# 63 y/o ams



## knxemt1983 (Oct 3, 2008)

ok heres the details

respond code three to the subsidized housing district. upon arival fire is standing with the patient in the bathrom. she is mumbling unintelligable words, and very sweaty, swingin her arms up in the air like shes a bird.

only Hx is of current case a shingle being treated by only meds of neurontin, and valtrex.

63 y/o
v/s 138'88
pulse 102
rr 20
sp02 95%
BGL 117
pupils PEARL
monitor shows NSR borderline ST
no trauma
anything else you want let me know and I'll get it


she got the usual, 02, iv tko, monitor


on the way into the hospital she she strated with bigeminy pvc's, then bigemy couplets, then would have runs a vt with a pulse lasting ~15-20 seconds, then back to nsr. we were <a minute out so I didn't get to treat, and honestly don't know if I would have since I had ni idea what was going on. 
So what would you all have done, and what Dx can you come up with


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## KEVD18 (Oct 3, 2008)

well the numbers you gave us mark her as hemodynamically stable, but my first question is when were those taken. specifically, what were her vitals during the period of time from when she started throwing pvc's, then couplets and salvos and runs? if she remained hd stable throughout, then no treatment is indicated. you only treat pvc's prehospital if the pt becomes symptomatic, so i agree with you there.
but if they were in fact symptomatic, then they needed to be treated.

other than that, i wouldnt have done much differently, other than to have my anti antiarythmics ready to go.


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## knxemt1983 (Oct 3, 2008)

my last vitals were as follows:

108/60
p110 and irregular
sp02 99%
rr 20


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## KEVD18 (Oct 3, 2008)

130/88 to 108/60 in how long?

skin signs?
mental status?


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## DenverEMT (Oct 4, 2008)

I'm going to go out on a limb here and say stroke, or possibly a severe untreated UTI. We recently had a patient present with pretty similar findings that was in fact a stroke. Now without knowing her mental status, I cannot say for sure, but her BGL being within normal range and the uncontrollable (I'm assuming) movement of the arms in air (which our patient was doing as well) leads me to think stroke


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## VentMedic (Oct 4, 2008)

History of N/V and/or diarrhea? (side effects from the meds)

Would love to see some labs especially the electrolytes and anion gap.

Did she see the attorneys' ads on TV concerning neurontin?


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## AnthonyM83 (Oct 5, 2008)

KEVD18 said:


> well the numbers you gave us mark her as hemodynamically stable,


 Which numbers specifically? (As a learning point for me, if you would).


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## Sasha (Oct 5, 2008)

AnthonyM83 said:


> Which numbers specifically? (As a learning point for me, if you would).



Blood pressure and pulse. The first set of vitals are pretty good, second BP not so much. Kind of alarming that the BP would drop around 30 mmHg. How long was the transport time? Had you given any nitro?

If her pulse and BP were not WNL and she was exhibiting symptoms like SOB (or that whole respiratory amd cardiac arrest thing. ) then she is symptomatic and needs to be treated by the ACLS vtach algorithims (The bane of my medic school exsistance! AAARGGH! For some reason I have a load of trouble with narrow complex VT.)


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## Sasha (Oct 5, 2008)

Cancel that nitro question. C/C is AMS not CP.
Dur Sasha!


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## AnthonyM83 (Oct 5, 2008)

Sasha said:


> Blood pressure and pulse. The first set of vitals are pretty good


That's why I thought, which is why I asked. His comment was regarding the original set.


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## Flight-LP (Oct 5, 2008)

Ideopathic psychosis with altered mentation secondary to Neurontin......................

Neurontin, for some unknown reason, has shown to cause some memory loss along with altered mentation. It could also be anxiety secondary to postherpatic neuralgia, along with an underlying unknown cardiac issue, which could be causing the tachycardia associated with the monitor's findings.

However, if the pt. was truly in a salvo or VT rhythm, then the pulse is not 102 or 110. Regardless of being symptomatic or not, VT that last 15-20 seconds is never stable and needs to be treated. An anti-dysrrhythmic would have been appropriate in this case.

