# Skinny Chick



## NomadicMedic (Jan 13, 2011)

It's a rather warm (Low 90's) summer day, about 1600. You (a paramedic) and your EMT-I partner respond priority to “an unconscious female”. 

You arrive on scene to see a fire engine parked in front of a well kept single story home. You grab your gear and walk in to the very warm back bedroom where you find a firefighter providing good OPA/BVM ventilation to a approximate 20 year old female, laying supine in a large bed. She's wearing only panties and a bra and covered with a sheet that seems to be wet. She is skinny (approx 110lbs) and there are no visible track marks, rashes, bruises. Her hands, feet and legs are mottled.

Pt is GCS 5 (1,1,3)
Resp: 10 per minute via BVM
HR: 116 Sinus tach on the monitor
BP: 94/62
BGL: 110
Pupils: Equal at 8mm
Temp: 100.1

Mom was on scene and was NO HELP at all, simply getting in your way. (She might be intoxicated.) Dad shows up as you're getting the lowdown from the firefighters and he says she's had a cold for the past few days and they think she may be on some drugs. No other HX, meds or allergies that they can provide. She's been out partying a lot lately and they're not quite sure what she's been doing or with whom.

You're less than 15 minutes away from THE hospital. (A level 3). There is no HEMS available.

What's your differential and your treatment plan?

I'll fill you in on what happened in a couple of days after everyone has a crack at it.


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## jjesusfreak01 (Jan 13, 2011)

ParathinkIam Brad wants to take a stab at this one.

Possibly underweight 20yo female with normal pupils and BGL, elevated temp, low BP, GCS, and elevated HR. Is the sinus tach the only ecg finding? Are we looking at a 3/5 lead monitor or 12 lead? Is the sheet wet because the patient is wet, or because they were trying to cool her down?

Sounds like it could be sepsis from the elevated temp, tachyness, and shockyness of the patient. My initial treatment would be iv fluids to raise her pressure a bit assuming no other findings that contraindicate raising the bp (if its sepsis, a quick trip to the hospital is about all I can do). 

I would like to know what she's been on? Do we have a downer causing the depressed respirations, or something like cocaine thats causing cardiac ischemia? Also, does her mother know what stage of her menstrual cycle she's in, since low blood volume in an underweight girl with added unknown drugs could pretty much explain all the symptoms. 

I want the full twelve lead to rule out the ischemia. 

I suppose some sort of internal bleed could also be a culprit here, but I have very few good ways to diagnose that in the field. Best I can do is visualize the airway to look for blood and hope it isn't anywhere I can't see.

Can't think of anything else to do for the poor girl at the moment.


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## 18G (Jan 13, 2011)

Dad said she has been sick with a cold the past few days. Perhaps she had something viral going on explaining the temp. Parents also alluded to substance abuse so perhaps she also took a narc, benzo, or some other depressant resulting in the low B/P, depressed resp, and compensatory sinus tachycardia. 

Ecstasy is known to increase body temp and it was said that she had been out partying a lot lately so that could be a factor as well if she took "E". Maybe she got really hot and put the wet sheet on herself to cool down which also explains no clothes? Was the sheet wet from water or sweat?

Is she skinny as in anorexic skinny or just skinny?

Based on info provided with no clear etiology of the presentation... I would try Narcan at 0.4mg and titrate to adequate resp rate if patient responds at all to the Narcan. If no response, I would provide advanced airway support with an ETT, monitor EtCO2, and BMV at 8-10min. Continue to monitor ECG, do a 12-lead, and give a fluid bolus. I may consider an NG tube depending on how the  stomach looks and how long BVM ventilations were going on prior to my arrival. 

Until labs are done it may not be apparent what the etiology is. 

Curious to hear the rest of the case....


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## abckidsmom (Jan 13, 2011)

I don't have time for a well thought out post, but I want to register my guess of an anorexic taking pseudoephedrine.  Maybe she convinced dad to be her supplier by showing those "cold symptoms."

Not sure what explains the AMS, but I'll be able to think more clearly later.


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## NomadicMedic (Jan 13, 2011)

Good questions all. 

