# Vomiting, abdominal pain, significant bradycardia



## TF Medic (Sep 14, 2016)

Just looking for a round-table type discussion on this hypothetical scenario. 

35 year old male, calls 911 after he been vomiting "nonstop" for the past "three or four hours." Complains of abdominal pain 10/10, has sharp grimace on his face, appears lethargic but restless. Eyes appear heavy but he paces from the bed to the room. Your gut instinct is that he is in significant pain, has been vomiting a lot, and can't find a comfortable position. Toilet has a small amount of bile in it, but he's only dry-heaving now. 

History- TBI,  hypothyroidism, denies any other. 
States he has had these episodes on and off over the past year and a half, has lost a significant amount of weight (100lbs), and has been seen a few times and the hospital "doesn't do anything to fix it."

Meds- Trazodone, Gabapentin, Bupropion, Disulfiram, Levothyroxine. Pill counts are estimated but appear correct for prescription dates. 

Vitals on scene
BP 160/100
HR 50
98% room air
RR 16
Lungs clear all fields
Pupils =/R

In the truck you notice the heart rate is 48-50. PT is lethargic but answers all questions appropriately. States his eyes are closed because he is "tired." 12 lead unremarkable - sinus brady. 

IV is started, your partner gives 4mg zofran, 100mcg fentanyl, and hangs NS wide open. Normal traffic transport. 

Enroute heart rate noted to be as low as 36, BP remains hypertensive, PT states pain is unchanged post Fentanyl. PT still alert and oriented. 

What else do you want to know? What else do you want to do? What is included in your field impression/differential diagnoses?


----------



## NomadicMedic (Sep 14, 2016)

Interesting. Is he bradycardic from increased vagal tone secondary to the vomiting and pain, is he bradycardia from the hypothyroidism or does he have sick sinus syndrome or another issue that's not readily addressed in the back of a truck.

He seems lethargic and a bit bleh. I think I'd try a 0.5 mg atropine dose and see what I saw. It certainly would address the vagal tone question.


----------



## Gurby (Sep 15, 2016)

Check a blood sugar and repeat 12 lead en route but not expecting to find anything.  Does the bradycardia coincide with vomit/wretching episodes?

What has his alcohol intake been like recently?  What was his oral intake today?  Specific location and character of the pain?  Any unusual family history (Addison's Disease, etc)?

I don't have a clue really.  I put him in the truck and go lights and sirens to the hospital.

... Did you happen to pick this gentleman up from the Section 8 housing complex?  Is he also unable to work, disabled for depression and anxiety?  .... Probably doesn't get fentanyl from me.


----------



## NomadicMedic (Sep 15, 2016)

Gurby said:


> Check a blood sugar and repeat 12 lead en route but not expecting to find anything.  Does the bradycardia coincide with vomit/wretching episodes?
> 
> What has his alcohol intake been like recently?  What was his oral intake today?  Specific location and character of the pain?  Any unusual family history (Addison's Disease, etc)?
> 
> ...



I agreed... right up to the "go lights and sirens" part.


----------



## Handsome Robb (Sep 15, 2016)

DEmedic said:


> Interesting. Is he bradycardic from increased vagal tone secondary to the vomiting and pain, is he bradycardia from the hypothyroidism or does he have sick sinus syndrome or another issue that's not readily addressed in the back of a truck.
> 
> He seems lethargic and a bit bleh. I think I'd try a 0.5 mg atropine dose and see what I saw. It certainly would address the vagal tone question.



Even with the hypertension? Not sure I agree with you on that one my friend. 


Sent from my iPhone using Tapatalk


----------



## TF Medic (Sep 15, 2016)

DEmedic said:


> Is he bradycardic from increased vagal tone secondary to the vomiting and pain, is he bradycardia from the hypothyroidism or does he have sick sinus syndrome or another issue that's not readily addressed in the back of a truck.



If I could answer those I wouldn't have posted here. 

To answer some other questions: 

Bradycardia seems constant, he only retches once when you first arrive on scene. HR stays under 50 for duration of care. 
BGL within normal range. 
Unknown recent ETOH intake. Food intake is "breakfast, then I've been vomiting since." (it's ~2pm now)
Housing is low income but not co-op or subsidized. No call history from this address, name/DOB not in system. (IE, appears to be first time caller)
Is able to work but diagnosed with PTSD. 
Atropine was not given. 
Also, just curious, lights and sirens for an alert and oriented PT who seems asymptomatic (at least in regard to his bradycardia)? Not saying I would have disagreed to a priority transport, just wondering your thoughts. I can see it either way. 

Ride in is relatively uneventful. This wasn't my call so I wasn't in charge of treatments/lack of, but I was stumped as well. Trazodone OD crossed my mind but I didn't get a tox screen back. Just wondering if anyone had an off the wall "it's XYZ condition" they could think up.


----------



## Hemostatic (Sep 15, 2016)

TF Medic said:


> History- TBI



How long ago was his TBI? Cause? Severity? Treatment?


