FD has been bagging him while Sasha was intubating.

I saw we went with an OPA because of the difficult intubation, anyone want to take another swing at it with a different airway?

Whoever said right axis deviation might be understating; looks like mega super ultra extreme right axis deviation to me. (That was a hint)

@rid: I realize the times are just a complication but this is coming directly out of my book and in order to not cloud things with my student status I decided to paraphrase as little as possible.

@everyone: Good job so far, as this is really a scenario that would be above our level. But it's good to have fun !


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## emtbill (Aug 31, 2009)

ceej said:


> Lung sounds are clear.
> 
> Heart sounds are significantly stronger on the right side.
> 
> ...



I really don't feel that this is an ERAD due to the positive deflection of the inferior lead III. If this was ERAD we would most likely be seeing a ventricular arrhythmia and this is clearly a supraventricular rhythm.

Per the heart sounds I believe the patient has had a massive pulmonary embolism. The right ventricle has to pump a lot harder against the increased pressure in the pulmonary vein which can cause a right axis deviation on the ECG as well as the change in heart sounds. This can also account for the patient's bradypnea. The EtOH along with the PE would be enough to cause the syncope along with the trauma on the way down.

On the airway: I really don't like intubating without a cannogram to look at. It provides objective evidence throughout transport of good tube placement, as well as an early indication that my sedatives and paralytics may be wearing off if the capnogram shows that the patient is trying to breathe on his/her own. With that being said I don't know that I would try an NPA or nasal intubation in this patient. It's unlikely but with the evident head trauma you can cause further damage to the brain by poking around at the base of the skull.  We could try a fiberoptic scope if we have one available but if we absolutely can't get the patient intubated I am happy with just a BVM since we seem to be getting good compliance with it. We could try a rescue airway as well, but I would try oral intubation again before I did that. Yes, let's spend the 2 minutes or whatever it is to clean out the patient's airway then try again. We have to wait on HEMS anyway.


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## ceej (Aug 31, 2009)

emtbill said:


> I really don't feel that this is an ERAD due to the positive deflection of the inferior lead III. If this was ERAD we would most likely be seeing a ventricular arrhythmia and this is clearly a supraventricular rhythm.
> 
> Per the heart sounds I believe the patient has had a massive pulmonary embolism. The right ventricle has to pump a lot harder against the increased pressure in the pulmonary vein which can cause a right axis deviation on the ECG as well as the change in heart sounds. This can also account for the patient's bradypnea. The EtOH along with the PE would be enough to cause the syncope along with the trauma on the way down.
> 
> On the airway: I really don't like intubating without a cannogram to look at. It provides objective evidence throughout transport of good tube placement, as well as an early indication that my sedatives and paralytics may be wearing off if the capnogram shows that the patient is trying to breathe on his/her own. With that being said I don't know that I would try an NPA or nasal intubation in this patient. It's unlikely but with the evident head trauma you can cause further damage to the brain by poking around at the base of the skull.  We could try a fiberoptic scope if we have one available but if we absolutely can't get the patient intubated I am happy with just a BVM since we seem to be getting good compliance with it. We could try a rescue airway as well, but I would try oral intubation again before I did that. Yes, let's spend the 2 minutes or whatever it is to clean out the patient's airway then try again. We have to wait on HEMS anyway.



Tube is successful but that tongue is still swelling. HEMS is 9 minutes out, want to start booking it for the LZ?


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## ceej (Aug 31, 2009)

I came to that very conclusion emtbill.

This is where the scenario ends in my book and the doctor threw me the curve ball that I suppose should be in a differential with a patient with right axis deviation.

He took me along the path of the patient coding and being unable to get the AED to analyze properly and such. I don't think that's a fair assessment and I wanted to see where you would all go given the same initial information as I was, and I'm glad you wound up where I did.

Here's the final chapter:








> Notice the obvious change in axis. A negatively deflected lead I would indicate right axis deviation. When leads II & III become deflected in addition, this would indicate extreme right axis deviation (ERAD). ERAD is most often seen when impulses originate in the ventricles as with ventricular tachycardia, or ventricular pacemakers. ERAD may appear with dextrocardia.
> 
> When you see a negative QRS in lead I, and a positive QRS complex in aVR, you should first suspect misplaced leads. If they are placed correctly, dextrocardia should enter your differential.



I realize that this is an extremely complicated situation and I thank everyone for taking the time to have fun 

Apologies if I did not set things up perfectly, first scenario


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## emtbill (Aug 31, 2009)

Epic fail on my part then. So what was the etiology of the syncopy and respiratory depression? The beer? He couldn't drink a case of beer without dying? Haha...someone needs to learn to hold their liquor. 