Here's some answers to some of the questions.

The ECG was just Lead II. Sinus Tach with no ectopy. No 12 lead.

The sheets were wet with what appeared to be sweat. Her hair was matted and she was warm to the touch. It was also at least 100 degrees in the bedroom, no windows open, no fans or A/C.

I got the parents off to one side and started asking some questions.

Dad told me that she has a psych history and she was on several drugs. He kept the Seroquel, Ativan and Depakote locked in a drawer in his desk and he doled out the drugs to her every day. He told me there was no way she could gain access to them.

Mom told me that the patient had her tongue pierced 3 days ago and that she hasn't eaten much. Dad said he heard her vomiting this morning when he got up to go to work.

Mom thinks she is on her period now, as there is an open box of Tampax in the bathroom on the counter.

...And yes, she was out last night. Dad heard her come in around 0130.

IV access obtained with 18ga in right AC. 

0.4mg Narcan to no effect.

What else do you want? More questions?


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## 18G (Jan 14, 2011)

Was only 0.4mg Narcan tried? I prob would have also tried a second dose of maybe 0.8 or 1mg since some narcs require higher doses of Narcan to reverse. 

With the ambient temp in the room being 100F her body is going to be absorbing heat from the environment since it is hotter than the body's normal temp. The excessive fluid loss from sweating and increased resp due to the heat may have been enough to cause the dehydration/hypovolemia in the patient with already low fluid volume.  

I'm still pondering what is causing the depressed resp status so I am still going with drug induced or at least contributing.


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## jjesusfreak01 (Jan 14, 2011)

Shot in the dark: Either liver failure from extended use of medications or...

Overdose of the medications. Its possible she's been keeping them hidden after her father gives them to her to take, and then ODd on them. Its also possible that she mixed alcohol or other drugs with her medications, causing massive CNS depression, leading to her visible symptoms. If her last dose was recent, we could do a gastric lavage on the way to the hospital. Regardless, she needs stabilizing treatment and a quick trip to the hospital for further labs.

After giving 1000ml of saline (and getting her out of the hot room into the cool ambulance), how's her pressure, mental status (GCS or AVPU), and heart rate?


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## Smash (Jan 14, 2011)

Sorry, can you just clarify: is she breathing spontaneously with BVM for assistance, or is 10 the rate that she is being ventilated at as she is apneic?  Stating that her resps are 10 suggests an inherent rate of her own, but BVM then confuses things.

A bit more exam would be nice.  Head: Any signs of trauma?  Pupils, aside from being dilated, is there any nystagmus or other abnormal findings?  What does her tongue look like?  
Chest:  Again, trauma?  Breath sounds?  If she is breathing, what is the pattern/depth/rate?  
Abdo: Palpated?  Genito-urinary: anything abnormal?  Tampon in place?  Signs of trauma?  
Can you move her limbs freely or are they stiff?  
What is her skin like (aside from mottled extremities) Good or poor turgor?  EtCO2?  SpO2? ECG findings aside from Sinus tach?  PR interval?  QT length?  QRS length? Morphology?
Her temperature is only slightly elevated and doesn't actually fit the criteria for sepsis (it's only 37.8C in normal people scale)

Ok, so what are her problems?  Airway is fine.  Breathing is either fine or managed.  Circulation is not so good, she has poor perfusion evidenced by mottling of limbs (consistent with sepsis), but her BP wouldn't normally strike me as being that low given her body habitus.  Heart rate is also not particularly high if pure volume depletion was the cause of her problems.  Slightly elevated temperature.

This could be:  Sepsis - she has new piercing, nice way for nasty things to get in.
Toxic Shock Syndrome - Maybe, although it doesn't all fit together nicely.
Spontaneous intracranial bleed - could account for most things here, including her mild fever.
Valproic acid toxicity - although miosis should be occuring, not mydriasis, but then there could be co-ingestants
Neuroleptic Malignant Syndrome - I like this one, it accounts for pretty much everything, taking into account the environment (high ambient temperature) and she is on neuroleptics and may have been taking ather things that mess with dopamine (like MDMA) while she is out partying.  Her temp isn't quite high enough (but then patients never read the right textbooks) and I'd like to know if she is stiff or not, but I still like it.
Or about eleventybillion other things.

