# Dizziness while driving



## DesertMedic66 (Sep 8, 2019)

You are called out to a 30-year-old male who pulled over on the side of the road because he became extremely dizzy. Patient is alert but altered, person/place. The car is well kept and there is no damage to it. Patient is approx. 6’ and weighs 90kg. Patient is very pale and is sweating profusely.
You start questioning the patient and he denies any medical history, medications, and allergies. He is now not able to provide you with a specific complaint and states he just feels horrible. As your partner is obtaining vital signs the patient now becomes responsive to verbal stimuli only.
Vitals come back:
B/P: 82/40
HR: 170 sinus tach
RR: 40
Lungs: clear in all fields
Pupils: PERRL 3mm
During the vital check the patient also has several episodes of vomit with no obvious traces of blood or “coffee grounds”.

You have a local rural hospital with 1 doctor, 1 nurse, and no specialties approx. 20 minutes away by ground. Your closest facility with all services is 90 minutes away. HEMS is 15 minutes away.

You are an ALS ground ambulance with a BLS fire department. You are limited in your skills: intubation/king (no RSI/DSI), standard code medications, versed, fentanyl, ketamine (pain only), push dose epi, no pressor infusions, 12-lead EKG, etc.

What do you want to assess? Treatments? Transport decision? Dx for the patient?


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## NomadicMedic (Sep 8, 2019)

Let's see a 12 lead first thing. 

Sounds like an MI. Goes by HEMS if it is.


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## StCEMT (Sep 8, 2019)

12 lead first, I'll decide from there.


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## VFlutter (Sep 8, 2019)

Get them on the monitor. Assuming it is VT then MI is high on the list. If not VT, MI tend not to be tachycardic so potentially other Dx are primary arrhythmia, PE, Electrolytes, etc. Patient likely needs to be cardioverted, if not AF, and evaluated at a Tertiary care center. HEMS seems appropriate.


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## DesertMedic66 (Sep 8, 2019)

Here is the initial 12-lead. By the time the 12-lead is recorded the patients HR has slowed down to the 100-120 range with weak corresponding radial pulses. No other changes in patient condition at this time.


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## VentMonkey (Sep 8, 2019)

VFlutter said:


> Get them on the monitor. Assuming it is VT then MI is high on the list. If not VT, MI tend not to be tachycardic so potentially other Dx are primary arrhythmia, PE, Electrolytes, etc. Patient likely needs to be cardioverted, if not AF, and evaluated at a Tertiary care center. HEMS seems appropriate.


//Inserts Shanter impression// 

Perhaps..it...was....(dun duh duuuuun) V Flutter.


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## CALEMT (Sep 9, 2019)

I never read your scenario but I know it’s 100% Lupus.


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## DesertMedic66 (Sep 9, 2019)

CALEMT said:


> I never read your scenario but I know it’s 100% Lupus.


/thread


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## GMCmedic (Sep 9, 2019)

CALEMT said:


> I never read your scenario but I know it’s 100% Lupus.


Wrong. It's Sarcoidosis.


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## DrParasite (Sep 9, 2019)

any change to the patient's condition is you lay him down?  I'm assuming much of his symptoms were while he was sitting upright in the car.

other than the obvious answer of lupus, it sounds like HEMS would be the appropriate call, based on his presentation. dude is sick, and needs to go see a doctor.


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## DesertMedic66 (Sep 9, 2019)

DrParasite said:


> any change to the patient's condition is you lay him down?  I'm assuming much of his symptoms were while he was sitting upright in the car.
> 
> other than the obvious answer of lupus, it sounds like HEMS would be the appropriate call, based on his presentation. dude is sick, and needs to go see a doctor.


No changes as patient is moved into a lateral position due to vomiting.


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## E tank (Sep 9, 2019)

No one is going to run in some fluid?