I too would love to see the Chemistry results.

Interesting case!


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## VentMedic (Oct 5, 2008)

Flight-LP said:


> However, if the pt. was truly in a salvo or VT rhythm, then the pulse is not 102 or 110. Regardless of being symptomatic or not, VT that last 15-20 seconds is never stable and needs to be treated. An anti-dysrrhythmic would have been appropriate in this case.


 
The *pulse* rate would depend on the perfusion quality of the ventricular rhythm. If one can feel a pulse then there is some perfusion. 

I have seen a Ventricular Rhythm at that rate last for a lot longer than 15 - 20 seconds. A long as they maintained adequate perfusion they felt good. If you ever watch monitors in a large tele unit or ICU at a teaching hospital, you never know what you might see. 

I also worked with a team of physicians that studied patients with frequent VT on continous monitoring for research with various class 1C meds such as Encainide in the 1980s. Google that med for some interesting history.


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## Ridryder911 (Oct 5, 2008)

Flight-LP said:


> Regardless of being symptomatic or not, VT that last 15-20 seconds is never stable and needs to be treated. An antidysrhythmic would have been appropriate in this case.



Unusual, but I would have to disagree with this statement alone. It is not unusual for patient to have V-tach and never need treatment. Again, one has to determine what to treat? Anti-arrhythmic is not going to abolish until the etiology is found. 

It is not unusual to see patients in ICU, CCU all the time in V-tach and never be treated until they are symptomatic or until it is apparent the V-tach is not going to abolish itself on its own. 

This was something for me to learn to develop as an ER nurse to a ICU nurse.

R/r 911


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## Flight-LP (Oct 5, 2008)

Ridryder911 said:


> Unusual, but I would have to disagree with this statement alone. It is not unusual for patient to have V-tach and never need treatment. Again, one has to determine what to treat? Anti-arrhythmic is not going to abolish until the etiology is found.
> 
> It is not unusual to see patients in ICU, CCU all the time in V-tach and never be treated until they are symptomatic or until it is apparent the V-tach is not going to abolish itself on its own.
> 
> ...



Your absolutely right, that could have been worded better, my apologies....................

However, specific to this pt. with altered mentation, a drop of 30mm/hg in her MAP, and an irregular rate, you may not not be able to determine etiology, but I would still start Lidocaine to get those ventricles slowing down before the MAP drops to a level of inadequate perfusion. Just my humble opinion though


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## Ridryder911 (Oct 5, 2008)

Sorry, I did not read the entire scenario... Your again right on the basis of the MAP dropping...

R/R 911


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## mycrofft (Oct 5, 2008)

*Pt temp? Pt odors? Pt "edentulous" (or "edentate")? Medicine cabinet?*

Herbal or other dietary supps? ETOH? Do we need to go back break in and look for mold, crank, or cadmium paint or something? Is there evidence the pt speaks English well enough to be understood or is her "gibberish" Croatian or Romani or Brazilian Portugese?

Arm swinging and perspiration could be related to shortness of breath (use your favorite acronym there). I've seen it in relation to atrial tach, the pt felt as though someone had dumped hot water on his upper half (tingling/flushing sensation) and w releived by standing up and pumping his arms for a few seconds. Later had a pacer implanted and the "Rocky" imitations went away.

Yeah, pulse rate versus BP would reflect inefficient but not ineffective hemo round-and-round, at that datum point BP and pulse still supporting life OK, so TKO/O2/go. Bring her scrips, vitamins, herbal remedies, teeth.
Oh, and look for advertising pencils.


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## AnthonyM83 (Oct 5, 2008)

mycrofft said:


> Herbal or other dietary supps? ETOH? Do we need to go back break in and look for mold, crank, or cadmium paint or something? Is there evidence the pt speaks English well enough to be understood or is her "gibberish" Croatian or Romani or Brazilian Portugese?


I like your House-ness.


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## mycrofft (Oct 6, 2008)

*House likes my "mycroftianity"*

One episode of House had two anecdotes from one book about medical detectives...but we digress.