Treatment.

Oxygenate and ventilate as required with BVM whilst doing other stuff.  If she is apneic, then intubate (RSI) and ventilate. A fluid bolus is probably in order, and I'd start organising some pressors as well (whilst waiting to see repsonse to fluids). Narcan 0.4mg given as..... nah!  Don't be silly, why the hell would I give her narcan?  That's just plain stoopid.
Supportive care from there, drive to hospital.


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## ah2388 (Jan 14, 2011)

care to explain why pressors are indicated in this pt?


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## Smash (Jan 14, 2011)

ah2388 said:


> care to explain why pressors are indicated in this pt?



Sure.

Pressors and intropes may be indicated if there is not an adequate repsonse to crystalloid resuscitation.  Despite having what _seem_ to be ok numbers this patient is exhibiting signs of pretty poor perfusion given her mottled legs and so on.  Mottling of the skin is a reasonably common and reasonably clear indication of sepsis, particularly in meningococcemia where aching legs and joints along with mottling of the skin is an early sign of this particular disease.
Sepsis has to be reasonably high on a list of differentials, even though she doesn't fit all the numbers according to the textbooks.  She is in a population that shows a spike in the incidence of meningococcal disease, she seems to have been engaged in behaviour that increases the risk of transmission of diseases and she certainly has one obvious portal for infiltration.
If this is sepsis, then early and aggressive management of hemodynamic parameters is generally accepted (thanks to Dr Rivers) to be the cornerstone of management.  The major pathologies of sepsis that lead to poor perfusion are capillary leak and myocardial stunning, so after replacing some volume it is important to manage these.  I don't know that the choice of drug matters too much, although there is a relatively recent paper published in Lancet (I think) that suggests that dopamine is probably not that effective.  I like epi: it does everything I need it to do (inotropy, vasoconstriction), it's cheap, it's easy to titrate, everyone is familiar with it and lets face it, they all end up being epi anyway.

Regardless of this, it is very difficult to come up with a diagnosis, both in the field, and especially from posted scenarios.  However, sometimes that doesn't really matter too much as we might just need to focus on the clinical problems (in this case, Airway, Ventilation and Circulation) and manage them with the tools at our disposal.

I still like NMS for her though.


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## Simusid (Jan 17, 2011)

Smash said:


> If this is sepsis, then early and aggressive management of hemodynamic parameters is generally accepted (thanks to Dr Rivers) to be the cornerstone of management.  The major pathologies of sepsis that lead to poor perfusion are capillary leak and myocardial stunning, so after replacing some volume it is important to manage these.  I don't know that the choice of drug matters too much, although there is a relatively recent paper published in Lancet (I think) that suggests that dopamine is probably not that effective.  I like epi: it does everything I need it to do (inotropy, vasoconstriction), it's cheap, it's easy to titrate, everyone is familiar with it and lets face it, they all end up being epi anyway.
> 
> .


I'm a basic with zero pharmacology.   What I think you're saying is that it looks like sepsis, she's in an at risk population for meningitis, sepsis causes systemic leakage from the vasculature into the body.   I think I'm reading that pressors cause constriction and you want to use them to try and stop the leaking?

Inotropes cause the heart to squeeze harder?   Is that to compensate for the smaller piping?


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## NomadicMedic (Jan 18, 2011)

Smash said:


> Sorry, can you just clarify: is she breathing spontaneously with BVM for assistance, or is 10 the rate that she is being ventilated at as she is apneic?  Stating that her resps are 10 suggests an inherent rate of her own, but BVM then confuses things.


*
She has spontaneous resps of 3 or 4 per minute, certainly not anything like effective respiration.*



> A bit more exam would be nice.  Head: Any signs of trauma?  Pupils, aside from being dilated, is there any nystagmus or other abnormal findings?  What does her tongue look like?



