# Unresponsive 32 year old female



## paccookie (Feb 27, 2008)

You are an ALS unit consisting of a new paramedic and an EMT-I.  You are called to an unresponsive 32 year old female.  Upon arrival to the scene, you find the patient lying prone on the floor, naked with a sheet covering her body up to her shoulders.  Patient has small cuts on her hands and fingers, which the family states are the result of hitting her hand on some broken glass on the floor when she fell out of bed.  You see the bed has been moved to the corner of the room, mattresses leaned up against the wall (presumably to assist in your access to the patient).  Patient appears to weigh approximately 350 lbs.  Fire dept is en route to assist, but is about 2 minutes away.  Patient has snoring respirations and is responsive to painful stimuli only.

Go.

Questions will be answered as asked.


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## Outbac1 (Feb 28, 2008)

OK I'll bite.
 What was she doing prior to falling out of bed onto the floor? What meds is she on and/or what may she have taken? What's her health history? (heart, lung, diabetic, kidney function, mental state).
 If she fell out of bed I'm not too worried about c-spine. So roll her over . How does she respond to pain stimulus? Wake up?  GCS? If not an OPA/NPA, vitals?
RR
HR
B/P
BGL
 Are the cuts on her hands small or something to worry about later?
Check on ALS availability, load her up (fire would be there by now), O2 and/or bag depending on her resp drive, and head for hosp.


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## paccookie (Feb 28, 2008)

What was she doing prior to falling out of bed onto the floor? 
Sleeping in the bed.  Family states she started snoring at around 4am and they thought it was a deep sleep.  EMS called at 2pm when family couldn't wake her up.

What meds is she on and/or what may she have taken? 
Lortab PRN

What's her health history? (heart, lung, diabetic, kidney function, mental state).
diabetic (controlled with diet), no other history per family

 If she fell out of bed I'm not too worried about c-spine. So roll her over . How does she respond to pain stimulus? 
groans and moves her arms

Wake up?  GCS? 
GCS initially 8

If not an OPA/NPA, vitals?
RR about 12, snoring
HR 110
B/P 140 palp (arm too large for cuff, no extra large cuff on truck)
BGL 144

Are the cuts on her hands small or something to worry about later?
They are small, superficial and there is dried blood on her hands.  No bleeding that you can see.

Check on ALS availability, load her up (fire would be there by now), O2 and/or bag depending on her resp drive, and head for hosp.

You ARE ALS - paramedic and EMT-I.  

You give her O2 @ 15L NRB.  Snoring stops, so you hold off on an adjunct for now.  RR up to approximately 20 on NRB.

She is still responsive only to painful stimuli.  As you try to talk to her, she will occassionally respond to her name, but does not speak.  

You have a drug box, IV supplies and other ALS tools at your disposal.  Anything else you want to do?


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## Outbac1 (Feb 28, 2008)

Why is she taking lortab? There is something missing in the Hx. How old is the script? Quanity left in bottle?  I forgot to ask about her pupils, pin point,dilated? 
 As an ACP,  IV of ns or saline lock, could give narcan 0.4mg IV to see if that has an effect. She may have O.D. on the lortab, the narcan won't hurt if she didn't. An O.D. of lortab may be starting to wear off if she O.D on it ten hrs ago. Hence starting to respond to her name. She is still a load, O2 and transport pt. Iv's and stuff enroute. 
 BTW what was the glass from that she cut herself on?


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## ccems644 (Feb 28, 2008)

What and when was her last oral intake? do a blood stick and see what her blood sugar is.


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## paccookie (Feb 28, 2008)

Why is she taking lortab? There is something missing in the Hx. How old is the script? Quanity left in bottle?  

Family says she takes Lortab for pain related to a shoulder injury.  No meds produced, no info on how old or how many are left.

I forgot to ask about her pupils, pin point,dilated? 

Pupils are 3 mm, equal and fixed.

As an ACP,  IV of ns or saline lock, could give narcan 0.4mg IV to see if that has an effect. She may have O.D. on the lortab, the narcan won't hurt if she didn't. An O.D. of lortab may be starting to wear off if she O.D on it ten hrs ago. Hence starting to respond to her name.  She is still a load, O2 and transport pt. Iv's and stuff enroute. 