I don't know about the AED not being able to analyze his rhythm in cardiac arrest though...didn't we just have a thread about this topic? VF should look the same in anyone's heart.


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## ceej (Aug 31, 2009)

emtbill said:


> Epic fail on my part then. So what was the etiology of the syncopy and respiratory depression? The beer? He couldn't drink a case of beer without dying? Haha...someone needs to learn to hold their liquor.
> 
> I don't know about the AED not being able to analyze his rhythm in cardiac arrest though...didn't we just have a thread about this topic? VF should look the same in anyone's heart.



He told me to place the pads opposite. Never had to do it, so I couldn't tell you =p


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## Brandon O (Aug 31, 2009)

emtbill said:


> Epic fail on my part then. So what was the etiology of the syncopy and respiratory depression? The beer? He couldn't drink a case of beer without dying? Haha...someone needs to learn to hold their liquor.



Went down from the hyperglycemia, hit his head and started to bleed (note his meds), went down from the ICP.

Yeah, I wouldn't have guessed in about a million years. The vitals were far from obvious for Cushing's. But you guys win for making it trauma at least.


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## ceej (Aug 31, 2009)

Brandon Oto said:


> Went down from the hyperglycemia, hit his head and started to bleed (note his meds), went down from the ICP.
> 
> Yeah, I wouldn't have guessed in about a million years. The vitals were far from obvious for Cushing's. But you guys win for making it trauma at least.



It's like if House was a paramedic.

Edit: IT'S NOT LUPUS


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## BruceD (Aug 31, 2009)

ceej said:


> It's like if House was a paramedic.
> 
> Edit: IT'S NOT LUPUS



Ya.. but did you rule out sarcoidosis and Wilson's disease


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## MrBrown (Aug 31, 2009)

*sticks his nose back in his 12 lead book


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## Dominion (Aug 31, 2009)

MrBrown said:


> *sticks his nose back in his 12 lead book



Gonna go ahead and agree with you here.


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## boingo (Sep 1, 2009)

Look at lead I, aVr and the precordial leads....does the r wave progression look kind of backwards?  Look at the chest x-ray....something seems to be where it shouldnt....


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## emtjack02 (Sep 2, 2009)

Well it's official...I do feel lost.  CXR: possible left pneumo, probable pneumopericardium. Lack of ETT that sasha placed. I do not see the ERAD so if someone could throw me a bone that'd be great.


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## boingo (Sep 2, 2009)

Its dextrocardia.  If you look at the cxr, you'll notice the heart is on the right, also, the ekg shows reversed r wave progression and a negative complex in I and upright in avr.


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## emtjack02 (Sep 2, 2009)

boingo said:


> Its dextrocardia.  If you look at the cxr, you'll notice the heart is on the right, also, the ekg shows reversed r wave progression and a negative complex in I and upright in avr.



I guess I've forgotten to look at avR. That is pretty cool.


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## daedalus (Sep 3, 2009)

Yea, the dextrocardia is really interesting and all, but I am just not seeing how it has anything to do with a drinking a few beers and passing out. Granted I did not read the whole thread but this scenario makes little sense to me.


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## Brandon O (Sep 3, 2009)

You should read the whole thread.


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## daedalus (Sep 3, 2009)

Brandon Oto said:


> You should read the whole thread.



Yea, no. I am still not seeing any relevance. I read the thread, maybe I am tired and missing something very obvious. This head injury patient is uncomplicated by any cardiac problems. While he may have RAD, it may be from improper lead placement, and if it actually is present, it will not change the diagnosis or treatment of this patient (other than to change paddle position in the event of a cardiac arrest if a confirmed history of dextrocardia situs inversus is present). The patient is hemodynamicly stable with a good pressure and normal heart rate, and the EKG shows a regular sinus pacemaker without ectopy or evidence of acute ischemic changes. That is a strong case for ruling out a cardiac etiology for his unresponsiveness.


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## daedalus (Sep 3, 2009)

In fact, the care of this patient is also pretty routine and unremarkable, so I am not sure how any one would "fumble" on this one. The patient should get good airway control, be placed into c-spine precaution, and monitored in route tot he hospital while a detailed survey is done, managing any additional injuries found. He should be transported to a facility with trauma/CT scan services are available. And that is about it. B)


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## sdadam (Sep 3, 2009)

Ummm

I hate to break it to your doctor, but an AED would have no problem analyzing a PT with dextrocardia.

Looking at the 12 lead that you posted an AED would simply say "shock not indicated".

If the PT happened to be in vFib or vTach, the fact of the matter is that there is NO difference on an EKG between those two rhythms in a dextrocardia PT and a normal patient.

