# C/T BP problems



## Aussie_Medic_Girl (Aug 12, 2012)

Ok guys bear with me, this is my first ever scenario posting so i'll do my best to make it flow! 

You are a double ACP (Aus standards) crew so roughly EMT-I. You are called code 2 (no L & S) to a 50YOF c/o BP Problems-your MDT states that the pt's husband thinks the machine may be broken as it is reading really low and he'd like someone to come and check. Enroute you are given additional information that pt is approx. 10 months post heart transplant and as a result are upgraded to L & S. 

O/A Pt's husband apologises for "dragging you out" but he couldn't get pt to walk to car. Husband states he thinks there machine is broken as it's reading 85/40. Pt is lying semi recumbent in bed, pale, diaphoretic, looks unwell. Pt describes 3/7 hx of feeling generally unwell-lethargic, weak, chills.

Initial VSS
*GCS* 15
*BP* 80/40
*HR* 120
*ECG* Sinus Tach
*Temp* 36.4
*BSL* 5.7
*Lungs* clear and equal

Pt Hx
Heart transplant 10/12 ago as a result of massive MI. HTN. Pt is on meds for HTN and also anti-rejection drugs.

NKA

Alright guys go for your life! Any other questions shoot away


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## Melclin (Aug 13, 2012)

Aussie_Medic_Girl said:


> Ok guys bear with me, this is my first ever scenario posting so i'll do my best to make it flow!
> 
> You are a double ACP (Aus standards) crew so roughly EMT-I. You are called code 2 (no L & S) to a 50YOF c/o BP Problems-your MDT states that the pt's husband thinks the machine may be broken as it is reading really low and he'd like someone to come and check. Enroute you are given additional information that pt is approx. 10 months post heart transplant and as a result are upgraded to L & S.
> 
> ...




Immunosuppressed pt, recent hx of feeling unwell, hypotensive and tachycardic. I'd be thinking sepsis or rejection.  

More info: resp rate, further info about the nature of the illness trying to identify a source infection and a better picture of sepsis before I loaded a pt with a potentially failing heart up with fluid. Orthopnea? JVD? Pretibial oedema? Exercise tollerance? 

With the information I have, I'd be thinking fluid (as long as acute heart failure type signs/hx weren't present), ICP backup, transport to the hospital responsible for the transplant if possible.


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## OzAmbo (Aug 13, 2012)

what he said + chest auscultation...


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## Aussie_Medic_Girl (Aug 13, 2012)

RR18
Nil increased effort at rest, mildly increased effort after exertion (ie. couple of steps to stretcher <no other way to get her out>). Regular respiratory rhythm. As per above post lung sounds were clear all fields. 

Describes her grandchildren as having had "colds" when they visited 1/52 ago. States she's had a mild dry cough, weakness, general malaise, chills.

Normally able to exercise in moderation (eg. able to go walking, etc). 

Nil JVD, orthopnea or oedema. 

Nearest hospital just happens to be the transplant hospital! approx. 30 min tx time. ICP can meet you enroute (20 mins in).


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## usalsfyre (Aug 13, 2012)

On the surface it looks like sepsis, start fluid resus and broad spectrums if you've got them.


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## shiroun (Aug 13, 2012)

usalsfyre said:


> On the surface it looks like sepsis, start fluid resus and broad spectrums if you've got them.



x3 (?) on sepsis. Might be a problem with the heart transplant though.


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## jwk (Aug 13, 2012)

usalsfyre said:


> On the surface it looks like sepsis, start fluid resus and broad spectrums if you've got them.



Based on what?  Most septic patients aren't afebrile.

And even if I had them available, I wouldn't try to treat an immunocompromised patient such as this.


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## FLdoc2011 (Aug 13, 2012)

jwk said:


> Based on what?  Most septic patients aren't afebrile.
> 
> And even if I had them available, I wouldn't try to treat an immunocompromised patient such as this.



Remember SIRS criteria... can also have hypothermia.   And if immunosuppressed may not be able to mount a good response and possibly no fever. 

Regardless this person needs to go back to transplant center, not much prehospital besides supportive care and possibly fluids depending on clinical exam and vitals.


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## VFlutter (Aug 13, 2012)

Did you happen to see 2 sets of P waves with different morphologies on the EKG? May be difficult to see with that HR. Transplant patients usually have some interesting rhythms. 

Also they cut the vagus nerve during transplant therefore after surgery many patients will be tachycardic due to loss of vagal tone. So that HR could be her normal


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## OzAmbo (Aug 13, 2012)

FLdoc2011 said:


> Remember SIRS criteria... can also have hypothermia.   And if immunosuppressed may not be able to mount a good response and possibly no fever.
> 
> Regardless this person needs to go back to transplant center, not much prehospital besides supportive care and possibly fluids depending on clinical exam and vitals.



The OP doesn't happen to have a white cell count or Lactate by any chance??


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## Aussie_Medic_Girl (Aug 14, 2012)

OzAmbo said:


> The OP doesn't happen to have a white cell count or Lactate by any chance??



Sorry but don't have either of those. 

Chase...don't recall seeing any ECG changes but will keep it in mind for future transplant pt's. 

I'll let conversation carry on till tomorrow then i'll post dx.


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## the_negro_puppy (Aug 14, 2012)

Difficult to say, guessing you ran them to the P.A? 

Any nausea, vomiting or pain?

I think you'd definitely have to rule out Sepsis on this one.

But I think you also need to consider some sort of cardiac failure or dysfunction maybe?

I do recall reading that when a heart is transplanted the vagus nerve is severed and the heart usually beats at a much faster rate as a result.?