IV established, NS running at wide open rate.  2 mg Narcan given per protocol.  

BTW what was the glass from that she cut herself on?

Glass was from a broken glass or lamp on the floor that she apparently hit her hand on when she fell, per the family.


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## paccookie (Feb 28, 2008)

What and when was her last oral intake? do a blood stick and see what her blood sugar is.

Last oral intake was dinner the previous evening.

BS was 144.


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## traumaangel26 (Feb 28, 2008)

Whats the cardiac rhythm?  What are her lung sounds? Are there any nuro deficits present?  Any other trauma present?  Does the scene add up to the story the family is telling you? Did she have a seizure?


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## paccookie (Feb 29, 2008)

Whats the cardiac rhythm?  
sinus tach @ 110, no ectopy

What are her lung sounds? 
lungs clear and equal bilaterally

Are there any nuro deficits present?  
no neuro deficits intially.  patient is decorticate after administration of Narcan.

Any other trauma present?  
no other trauma noted

Does the scene add up to the story the family is telling you? 
scene appears to add up to the family's story, although you feel that the bed being disassembled is strange.  You also feel it is strange that there is broken glass just lying on the floor (perhaps the family members are just slobs though?) and that no one bothered to check on the girl for so long.

Did she have a seizure?
no seizure activity witnessed by EMS or the family.


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## ccems644 (Feb 29, 2008)

What and when was her last oral intake? do a blood stick and see what her blood sugar is.

Last oral intake was dinner the previous evening.

BS was 144.


Does she have any allergies?
If so what is she allergic to?


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## skyemt (Feb 29, 2008)

is police on scene? what do they say?

pt exhibits signs and symptoms of severe brain injury, and hypoxia.

hands show signs of possible struggle.

the issue of foul play can not be discounted, as there are some strange circumstances, the glass, the bed.

with no signs of trauma, this patient seems to have deprived of oxygen for some time...


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## traumaangel26 (Feb 29, 2008)

With the decorticate posturing she has a brain stem injury.  I think the family hit the patient in the back of the head with the lamp and thats why there is glass all over the floor.


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## skyemt (Feb 29, 2008)

traumaangel26 said:


> With the decorticate posturing she has a brain stem injury.  I think the family hit the patient in the back of the head with the lamp and thats why there is glass all over the floor.



glad i could lead you to the brain injury idea...
however, as stated by the poster, there is no sign of trauma.


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## traumaangel26 (Feb 29, 2008)

The posturing lead me to the brain stem idea.  The pt is on 15 lpm via NRBM.  As for trauma, not all trauma is evident right away.  Contusions can take a while to show.  Somehow she got hit in the back of the head.  Why is the bed put up?


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## traumaangel26 (Feb 29, 2008)

After giving the pt narcan.  What is her pupil size after narcan?


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## skyemt (Feb 29, 2008)

i thought they could have tried to use a pillow over her face...

she grabbed the nearest object, the glass, to defend herself, smashing the glass and cutting her hands in the process.

i say, check the family for trauma... maybe one of them got hit by the glass! 

and one last thing...

is the rest of the bedding with the bed? do they reveal anything?


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## Outbac1 (Mar 1, 2008)

Interesting thoughts. What was the outcome?


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## Ridryder911 (Mar 2, 2008)

I have not read each post, but briefly disagree with some interpretations and treatment. 

Simplistic enough that it either has to be traumatic or cerebral bleed. Decorticate posturing is a lower response on the pons but not as dramatic as decerebrate posturing. As well, since the pupils are at 3mm and fixed ? Administering Narcan should not be considered as the "coma cocktail" has been outdated for several years. Lortab and other opioid derivatives would produce pinpoint type pupillary response not dilated and fixed. In regards to the posturing type response after Narcan, I truly doubt it was decorticate posturing. Rather I believe it was  due to improper administration and dosage of Narcan in a patient with history of analgesics. Again, a foolish treatment regime. 