See the recent post "Dextrocardia" and I wrote ALOT of info on dextrocardia and pad placement.

Also keep in mind that an AED will work perfectly even if you put the pads on reversed in a normal patient.

Now people with dextrocardia often have other health problems, but there is nothing inherent to dextrocardia that is a health risk, so this would be a PT with something else going on who just happened to have dextrocardia too.


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## Brandon O (Sep 4, 2009)

I guess ceej has been banned for a bit, so I'll answer best I can...

The way this plays out in full (at least as it did for me) is supposed to be:

LOC was caused by the diabetic condition. This is otherwise a red herring; you're just supposed to treat it and move along. Airway problems are similarly just an obstacle, do what you need to do. (Apparently in the original material OPAs were supposed to be contraindicated because of the swelling tongue and NPAs because of the head trauma -- not sure I agree with either of those but oh well, it's an ALS scenario.) The respiratory changes are Kussmaul secondary to the hyperglycemia.

however

When he went down and hit his head, he began to hemorrhage (no further info here). Your index of suspicion was supposed to be the Heparin -- and vitals should have exhibited Cushing's Triad as things moved along, which we never got to. (When I went through this the vitals didn't say anything, so that's where things went south for me.)

The timeline is tight on this, so no matter how you treat or transport, the patient codes en route (or on scene if you're slow). Whereupon the dextrocardia becomes relevant, which you hopefully diagnosed earlier (or figure out now). As for me I just kept getting "pads misplaced" and scratching my head; maybe with a manual defib you could be more intelligent about it.

Buuut that's all I know. Dextrocardia's new to me so I'm no expert.


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## Brandon O (Sep 4, 2009)

Just caught the dextrocardia thread sdadam, good info.


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## ceej (Sep 4, 2009)

sdadam said:


> Ummm
> 
> I hate to break it to your doctor, but an AED would have no problem analyzing a PT with dextrocardia.
> 
> ...



Like I said, I am a student and this is what I was told. Thanks for the clarification.


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## paccookie (Sep 10, 2009)

Brandon Oto said:


> I guess ceej has been banned for a bit, so I'll answer best I can...
> 
> The way this plays out in full (at least as it did for me) is supposed to be:
> 
> ...



Disagree with you on the kussmaul respirations.  Sounds more like central neurogenic hyperventilation...which looks just like kussmaul but has a neurological basis (staving of herniation in the face of IICP).  I've never seen a diabetic have such several symptoms in the 200's, so I'm not convinced that the LOC and the respirations are to be blamed on the blood glucose.


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## daedalus (Sep 11, 2009)

paccookie said:


> Disagree with you on the kussmaul respirations.  Sounds more like central neurogenic hyperventilation...which looks just like kussmaul but has a neurological basis (staving of herniation in the face of IICP).  I've never seen a diabetic have such several symptoms in the 200's, so I'm not convinced that the LOC and the respirations are to be blamed on the blood glucose.



I agree with pacookie. This whole scenario is just strange.


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## Brandon O (Sep 11, 2009)

Just going on what I was told, fair enough guys.


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## mycrofft (Sep 12, 2009)

*More scene questions.*

Was he wearing synthetic socks and was there Armorall on the floor?


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## fiddlesticks (Sep 13, 2009)

well i would suction first to clear the airway then put in an opa and get my partner to bag the guy. then get the guy out to the truck and start and iv and put him back on the monitor, i would only take him to the er casue well i dont see a need to add that much time on to the call. is there anything else you would like added?


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## thowle (Sep 17, 2009)

ceej said:


> Cspine and LBB are done.
> 
> Intubation failed times 3 attempts. Too much blood and too many broken teeth obstructing the airway.
> 
> ...





ceej said:


> A - Airway is being partially obstructed by broken teeth and blood. He bit his tongue on the way down and it is swelling fast.
> B - 4/min and shallow when you find him.
> C - Pulse is 89 and strong.
> S - Appears to be in respiratory distress, first vitals are below.
> ...



On Scene:
Suction airway, establish; re-evaluate airway and breating; bag valve, OPA, c-spine, move to ambulance...

In Ambulance (enroute to ED):
Intubate (failed 3 times), King Airway LTD, 100% Oxygen, Bag Valve -- I guess he's breating 30/m now, or still 4/m?  Either way -- BVM. Keep eye on skin condition, temp, BP, and pulse, treat for shock as neeed, Monitor, IV started, ready to push as needed, transport ALS to "Level I Trauma Center: 21 minutes hot. (Out of the city)" -- (Possible trauma causing additional airway obstruction) initially, if subject deteriorates much, consider transport to another ED or radio to local area and request air transport and setup LZ wherever closest to; depends on location.


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