# Altered



## vf116 (Apr 17, 2016)

New Paramedic here.. Bear with me on this scenario..

Dispatched to a board and care for an unresponsive male.

Arrive to find a 77 year old male sitting semi-fowlers in bed with rapid respiratory rate and rapid radial pulse. His eyes are open, not tracking, he is moaning/grunting with every other respiration. Pt is not able to communicate only the grunting noises. Pt is for lack of a better word rigid and unable to follow simple commands. 

Per staff pt normally is able to communicate and is oriented to person and place, however is slow to respond. Last time pt seen acting normal is 20 minutes prior to EMS arrival. No complaints of pain or falls/trauma from pt prior to ALOC. 

I notice slight facial droop, but staff states this is normal for pt. No hx of stroke. 

BP:76/48 
PERRL
Resp: 30 clear lung sounds
Sat: 85% room air
Pulse: sinus tach 130
Skin: Pale, cool, dry
Blood glucose: 161mg/dL
12 Lead: Sinus Tach

BP auto-cycles 70/42 
Sat: 90% on 15lpm NRB

Hx: Dementia and Diabetes
NKDA
Meds: Namenda, Metformin, Omeprazole

Load him in the ambulance and I prepare to start an IV so I switch BP cuff to right arm and run it again. 188/160 ....(?)... Take the cuff off pt and disconnect it from monitor to make sure all air is out. Reconnect and run it again. 194/170. (Kicking myself right now for not feeling for radial pulse on right arm)

Partner and I miss several IV attempts. 4 minute ride to ER which is a level 3 trauma.

Get last set of vitals:
BP: on initial left arm 78/48
Resp: 26 
Sat: 95% on O2

Let Doc know about BP, calls for CT of head and chest..
BP at hospital is 70's/low 50's - bilaterally


Haven't been back to ER yet so I have no news.




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## Aprz (Apr 17, 2016)

The totally different blood pressures compared to both arms makes me think of some sort of dissecting aneurysm. I know you didn't have a lot of time, but it would've been nice if you could've confirmed if the blood pressure was correct on both arms doing a manual blood pressure. It would raise red flags to me if the blood pressures on both arms are *totally* different like what you had. I am personally OK with using the machine blood pressure without doing a manual if it makes sense and nothing conflicts (I actually do a manual every call still because it is considered good practice here and it is pretty much what I was taught to do / get into the habit of), but since there is something odd, I would've definitely confirmed it with a manual personally. Even with a short transport time (I work in a very urban/suburban area), I still feel like I have enough time to do a manual during transport.

Did you get a temperature? The tachycardia, tachypnea, and setting (skilled nursing facility) always makes me think of sepsis. I would be surprised if this all suddenly happen within the 20 minutes since he was last seen normal, but it is always possible that they are just saying they last saw him normal 20 minutes ago or just it finally clicked in their heads that something was wrong 20 minutes ago, lol. *shrugs* For our protocols, <96.8 degrees (since he was cold) would've been one more criteria to meet sepsis/SIRS if the patient is a suspected infection. Another nearby county uses <96.0 degrees. It is important to associate this with a suspected infection though...

Those are the two main things I am thinking of with this call.

Pretty basic, but I always think of AEIOUTIPS.

Alcohol: Doubt it
Arrhythmia: 130, sinus tachycardia
Epilepsy: Maybe? Doesn't seem like it. No history of seizures listed.
Environment: Too hot or cold? Doesn't seem like it either.
Insulin: Blood sugar was 161 mg/dL.
Electrolytes: You didn't mentioning any widening of the QRS complexes so not really thinking of anything like hyperkalemia. I haven't really heard of hyperkalemia causing altered mental status by itself, but causing something like an arrhythmia. Kind of hard to figure out other electrolyte problems in the field (eg hyponatremia from like an illicit drug or something), but I still like to think of something metabolic with altered mental status call for whatever reason.
Overdose: Did they give him any medication earlier (eg 20 minutes ago)? Maybe the wrong dose of it? Wrong medication? Like you said, he was rigid so maybe like dystonia or something? Possible, but doesn't really seem like it from what you wrote.
Oxygen: He is hypoxic if that SpO2 is correct. Is the hypoxia secondary to something else or is it causing his symptoms? You said his breath sounds were clear and equal, but he was grunting with breaths. Was any adjunct use (eg NPA) to open up his airway better? Was the pleth waves good? I know you mentioned no trauma, but did he have any recent surgeries? Along the lines of underdose, I don't see heparin on his list of medications. Does make me think of something like a pulmonary embolism, but I don't really consider this super likely still for some reason. (On the ECG, sinus tachycardia is the #1 ECG change you see in pulmonary embolism, but obviously lots of things cause pulmonary embolism).
Underdose: Doesn't seem like it either. I really usually think of this with psychosis, seizures, or diabetic calls.
Uremia: No mention of he does dialysis so I kind of doubt it. No signs of hyperkalemia on the ECG I assume.
Trauma: No known recent trauma. No obvious signs of trauma I assume.
Infection: Like I said, it is possible. He is tachycardic, tachypneic, and cold. He is also in a skilled nursing facility.
Psychosis: Doubt it.
Stroke: Possible due to the face being asymmetrical, but you said that the nurse said it was normal for him. If he wasn't following commands or talking, doesn't sound like could assess it further. Did they say if there was any reason he had facial asymmetry? Bell's Palsy? Any liver problems that could cause something like hepatic encephalopathy that could mimic stroke-like symptoms?
Shock: Definitely shocky with the tachycardia, tachnpnea, poor skin signs, and possibly low blood pressure. If no trauma, maybe a dissecting aortic aneurysm since you said the blood pressure wasn't equal and he is old.


