# Rapid Deterioration: Altered and Difficulty Breathing



## BobBarker (Mar 30, 2021)

I work part-time for an IFT company. I mainly do ALS and CCT shifts were we actually get a bunch of emergency transfers but yea, still not 911 lol. Our RN called out so we were moved to a BLS rig. Got dispatched for a discharge from ER to home.

73yo chief complaint of chest pain. Hx of back pain, UTI and Alzheimers Dimentia. Baseline is AxOx1 to name only, says confusing statements in spanish only, but always moves around and tries to get out of bed some of the time per staff although he is non-violent. He has been in the ER for about 14hrs at this point. Upon arrival, staff said CT+xray chest, EKG and blood test were all negative, so they are discharging him home about 16min away. They gave him aspirin only upon his arrival earlier. His vitals are all good: BP in the 130s/70s, R16, P78 and satting at 96% on RA. We take report, gather his belongings and move him to our gurney. He smiles and moves his arms and seems fine.

After we get him in our rig, my partner gathers a manual BP and it's close to what we got in the hospital. During transport about 5min away from his house, my partner tells me that our pt is now not moving his arms, opens his eyes for a second and shuts them when he taps on his shoulder and respirations are now at 8-10. My partner tells me to upgrade code 3 to the MAR which is 5min away (diff hospital) and puts him on 10LPM. As he tries to get another BP, the gentleman's arms just falls down instead of him holding it up like he could before (took BP on both arms). About 2min away from the hospital, my partner advised me that his respirations are now 6, he is bagging him at 15LPM and he is barely waking up when he does a sternal rub. Lung sounds were slight wheezing on upper right side, no obstructions/secretions, otherwise clear and eyes were PEARL. We pull into the hospital and MD and RN's are waiting for us. MD, who happens to know the patient from many previous visits, says that he agrees he has never seen the pt like this as he is usually constantly moving. 12lead EKG shows HR at 83 with 1st Degree AV block, otherwise nothing else (no previous heart hx). Blood sugar is normal, BP is 120s/80s and pt is satting at 96 on 15LPM with 10 respirations, so they switch to NRB. Pt is now slightly more responsive but still not moving that much. RN's drew blood with no resistance from our patient and doctor was ordering a chest xray and head CT as we were leaving.

I know we did everything right but I am just wondering how this gentleman deteriorated quickly given he was only administered aspirin 14hrs before and all tests came back negative.


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## Peak (Mar 31, 2021)

Given your story it is difficult to really know what happened. That being said it sounds like this guy probably has very little reserve and is pretty close to the end stages of Alzheimer’s. You unfortunately are probably watching the last bit of his clinical decline.


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## BobBarker (Mar 31, 2021)

Peak said:


> Given your story it is difficult to really know what happened. That being said it sounds like this guy probably has very little reserve and is pretty close to the end stages of Alzheimer’s. You unfortunately are probably watching the last bit of his clinical decline.


I was thinking that and/or he threw a stroke but the BP and hx doesn’t realy support that.


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## Akulahawk (Mar 31, 2021)

Peak said:


> Given your story it is difficult to really know what happened. That being said it sounds like this guy probably has very little reserve and is pretty close to the end stages of Alzheimer’s. You unfortunately are probably watching the last bit of his clinical decline.





BobBarker said:


> I was thinking that and/or he threw a stroke but the BP and hx doesn’t realy support that.


With a stroke, the BP can be basically normal, elevated, or decreased. Don't discount the possibility of a stroke because the BP was basically OK. He easily could have had an acute progression of his Alzheimer's to it's final stages but given the rapid onset, I'd put my money on a stroke until proven otherwise.


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## BobBarker (Mar 31, 2021)

Akulahawk said:


> With a stroke, the BP can be basically normal, elevated, or decreased. Don't discount the possibility of a stroke because the BP was basically OK. He easily could have had an acute progression of his Alzheimer's to it's final stages but given the rapid onset, I'd put my money on a stroke until proven otherwise.


Thanks!


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## Peak (Mar 31, 2021)

Akulahawk said:


> With a stroke, the BP can be basically normal, elevated, or decreased. Don't discount the possibility of a stroke because the BP was basically OK. He easily could have had an acute progression of his Alzheimer's to it's final stages but given the rapid onset, I'd put my money on a stroke until proven otherwise.



Ill bet hypercapnia from progressive hypoventilation and poor respiratory drive.


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## Akulahawk (Mar 31, 2021)

Peak said:


> Ill bet hypercapnia from progressive hypoventilation and poor respiratory drive.


I would also say not a bad bet either. Regardless, this is quite potentially a good lesson in ensuring that the patient is not only breathing, but breathing well and adequately.


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