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## MonkeyArrow (Sep 9, 2019)

12 lead: tachycardia at ~110, not very convinced this is Afib RVR as rhythm strip appears regular enough, especially in the last 3/4 of the strip. Suspect acute MI due to elevation in v1 and v2, reciprocal depression inferiorly, and hyper acute T waves globally, although TCA overdose and hyperkalemia are considered.  

Request HEMS. Needs cardiac critical care/cath lab emergently.

Fluids and push-dose epi fairly aggressively to maintain MAP > 65. If patient is refractory to fluids/epi, I'd consider an amp of empiric bicarb and calcium.


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## StCEMT (Sep 9, 2019)

Definitely get HEMS heading this way for the more capable facility.

V1-V2 have STE so STEMI is up the list.

Hyperkalemia is also high up and what I'll start treating first. He has no visible P waves, peaked T waves, and a widened QRS. I wouldn't typically expect any form of renal failure, but I can't say that he doesn't have some unknown cause of acute renal failure either.

TX: IV (x2 eventually). Fluid boluses as needed since he has lost volume.  CaCl/Bicarb for treatment of Hyperkalemia. Pressors as needed if no improvement with fluids. 

If the treatment of K works and he returns to normal, continue down the treatment path for that as needed and reassess.

If I get no joy and switch to the STEMI treatment plan. Fluids and pressors for now until i can come reassess and see improvement. Can't give ASA with his mental status. I would hold off on rate control meds with his BP for now. No nitro. Rural EMS is way outside my area of familiarity, but it sounds like a rendezvous with HEMS at the small facility where they can start Heparin and potentially have a wider range of pressor support would be worth considering while you have to wait? I don't know if that's a commonly practiced thing, city EMS is all I've known.


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## E tank (Sep 9, 2019)

The guy is 30 years old with no history...that we're able to discern. I'd stick with fluid and not do anything to drive his heart rate. Slow him down, get a better EKG and look for something weird like a delta wave. Not so sure I'd call for a rotor just yet.


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## DesertMedic66 (Sep 9, 2019)

Patient is given 2 large bore IVs by EMS and transported to the rural hospital for further evaluation. Hospital gives the patient a total of 7,000mL of NS. With only an improvement upon patients BP. HEMS requested.

Upon landing patient is laying in the left lateral position. Normal skin signs. Patient is able to pull away from painful stimuli.

Vitals:
BP: 150/90
HR: 100 sinus tach
RR: 40
SpO2: 90% on 15lpm
Lungs: clear upper with rales in the lower
Pupils: PERRL

Rural ED does have iSTAT.

Chem 9
Na: 120
Cl: 82
K+: 7.9
CO2: 5
Creat: 2.3
Ca: 8.8
Glucose: 1250
Mg: 3.0

CBC
WBC: 22.14
RBC: 4.18
Hgb: 13.5
Hct: 48.2
Plt: 379

AST: 109
T Bil: 1.3
ALT: 29
Alb: 4.4

Gases:
pH: 6.72
PCO2: 30.2
HCO3: 4

Lactate: 8.19
Troponins: <0.04


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## StCEMT (Sep 9, 2019)

E tank said:


> The guy is 30 years old with no history...that we're able to discern. I'd stick with fluid and not do anything to drive his heart rate. Slow him down, get a better EKG and look for something weird like a delta wave. Not so sure I'd call for a rotor just yet.


I frequently get people at their day to day who can't accurately tell me their history, meds, or anything else. Someone with acute AMS I'm gonna take anything they say with a grain of salt.


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## Tigger (Sep 9, 2019)

No early BGL by the looks of it, which might have illuminated what was going on a little bit. This guy strikes me as an undiagnosed diabetic so there goes the history part. Tachypneic, altered, vomiting, and generally crappy look.

Diffusely pointed t-waves with a wide QRS along profound hyperglycemia should set off the bells for hyperK. 1g of Calcium q10, 1Meq/kg of BiCarb and continuous albuterol neb (start with 10mg) are in order. Fluid boluses as well.  