*Her head is atraumatic. Pupils are normal, aside from mydriasis. Her tongue looks like it's been peirced in the last few days.*



> Chest:  Again, trauma?  Breath sounds?  If she is breathing, what is the pattern/depth/rate?



*Chest is atraumatic, lungs are clear bilat. *



> Abdo: Palpated?  Genito-urinary: anything abnormal?  Tampon in place?  Signs of trauma?



*She doesn't have any masses as far as I can tell in her abdomen. she does have a tampon in place. No signs of trauma.* 



> Can you move her limbs freely or are they stiff?
> What is her skin like (aside from mottled extremities) Good or poor turgor?  EtCO2?  SpO2? ECG findings aside from Sinus tach?  PR interval?  QT length?  QRS length? Morphology?



*She seems to be a bit stiff, she's warm and dry and has moderatly poor turgor, with some tenting noted. No end tidal. SpO2 is 100% on 15lpm O2 via the BVM. PR interval was 0.12 and the QT interval was normal. No ST elevation noted.*

*I'll fill you in on the conclusion of this case tomorrow... So far you're all on the right track*


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## blindsideflank (Jan 18, 2011)

tampon soaked in booze stuck in her butt, im opting to go for a digital here...jk

did fire say she was any different upon their arrival? specifically pallor?
did i miss why the sheet was wet?
this is mottling not purpura?
edema? anywhere?


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## Bieber (Jan 18, 2011)

Any signs of local infection either from the tongue piercing or elsewhere on the patient's body?  In the absence of these, I'm leaning towards NMS as well.  The timeframe of gradually worsening over just a few days, the antipsychotic medication history, the diaphoresis, the fever and the muscle rigidity all fit.

My treatment's going to be supportive, and I don't think a definitive diagnosis is going to be made till they can get labwork done at the hospital.  Support the airway, intubate if apneic, get some fluids on board to replenish her volume and consider vasopressors if that doesn't work, and take her in to the hospital.  I don't think this is a narcotic overdose, but we could try up to 2 mg of Narcan (prior to intubation) just in case.  Going to want to keep a very close eye on her vital signs and do some passive cooling in the back of the ambulance.

Any idea how long she's been on those medications and what their dosages are?


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## juxtin1987 (Jan 18, 2011)

Brain Abcess as a result of spread infection from tongue piercing. Explains Fever, Diaphoresis, Mydriasis, and depressed Respirations. Blood loss from Menstraution coupled with an ilplaced tongue ring's blood loss explains low BP.


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## 18G (Jan 18, 2011)

I'm really curious about this case.. let us know the outcome today!


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## NomadicMedic (Jan 18, 2011)

For those of you who guessed sepsis, you were correct. It turned out that this unfortunate patient was in severe septic shock.

My treatment for this patient was supportive and included RSI and intubation, two large bore IVs and 2000ml of NS prior to arriving at the hospital.

The patient was started on IV antibiotics while in the ED and transferred to the ICU where she died 2 days later following agressive antibiotics and dialysis.

Some interesting notes: 

This PT tested positive for Meth and cocaine. No opiates were found in her tox screen. (The benos found were from me, following the RSI). I did draw blood prior to the RSI and this was used for the baseline lab work.


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## Bieber (Jan 18, 2011)

What was the initial source of the infection?  The tongue ring?


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## NomadicMedic (Jan 18, 2011)

Sorry... there was more but I was called away.

The cause of the infection was undetermined, although she did have a UTI. 

After we got in the rig, prior to RSI, her pressure had dropped lower, to the mid 60's. At that point I thought of adding pressors, but knew that fluid was the important part of prehospital treatment for sepsis.

And the doc told me her infection wasn't caused by the tongue ring.

All in all, a sad case, but one I learned quite a bit from.


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## Aidey (Jan 18, 2011)

I can't find any decent statistics, but it wouldn't surprise me if tongue piercings actually had a lower infection rate than most other piercings. They heal really fast when compared to cartilage piercings (in any location) and belly button piercings. However, I also wouldn't be surprised if tongue piercings have a higher percentage of systemic infections because it is easy for bacteria to travel.