In one of the responses I read where the GCS was 8 and the patient had "snoring respirations". Perform a quick detailed neuro assessment (brachial cephalic response, Babinski  reflexes, cornea reflex, uvula mid-line?, cold water tympanic response? ) and prepare the patient for RSI. Sorry, this patient exhibits the inability to maintain airway and intubation should be performed. Maintaining ICP (exhibition of decorticate posturing?) can also assist by sedating the patient and maintaining oxygenation. As well, ICP patients have a bad habit of projectile vomiting. Etiology at this time is really irrelevant at this time, (it would be nice) but realistically it will be assumed a closed head injury (CHI) no matter what (trauma or medically) induced. A CT will verify the true injury and assist in deduction of the cause.  

Not having a "large cuff" is not good enough answer not to get a blood pressure. It only comes from those that do not know how to assess patients. Take a forearm, calf, etc blood pressure. Use your brain.

If trauma was suspected, one should see a scalp laceration or hematoma within a few minutes. Scalp injuries are one of the fastest areas to swell and bleed due to the vast circulation. 

At this time all the focus should be on airway control and monitoring changes. Neuro changes would not be noted since RSI has occurred, but along with the usual continuation of ECG, EtCo2 (which would change in ICP as well) and changes in variation of pressure and heart rate (Beck's Triad). 

If one cannot RSI, then intubation should still be attempted by facilitation of medications (Versed, Valium) etc. Alike above a very detailed neuro examination prior to administration. Continuation of neuro changes and again vital sign changes. 

As many like to point out, maintain the ABC's. Due to the obvious signs of obesity, this patient has multiple causes of < LOC. Anything from HTN/head bleed to P.E. ... who knows?  

R/r 911


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## paccookie (Mar 2, 2008)

ccems644 said:


> What and when was her last oral intake? do a blood stick and see what her blood sugar is.
> 
> Last oral intake was dinner the previous evening.
> 
> ...




Allergy to penicillin.

(sorry - I'm on vacation and have very limited internet access until Tuesday night)


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## BruceD (Mar 2, 2008)

1) You said she is naked.  Why? Are there clothes nearby as if she was dressing?

2) What would I see if I flipped the mattresses off the wall and back down on the bed?  Blood? Signs of struggle/rape are there any marks on the wrist?

3) When was her shoulder surgery and how long did she lay in bed?

4) Did someone check under 'the sheet' to ensure the only blood was coming from the hands?

5) Any signs of abdominal discoloration?

6) Is she/could she be pregnant?

as for me, load'n'go


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## paccookie (Mar 5, 2008)

Simplistic enough that it either has to be traumatic or cerebral bleed. Decorticate posturing is a lower response on the pons but not as dramatic as decerebrate posturing. As well, since the pupils are at 3mm and fixed ? Administering Narcan should not be considered as the "coma cocktail" has been outdated for several years. Lortab and other opioid derivatives would produce pinpoint type pupillary response not dilated and fixed. In regards to the posturing type response after Narcan, I truly doubt it was decorticate posturing. Rather I believe it was due to improper administration and dosage of Narcan in a patient with history of analgesics. Again, a foolish treatment regime. 

>You are right that administering narcan was hasty and probably foolish.  However, we did not have much to go on at that point in time.  As I stated before, this was a new paramedic and a new EMT...neither of us has enough experience to know everything right off the bat.  I don't have a lot of experience with posturing, but this girl was definitely decorticate when we left the scene and when we arrived at the hospital.  The ER dr also made a comment regarding the posturing, so it wasn't imagined.

In one of the responses I read where the GCS was 8 and the patient had "snoring respirations". Perform a quick detailed neuro assessment (brachial cephalic response, Babinski reflexes, cornea reflex, uvula mid-line?, cold water tympanic response? ) and prepare the patient for RSI. Sorry, this patient exhibits the inability to maintain airway and intubation should be performed. Maintaining ICP (exhibition of decorticate posturing?) can also assist by sedating the patient and maintaining oxygenation. As well, ICP patients have a bad habit of projectile vomiting. Etiology at this time is really irrelevant at this time, (it would be nice) but realistically it will be assumed a closed head injury (CHI) no matter what (trauma or medically) induced. A CT will verify the true injury and assist in deduction of the cause. 