I went back and read the labs after...woof.


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## E tank (Sep 9, 2019)

DesertMedic66 said:


> Patient is given 2 large bore IVs by EMS and transported to the rural hospital for further evaluation. Hospital gives the patient a total of 7,000mL of NS. With only an improvement upon patients BP. HEMS requested.
> 
> Upon landing patient is laying in the left lateral position. Normal skin signs. Patient is able to pull away from painful stimuli.
> 
> ...


7 liters of NS?   Looks like the iSTAT was before that...be interested to know what the lytes and abg were after that NaCl load.... Anyway, it's clear what the problem is...anyway...pre-hospital management is...fluid. and a finger stick BG.


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## MonkeyArrow (Sep 9, 2019)

I'm now thinking DKA (probably caused by underlying infection) that is causing hyperkalemia. If calcium and bicarb haven't been given yet, lets do so. Let's give him a lot of insulin and avoid intubating if at all possible. Physiologically a nightmare tube. Probably now has pulmonary edema from the 7 L of crystalloids (which is also not helping his acidosis). If I was in hospital with appropriate support staff, would really want to try BiPAP, despite the AMS, to try to support ventilations and avoid further desaturation which would necessitate a tube. 

However, tough to tell if we can hold off on intubating this patient. Decreasing mentation plus (increasing) hypoxia is not great. If the clinical decision is made to intubate, premeditate with a couple of amps of bicarb couple of minutes prior to intubation attempt. Optimize for first pass success (good patient positioning, most experienced operator, VL +/- bougie or stylet, etc.). Upon passing the tube, very high RR and tidal volume (10 mL/kg) to try to prevent further acidosis and cardiopulmonary collapse.


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## DesertMedic66 (Sep 9, 2019)

E tank said:


> 7 liters of NS?   Looks like the iSTAT was before that...be interested to know what the lytes and abg were after that NaCl load.... Anyway, it's clear what the problem is...anyway...pre-hospital management is...fluid. and a finger stick BG.


The time stamp on the iSTAT was approx 15 minutes prior to landing. So I would imagine a decent amount of the NS was already infused by that time. 

With the rales that are starting to develop and the suboptimal SpO2 should we keep going to fluids at this point?


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## E tank (Sep 9, 2019)

DesertMedic66 said:


> The time stamp on the iSTAT was approx 15 minutes prior to landing. So I would imagine a decent amount of the NS was already infused by that time.
> 
> With the rales that are starting to develop and the suboptimal SpO2 should we keep going to fluids at this point?



Something fishy about that. A hct of 48 after almost 7 L of NS? The sodium and chloride don't make sense either. There should be a significant dilutional effect on on those results that doesn't seem to be there.  Have the receiving hospital labs?


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## Tigger (Sep 9, 2019)

E tank said:


> 7 liters of NS?   Looks like the iSTAT was before that...be interested to know what the lytes and abg were after that NaCl load.... Anyway, it's clear what the problem is...anyway...pre-hospital management is...fluid. and a finger stick BG.


I think I would want to do something about that QRS width combined with his altered mentation, especially if this is an extend transport time.


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## StCEMT (Sep 9, 2019)

Did he have any improvement in mental status while there to be able to tolerate BiPAP? Not someone I particularly want to intubate yet with that SpO2 and pH. If so, BiPAP of 10/5 to start. Still want an ETT, but not before some prep work in this area. I'm confident in my intubation ability, but I know those numbers are not something I want to trifle with or get wrong.

If the ekg is the same, Calcium Gluconate 2g, Bicarb 50mEq, and Albuterol 10mg for the K. I don't like the ekg one bit.

I'd possibly go with the same treatments we do for CHF as well just to move fluid and optimize oxygenation before any intubation. Nitro drip short term to try and create some space for the fluid and Lasix to offload fluid.