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## Blessed187 (Jan 19, 2011)

Could a UTI get bad enough to turn into this situation? I would think the UTI would turn into a kidney infection soon enough then the pain alone would send her to a doc or the ED... Do you think she would of had a chance if there were no street drugs in her system?

Very sad.


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## Smash (Jan 19, 2011)

Blessed187 said:


> Could a UTI get bad enough to turn into this situation? I would think the UTI would turn into a kidney infection soon enough then the pain alone would send her to a doc or the ED... Do you think she would of had a chance if there were no street drugs in her system?
> 
> Very sad.



UTI is the second most common cause of sepsis after chest infection.

n7lxi, was there any response to fluid challenge?  How much was given?


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## NomadicMedic (Jan 19, 2011)

I gave her 2000ml with only a small increase in pressure. I'm at work now, but I recall her last pressure with me was around 70/50.


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## Bieber (Jan 19, 2011)

Blessed187 said:


> Could a UTI get bad enough to turn into this situation? I would think the UTI would turn into a kidney infection soon enough then the pain alone would send her to a doc or the ED... Do you think she would of had a chance if there were no street drugs in her system?
> 
> Very sad.


Like Smash said, urosepsis is fairly common, especially in nursing homes.  The street drugs certainly didn't do her any favors, but it's impossible to say what the outcome would have been.  Sepsis is bad, in drug addicts or otherwise.


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## miranda (Jan 19, 2011)

*Maybe????*

Ok, so Ive only done ride alongs so far. I had a 19yr old male patient. O2 sat was 30. He was a drug overdose. 
Im kinda basing these two in the same category, but I would think...maybe. Narcan- High Flow O2, prevention for shock and code 3 to the hospital.


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## MediMike (Jan 19, 2011)

Interesting case, thanks for the headsup on the Neuroleptic Malignant deal, thats a new one to me.


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## Smash (Jan 19, 2011)

n7lxi said:


> I gave her 2000ml with only a small increase in pressure. I'm at work now, but I recall her last pressure with me was around 70/50.



Given her catastrophically bad perfusion and the lack of response to fluid (although 2000ml is a pretty small amount in this setting) was there a reason for not starting pressors?


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## NomadicMedic (Jan 19, 2011)

Smash said:


> Given her catastrophically bad perfusion and the lack of response to fluid (although 2000ml is a pretty small amount in this setting) was there a reason for not starting pressors?



I was very close to the hospital, less than 7 minutes. By the time I RSIed her and ran in the 2 bags, I was there. 

They waited on pressors in the ED, too. I asked the doc why, he said he wanted to try to improver her pressure and perfusion with crystalloid.


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## Atlas (Mar 7, 2011)

That was very interesting to read. A good many things to ponder about whilst heading to sleep


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## Farmer2DO (Mar 12, 2011)

I agree with the holding of pressors.  In order for them to work well, the tank needs to be full.  It sounds like you were behind the 8 ball before you even walked in the door.

In our system, RSI is only standing orders if three criteria are met:  1) GCS less than or equal to 8  2)  unable to maintain 90% or higher SPO2 with high flow oxygen and/or assisted ventilations  3) greater than 10 minute transport time.  If all 3 criteria are not met, then we must call and ask for permission.  For less than 10 minutes transport (which is almost always for me) it is almost always denied.  

As for the source of the sepsis, I believe the 4 most common sources are renal/urinary, respiratory, abdominal/peritoneal, and CNS.  I've heard the residents lectured that if they don't find the source in one of those 4 areas, go back and look, it is likely it was missed.

Smash is very wise.  Dr. Emanuel Rivers at Henry Ford is the source of much of our current theory on sepsis and EGDT.  

I also would not go with Narcan, since she is not an overt narcotic OD, and we are able to maintain her sats with assisted ventilations.  It sounds likely for her to be a polysubstance abuser, so removing the narcotic (even though it wasn't there) and allowing the coke and meth to have unchallenged sympathetic overdrive would not make your job any easier.


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## EMSrush (Mar 13, 2011)

Sad story, but good scenario to ponder...


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