I'd be very careful in treating this one. If 12 lead ECG appeared ok w/chest clear and nil pedal oedema etc i'd consider starting fluids enroute.

What has her oral intake like? her mucus membranes? Is she dehydrated?


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## Aussie_Medic_Girl (Aug 14, 2012)

Prince Charles actually . Nil nausea or vomiting. Skin turgor right around 2 sec, mucous membranes normal. The call was around 10am and she'd had a glass of water or two since waking. 

Pain wise she initially denied pain, however, once we moved her to the stretcher and got her in the back of the truck she began c/o 8/10 sharp thoracic back pain radiating through to the front of her torso. Nil palpable mass. Pt thought it may be because she was lying supine.


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## Melclin (Aug 14, 2012)

Aussie_Medic_Girl said:


> once we moved her to the stretcher and got her in the back of the truck she began c/o 8/10 sharp thoracic back pain radiating through to the front of her torso.



Oh dear. Is this normal for her when she lays supine? Back or muscular problems in the hx? I figure probably not... 

Radial pulses equal in timing and intensity? Bilat BP? Dizzy on standing?

Thoracic back pain radiating forwards makes the hairs on the back of my neck stand up.


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## Aussie_Medic_Girl (Aug 15, 2012)

Melclin said:


> Oh dear. Is this normal for her when she lays supine? Back or muscular problems in the hx? I figure probably not...
> 
> Radial pulses equal in timing and intensity? Bilat BP? Dizzy on standing?
> 
> Thoracic back pain radiating forwards makes the hairs on the back of my neck stand up.



No hx of back problems but we had her positioned supine with legs elevated. 

We did bilateral BP on scene (I always do if BP is abnormally low or high)-bilaterally equal BP and pulses. 

The pain description made my poor partner's neck hairs stand up too.


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## Aussie_Medic_Girl (Aug 15, 2012)

OK all...final dx was SEPSIS! I know I know not such a shock for some of you. I personally thought sepsis on scene but was never 100% convinced. I had never read/realised/been told that pt's on immunosuppressants may mask fevers (but it makes sence when you think about it). We gave 250mL bolus of NS, tx L & S, met up with ICP enroute who was also slightly baffled and held off on further fluids to due to pain description (which we ended up controlling with Methoxyflurane). Not sure final result.


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## usalsfyre (Aug 15, 2012)

jwk said:


> Based on what?  Most septic patients aren't afebrile.
> 
> And even if I had them available, I wouldn't try to treat an immunocompromised patient such as this.



In my current position I see a lot of sepsis. A LOT. I've seem them febrile, afebrile, hypothermic, hypotensive, hypertensive...they come in lots of forms. The common thread I've seen is tachycardia and hx of exposure to illness, especially in the immunocomprimised patient.


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## downunderwunda (Aug 17, 2012)

I am curious to those who wanted fluids running in a pt with this sort of cardiac history as to the reasoning behind it, as stated transplant patioens get funky rhythms, the patient was afebrile, hypotensive yes, but really not dangerously so. with the limited resources provided pre-hospital, if this was a cardiac issue, wouldnt overloading with fluids be detrimental to the patient? lets take out the fact we hae been told it was sepsis. 

Personally, i would be commensing fluids, small, measured doses, to maintain a good systolic BP above 90 to gaurentee perfusion to organs, but not significantly raising it. 

This was also an extended transport situation with Intensive Care Paramedics a fair way off. it5 is easier to increase the amount of fluids, you cant take it away once given.


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## VFlutter (Aug 18, 2012)

downunderwunda said:


> I am curious to those who wanted fluids running in a pt with this sort of cardiac history as to the reasoning behind it, as stated transplant patioens get funky rhythms, the patient was afebrile, hypotensive yes, but really not dangerously so. with the limited resources provided pre-hospital, if this was a cardiac issue, wouldnt overloading with fluids be detrimental to the patient? lets take out the fact we hae been told it was sepsis.
> 
> Personally, i would be commensing fluids, small, measured doses, to maintain a good systolic BP above 90 to gaurentee perfusion to organs, but not significantly raising it.
> 
> This was also an extended transport situation with Intensive Care Paramedics a fair way off. it5 is easier to increase the amount of fluids, you cant take it away once given.



If only we had PA/Swan lines in EMS, they are very helpful in these situations trying to differentiate between various shock states. A Lactate level would also help


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## downunderwunda (Aug 19, 2012)

ChaseZ33 said:


> If only we had PA/Swan lines in EMS, they are very helpful in these situations trying to differentiate between various shock states. A Lactate level would also help



However we don't have these so my question remains…


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## OzAmbo (Aug 20, 2012)

downunderwunda said:


> I am curious to those who wanted fluids running in a pt with this sort of cardiac history as to the reasoning behind it, as stated transplant patioens get funky rhythms, the patient was afebrile, hypotensive yes, but really not dangerously so. with the limited resources provided pre-hospital, if this was a cardiac issue, wouldnt overloading with fluids be detrimental to the patient? lets take out the fact we hae been told it was sepsis.



Fluid loading would be detrimental but bearing in mind im sure they didn't transplant a diseased heart with dialated or hypertrophic cardiomyopathy or advanced IHD so your biggest causes of failure are already out of the picture, and given the OP it doesn't really cross me as an MI

The other thought is that this is obsructive shock from PE, pericardial effusion/tamponade/pericarditis in which case she is preload dependent and not giving her fluid could be bad ju ju - given her atypical pain i wonder if there is an element of this

If it is sepsis (well, septic shock at the moment) even a B/P of 90 if she is perfused ok still gives her a mortality approaching 20% as she is hypotensive.

My answer is, given the OP failure is well down my differential dx, and not fluid loading the other possibilities carries far more benefit than risk IMO.


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