Insulin drip at 9U/hr. Once labs start shifting, eventually adding a Potassium drip as well. As high as it is now though, I don't see a need for it yet. Monitor BGL to make sure it isn't dropping too quickly.

RSI plan would be VL with a bougie and backup airway ready as needed. Hopefully everything else would have provided  more ideal intubating conditions. Etomidate and Roc 30/100. NC running at 15L during the pre-intubation and intubation phases.

Vent settings. AC/VC. Formula I have for minute ventilation in a patient like this says 21L. 8cc/kg tidal volume at a rate of 30 would give this. Reassess labs and EtCO2 to ensure settings are effective.


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## DesertMedic66 (Sep 9, 2019)

MonkeyArrow said:


> I'm now thinking DKA (probably caused by underlying infection) that is causing hyperkalemia. If calcium and bicarb haven't been given yet, lets do so. Let's give him a lot of insulin and avoid intubating if at all possible. Physiologically a nightmare tube. Probably now has pulmonary edema from the 7 L of crystalloids (which is also not helping his acidosis). If I was in hospital with appropriate support staff, would really want to try BiPAP, despite the AMS, to try to support ventilations and avoid further desaturation which would necessitate a tube.
> 
> However, tough to tell if we can hold off on intubating this patient. Decreasing mentation plus (increasing) hypoxia is not great. If the clinical decision is made to intubate, premeditate with a couple of amps of bicarb couple of minutes prior to intubation attempt. Optimize for first pass success (good patient positioning, most experienced operator, VL +/- bougie or stylet, etc.). Upon passing the tube, very high RR and tidal volume (10 mL/kg) to try to prevent further acidosis and cardiopulmonary collapse.


This was along our lines of thinking also. We went with a total of 2,000mg calcium chloride, 100mEq bicarb, bolus of 9U insulin followed by infusion at 0.1u/kg/hr. 

Due to how out of it he was and that he had several episodes of vomiting we felt intubating him was the better option. We were able to assist his ventilations with a BMV+PEEP and got his sats up to 96%. We went with with a standard 2mg/kg ketamine and 1mg/kg Roc. Intubation was a straight forward DL attempt with the C-Mac and bougie and passed on the first attempt. For vent settings we went with a Vt of 8mL/kg (630mL) and a rate of 30 for a Ve of 18.9L for our initial settings. We then ended up increasing the RR to maintain an EtCO2 in the 20mmHg range. We ended up having to bump the rate up to 36 for him to maintain an EtCO2 in the 20s. 

Our initial BGL check just read "HI" on our meter. The hospital does not want to use anymore iSTAT cartridges so we are SOL with any updated labs.


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## DesertMedic66 (Sep 9, 2019)

E tank said:


> Something fishy about that. A hct of 48 after almost 7 L of NS? The sodium and chloride don't make sense either. There should be a significant dilutional effect on on those results that doesn't seem to be there.  Have the receiving hospital labs?


The time stamp on the iSTAT print out was dated about 15 minutes prior to landing but with this specific hospital, who knows when they actually drew the sample. We are still attempting to do a follow up at the receiving but the PLN, Prehospital Liaison Nurse, is saying HIPAA laws are not letting them.....


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## GMCmedic (Sep 9, 2019)

DesertMedic66 said:


> The time stamp on the iSTAT print out was dated about 15 minutes prior to landing but with this specific hospital, who knows when they actually drew the sample. We are still attempting to do a follow up at the receiving but the PLN, Prehospital Liaison Nurse, is saying HIPAA laws are not letting them.....


With that pH, might check the obits.


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## E tank (Sep 10, 2019)

Tigger said:


> I think I would want to do something about that QRS width combined with his altered mentation, especially if this is an extend transport time.


If you had iStat ability in the field, absolutely. I suppose you could intuit dka from a finger stick and physical exam and treat accordingly...


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## E tank (Sep 10, 2019)

GMCmedic said:


> With that pH, might check the obits.


eh...he's 30....probably made his tee time the next weekend....