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## zFrostyy (Apr 17, 2016)

Aprz said:


> The totally different blood pressures compared to both arms makes me think of some sort of dissecting aneurysm.



If it was an aneurysm that had a significant difference of BP like that pt had, wouldn't that indicate a serious active loss of blood, therefore pooling on visualization of back/posterior(given position found)?

Altered+ dat BP + cold skins indicates shock, also sinus tach. He's also 77 y/o at a board and care, I wouldn't be surprised if there's some kind of disorder/dysfunction that explains why he's not sweaty.


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## Aprz (Apr 17, 2016)

A dissecting aneurysm isn't a complete rupture. The patient would be bleeding into one of the layers of the artery or I've heard of bleeding into the pericardium too if the dissection is from the ascending aorta. This could even cause ST changes in a 12-lead looking like an MI because of the obstruction the blood flow causes. I'm not 100% certain on the pathophysiology of this, but I could imagine that the low blood pressure side could be caused by obstruction from a dissecting aneurysm while catecholamine response from pain, obstruction, hypoperfusion to one part of the body, etc. would cause the blood pressure to the rest of the body to increase causing two totally different blood pressures without a lot of blood loss. Just an edu-ma-cated guess. *shrugs*

Doesn't sound like the original poster did a manual blood pressure to confirm that the blood pressure was correct. Like I said, if something was conflicting like totally crazy different blood pressures on both arms, I would have confirmed it manually.

I am not saying a manual > machine blood pressure, but I would use multiple methods to confirm it is correct when it seem off. This would definitely be one of those causes. Thankfully and unfortunately for the original poster, he was 4 minutes away from the hospital so I do understand that he sound what was like a critical patient and a short transport time. Didn't get the IV, which I would put over getting a manual blood pressure, so it is understandable why he didn't do a manual.

For the record, I am a fake paramedic... I might be totally missing something or totally off.


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## vf116 (Apr 18, 2016)

Well, as previously stated.. New medic so bear with me...  

I learned two things on this call:

1. Severe sepsis can/will have cool skin. 
2. Don't trust / rely on monitors BP. Should have taken manual BP on right. 

It threw me off cause I got two readings within 10 points. 

Also 20 minutes last seen normal is I'd assume false. They did say pt was able to take meds without assistance that AM, seemed reasonable at the time. 


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## zFrostyy (Apr 18, 2016)

vf116 said:


> Well, as previously stated.. New medic so bear with me...
> 
> I learned two things on this call:
> 
> ...




Severe sepsis? Usually when sepsis becomes very severe it presents visually in the affected area, I didn't see that in your assessment, neither for recent fevers. Where was he septic?


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## Aprz (Apr 18, 2016)

I assumed the patient was cold because he said


vf116 said:


> Skin: Pale, cool, dry


So was the final diagnosis sepsis?


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## vf116 (Apr 19, 2016)

Aprz said:


> I assumed the patient was cold because he said
> 
> So was the final diagnosis sepsis?



Yea, admitted. In CCU last I heard.


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## SpecialK (Apr 19, 2016)

You did not mention either a) taking a temperature nor b) examining the pt for, amongst other things, a site of infection so I presume it did not happen

If we put this patient's vital signs together the diagnosis is clearly "shock".  Given the primary task of ambulance personnel is now complete, i.e. make a diagnosis, we now have to decide if the patient needs any treatment from us, well, yes, but, we need to decide what kind of treatment and to do that we must decide what kind of shock the patient has.  To do this we need to look for clues.

For a patient to have septic shock they need a source of infection, this can be often found if the patient is appropriately exposed and examined, e.g. a big pus filled abscess on their bum or cellulitis which is red and nasty looking.  It will not alway be obvious such as if they have urosepsis (the most common kind of sepsis) but there should be _something _in the history which will lead you to it, e.g. the patient, family or rest home staff will tell you "grandpa has been complaining it hurts when he pees and has been up 5 x day to go to the loo" or "when we dipped Mr Smiths urine it was full or leukocytes and ammonia".

Temperature is helpful in building the "big picture"; it is not a "be all and end-all" rule in/rule out vital sign but as you note, a patient with sepsis/septic shock can be hot or cold and I've seen both.  They are cold because they have low cardiac output.

Personally I'd give him 2 g ceftriaxone IV, sltart fluid loading (initially one litre as a bolus) and take him to hospital.  It is worth noting the standard antibiotic carried pre-hospital is ceftriaxone (or in the UK it is benzylpenicillin) however ceftriaxone is not always the best agent, particularly in urosepsis.  It is very effective in meningococcal septicaemia however, for which it was originally introduced pre-hospital.  I hear gentamycin is the better choice as a second agent.  Thoughts?


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## zzyzx (Apr 21, 2016)

I can't account for why you would have two such wildly different BP's. Obviously my first thought is that one set was wrong. But who knows.
I don't believe that a thoracic aortic dissection should cause such a wide difference in BP's. Anyhow, most such patients will have equal BP's (it depends on the type of dissection).
In sepsis, the pt can have a labile BP's, meaning that you might get a BP of 100/60, and then a few minutes later you get 80/50. But again, you would not see such a wide difference as what you had.


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