>We cannot do RSI, although I agree that it was definitely indicated in this patient.  She had an intact gag reflex and was just conscious enough to be outside of our parameters for intubation.  She was intubated in the ER not long after arrival.  CT showed a temporo-occipital bleed of unknown etiology.

Not having a "large cuff" is not good enough answer not to get a blood pressure. It only comes from those that do not know how to assess patients. Take a forearm, calf, etc blood pressure. Use your brain.

>The BP we had was obtained on her forearm.

If trauma was suspected, one should see a scalp laceration or hematoma within a few minutes. Scalp injuries are one of the fastest areas to swell and bleed due to the vast circulation. 

>No visible injuries to the head.

At this time all the focus should be on airway control and monitoring changes. Neuro changes would not be noted since RSI has occurred, but along with the usual continuation of ECG, EtCo2 (which would change in ICP as well) and changes in variation of pressure and heart rate (Beck's Triad). 

If one cannot RSI, then intubation should still be attempted by facilitation of medications (Versed, Valium) etc. Alike above a very detailed neuro examination prior to administration. Continuation of neuro changes and again vital sign changes. 

>Good ideas, but we have no protocols for that.  

As many like to point out, maintain the ABC's. Due to the obvious signs of obesity, this patient has multiple causes of < LOC. Anything from HTN/head bleed to P.E. ... who knows? 

>Will post the results when I get home from work.  I need to see what (if anything) happened to her while I was out of town.


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## Ridryder911 (Mar 5, 2008)

The Paramedic may consider "nasal intubation" next time; no RSI required. 

R/r 911


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## AJemt (Apr 7, 2008)

Ridryder911 said:


> The Paramedic may consider "nasal intubation" next time; no RSI required.
> 
> R/r 911



i thought nasal intubation was not indicated in a pt with a brain bleed? or is that just a traumatic head injury?   sorry, been a very long week with little to no sleep and the brain is a little fried....

and as far as the scenario goes...i'm bls but first things first, after quick assessment when you roll the pt over, use c-spine and roll her onto a lbb and immobilize her.  can't hurt anything if there's no trauma and if there is you won't get yelled at for not immobilizing, plus it makes it easier to move her, as well as if she becomes combative you don't have to worry about getting orders for restraints (per local protocols).  RX: o2 vitals monitor load and go re-assess iv check sugar enroute then call MC with report - treat anything you find in your assessment and confer with MC for orders.  Transport emergent rate (L&S) and get her to the hospital.


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## emt2paramedic (Aug 29, 2008)

I'm a 2nd year paramedic specialist student so I thought I would give this a try for practice.    When u first arrived as the paramedic I would had my basic held C-spine due to the fact the family said she family out of bed and she weighs so much. (350 lbs)  Cuts to the hand and hit head. While Family and I or if the Fire department is there now would roll her on her back checking the back as she is on her side. While I fix the snoring problem with a jaw thrust maneuver also check in the mouth for any blood or glass due to the cuts on the hand. Respirations were 12 and snoring, so not adequate to me so she needs to be bagged with a bagged valvle mask with 100 percent 02 Hopefully the fire department was there cause i would make them work, there usaully trained as EMT Basic or higher, so have one of the FF bagged her once every 5 to 6 seconds.  No need to cut off clothes she's nakes, disclose the body and see if your missing anything (DCAP-BTLS)  Airway is the most import thing, u said she was at a 8 with the GCS, so she needs to intubated, so partner holding inline, i drop a ET tube.  She can't even talk, she only moans and responds to pain.  Secure the ET and make sure it in the proper place and have to FF switch to once every 6 to 8 seconds.  Get the back board secured with help from fire deparment and place head blocks in place and secure and place to cot and secured and lift to ambulance.  Family usaully tells you what history whether its has to medical, allergies, or whatever.  Or while your working on patient, have a firefighter get some information, usually firefighters come in big groups.  Hook up to the heart monitor, try to start a IV, good luck,   heart rate was sinus tach, lungs were clear resper were 12, BP/140, so just keep Normal saline open.  Sugar level was 144.  Try to fine out if family knows what her sugar level is usally.  Diabetic diet, Pupils fine. Narcan i think u said didn't work.  Can't get a IV, start start a IO of Normal saline.  What was wrong with her, doctor will figure that out.


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