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## E tank (Sep 10, 2019)

DesertMedic66 said:


> This was along our lines of thinking also. We went with a total of 2,000mg calcium chloride, 100mEq bicarb, bolus of 9U insulin followed by infusion at 0.1u/kg/hr.
> 
> Due to how out of it he was and that he had several episodes of vomiting we felt intubating him was the better option. We were able to assist his ventilations with a BMV+PEEP and got his sats up to 96%. We went with with a standard 2mg/kg ketamine and 1mg/kg Roc. Intubation was a straight forward DL attempt with the C-Mac and bougie and passed on the first attempt. For vent settings we went with a Vt of 8mL/kg (630mL) and a rate of 30 for a Ve of 18.9L for our initial settings. We then ended up increasing the RR to maintain an EtCO2 in the 20mmHg range. We ended up having to bump the rate up to 36 for him to maintain an EtCO2 in the 20s.
> 
> Our initial BGL check just read "HI" on our meter. The hospital does not want to use anymore iSTAT cartridges so we are SOL with any updated labs.


No MM QB here so don't take it as such...but why the etCO2 so low? That a protocol or something? It's a metabolic acidosis.


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## DesertMedic66 (Sep 10, 2019)

E tank said:


> No MM QB here so don't take it as such...but why the etCO2 so low? That a protocol or something? It's a metabolic acidosis.


For us when we have a patient in metabolic acidosis we either attempt to match their pre-RSI EtCO2 levels or if we have blood gasses we will try to match the EtCO2 with the PCO2.

The thinking behind this is that if we adjust the patient to a normal EtCO2 we may cause the patient to become more acidotic. We are trying to compensate as much as we can for the metabolic acidosis by causing a respiratory alkalosis.


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## Tigger (Sep 10, 2019)

E tank said:


> If you had iStat ability in the field, absolutely. I suppose you could intuit dka from a finger stick and physical exam and treat accordingly...


That EKG is almost pathognomonic for HyperK to me. That plus his symptoms (and even without the BGL), should be concerning enough to treat.


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## E tank (Sep 10, 2019)

DesertMedic66 said:


> For us when we have a patient in metabolic acidosis we either attempt to match their pre-RSI EtCO2 levels or if we have blood gasses we will try to match the EtCO2 with the PCO2.
> 
> The thinking behind this is that if we adjust the patient to a normal EtCO2 we may cause the patient to become more acidotic. We are trying to compensate as much as we can for the metabolic acidosis by causing a respiratory alkalosis.


Figured something like that...thanks...but the consequences of hypocarbia can't be discounted....in this guy...no big deal. He's 30 and bullet proof...but severe hypocarbia with attendant fall in cerebral blood flow in, for example, the elderly or someone with carotid artery disease shouldn't be ignored, IMHO. I'm in the end organ protection business and I understand field medicine is...well...field medicine. But folks are getting care in the field today that wasn't possible in the hospital a generation or so ago...


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## mrhunt (Oct 20, 2019)

So i literally had the same call today......Except vitals were all perfect and i didnt do a 12 lead cause pt was completely asymptomatic on scene and AMA'd.  he was driving a super long distance and fell asleep at the wheel, Swerved into center median not hitting anything and then went back onto road.....

No injuries, No mechanism, No medical history/allergies/meds/ drugs/ etoh....

I likely SHOULD have done a 12 lead cause of Possible dizziness before episode but from how he made it sound.....it was like he was nodding off and then fell asleep at the wheel. 

I AMA'd pt and left in care of law enforcement. Fire called me later and was like "that was a grey area, be careful, document well" etc....
After we left he mentions casually that "a passerby stated i was altered and not making sense after the incident" which he didnt tell us on scene which would have Def made me do a 12 lead...

But u know what? Signed AMA, tried our best to convince to go.....what else could you do (except 12 lead probally)..


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