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## traumaangel26 (Oct 6, 2008)

How long had she been taking the med?  As for the drop in BP she was active in the house was she that way in the back of the truck of did she calm down some?  That could explain the drop.:huh:


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## mycrofft (Oct 7, 2008)

*If the litter restraints were put on right..*

...her activity level dropped precipitously.
So, spiel, what was the denoument?


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## mycrofft (Oct 7, 2008)

*I wasn't kidding by the way about language, teeth, and herbals.*

An edentate sixty-plus year old woman high on ephedra tea and speaking Hmong could be interpreted as crazed (or even extraterrestrial) when all ahe is saying is she left her teeth in the bathroom and could we bring her tea along please?.


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## knxemt1983 (Oct 7, 2008)

KEVD18 said:


> 130/88 to 108/60 in how long?
> 
> skin signs?
> mental status?


in about 20 min. from scene time until destination. mental status never changed from the mumbling, never responded, even to painful stimuli


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## knxemt1983 (Oct 7, 2008)

DenverEMT said:


> I'm going to go out on a limb here and say stroke, or possibly a severe untreated UTI. We recently had a patient present with pretty similar findings that was in fact a stroke. Now without knowing her mental status, I cannot say for sure, but her BGL being within normal range and the uncontrollable (I'm assuming) movement of the arms in air (which our patient was doing as well) leads me to think stroke


no abnormal findings on ct


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## knxemt1983 (Oct 7, 2008)

Flight-LP said:


> Ideopathic psychosis with altered mentation secondary to Neurontin......................
> 
> Neurontin, for some unknown reason, has shown to cause some memory loss along with altered mentation. It could also be anxiety secondary to postherpatic neuralgia, along with an underlying unknown cardiac issue, which could be causing the tachycardia associated with the monitor's findings.
> 
> ...


not neurontin complications
I thought about anti-dysrythmics and we have protocols to treat cases like this, but by the time it progressed to more than an occasional pvc we were less than a minute from the ed doors, so I opted to go on into the ER, it would have taken longer to get out the amio, then mix it in a half NS bag per protocol etc etc etc


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## knxemt1983 (Oct 7, 2008)

traumaangel26 said:


> How long had she been taking the med?  As for the drop in BP she was active in the house was she that way in the back of the truck of did she calm down some?  That could explain the drop.:huh:


you could be onto something here, but I'm not totally sure. the activity did stop once we got her onto the cot.


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## knxemt1983 (Oct 7, 2008)

mycrofft said:


> An edentate sixty-plus year old woman high on ephedra tea and speaking Hmong could be interpreted as crazed (or even extraterrestrial) when all ahe is saying is she left her teeth in the bathroom and could we bring her tea along please?.


afraid thats not it either


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## knxemt1983 (Oct 7, 2008)

*the Dx from the hospital*



knxemt1983 said:


> ok heres the details
> 
> respond code three to the subsidized housing district. upon arival fire is standing with the patient in the bathrom. she is mumbling unintelligable words, and very sweaty, swingin her arms up in the air like shes a bird.
> 
> ...



all I could do was the usual o2 iv monitor until she developed the runs of VT.
by the time she developed VT we were almost to the er, and because I had no idea what was going on I opted to go on into the er instead of taking the time sitting in the er bay to hang amio or lido. 

once inside the er, gave usual report and left to do paperwork. I went back in to drop a copy of the run ticket off for the er staff and got questioned by the doc on what was going on, what the scene looked like, how the apartment was kept etc because he too was strugling with it.

I went back and checked on her after my shift was over, and it turned out she was suffering from..... acute COCAINE overdose..... they pushed 0.4mg of narcan, and she came around a little, by that time they had already RSI's her so she was tubed and went on up to ICU

I missed checking pupils, and she had no resp compromise, or I might have had an idea, but still 63 y/o that really caught me off guard. well I guess you live and you learn


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## mycrofft (Oct 11, 2008)

*OOPS, Litella maneuver, code 4*

Thanks!


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