----------



## NomadicMedic (Sep 15, 2016)

Handsome Robb said:


> Even with the hypertension? Not sure I agree with you on that one my friend.
> 
> 
> Sent from my iPhone using Tapatalk



Fair enough, but is that BP right? Did they take it with an automated cuff? Was he more symptomatic than was really presented here? I can't tell... I wasn't there. Was he puking and sick (and lethargic) because he was bradycardic? I don't know. Something here doesn't smell quite right. I still think 0.5 of atropine would be appropriate, because I really think the bradycardia is due to excessive vagal tone. But again, I wasn’t there.


----------



## Gurby (Sep 15, 2016)

I work in a city and do this call probably once per shift.  In my experience, 90% of the time, a 35yo with that profile of meds is drug seeking.  However, you still need to do your due diligence and assume it could be real.  The fact that fire/police aren't familiar with the patient and he's not in your system also makes it more likely that this is real.



TF Medic said:


> Also, just curious, lights and sirens for an alert and oriented PT who seems asymptomatic (at least in regard to his bradycardia)? Not saying I would have disagreed to a priority transport, just wondering your thoughts. I can see it either way.





DEmedic said:


> I agreed... right up to the "go lights and sirens" part.



Lights and sirens because the heart rate doesn't make sense.  If he were truly in pain, we expect it to be much higher.  If he's truly been vomiting all day we might expect him to be dehydrated which would also bring it up.  If he were faking to try to get narcs out of us, I'd still expect his resting HR to be a bit higher.  If the low HR was brought on by vagal stimulation, we would expect it to normalize now that he's not vomiting anymore.  It's possible that this is baseline for him, I have seen people with resting HR's in the 40's, but that's definitely unusual, and I assume this guy is not an athlete so even more unusual.

I want lights+sirens, but nice and easy.  I just don't want to sit in traffic for 30 minutes with this guy, then we get to the hospital and - surprise! -  he's having a cardiac event that we missed.


----------



## DesertMedic66 (Sep 15, 2016)

Any recent trauma? How long ago was the TBI? Any complications expected from the TBI? How are pupils? 

Based on what has been presented so far I would hold off on the Atropine. His BP Is elevated, he seems to be mentating fine (although lethargic). Skin signs weren't listed but I'm assuming they are going to be somewhat normal. 

IV Zofran, Benadryl (if Zofran has no effect), pain meds with repeat doses. 

Transport code 2 (no lights or siren) to the ED he is normally seen at. 

The unexplained weight loss of 100lbs is a concern for me


----------



## bakertaylor28 (Oct 25, 2016)

This sounds like it is most likely a GI blockage. (The presence of bile being the tale-tale sign, given that it does not appear to be an OD) I would go with a light dose of zofran (at say around 2.5 mg IV ) to deal with the vomiting temporarily, which is most likely causing the Sinus Bradycadia and the hypertension. (assuming it actually IS sinus bradycardia and not 1st degree AVB- given rates as low as the 30's!!!) I would consider pain meds if the Sinus Bradycardia wern't present- but pain meds on top of a brady-arrthmia is asking for trouble.


----------



## VFlutter (Oct 25, 2016)

bakertaylor28 said:


> This sounds like it is most likely a GI blockage. (The presence of bile being the tale-tale sign, given that it does not appear to be an OD) I would go with a light dose of zofran (at say around 2.5 mg IV ) to deal with the vomiting temporarily, which is most likely causing the Sinus Bradycadia (assuming it actually IS sinus bradycardia and not 1st degree AVB- given rates as low as the 30's!!!) I would consider pain meds if the Sinus Bradycardia wern't present- but pain meds on top of a brady-arrthmia is asking for trouble.



Why the "light dose" of Zofran? Why so concerned about a first degree block? 

I would think some of this could be explain by that combination of home meds but I don't have anything specific to cite.


----------



## bakertaylor28 (Oct 25, 2016)

First, the reason I would be careful to evaluate for first-degree AVB is that it can sometimes be mistaken as Sinus Bradycardia- with the difference being that First degree AVB involves a prolonged P-Q segment. (i.e. prolongation between the end of P and QRS), BUT with First-degree AVB there is STILL always a P before every QRS (i.e. unlike the rest of the AV blocks, there are NO dropped QRS complexes). This is virtually the only thing that confirms the difference in lead-2 ECG. (assuming I don't have a full 12-lead).

By a light dose of zofran, I mean at around half of the normal recommended dose of 4mg IV, because of the fact that it's most likely a surgical case, in my opinion. With GI surgical cases, the gastric contents have to be dealt with somehow before surgical anesthesia is induced, to reduce the risk of intraoperative sepsis later down the road.


----------



## NomadicMedic (Oct 25, 2016)

bakertaylor28 said:


> First, the reason I would be careful to evaluate for first-degree AVB is that it can sometimes be mistaken as Sinus Bradycardia- with the difference being that First degree AVB involves a prolonged P-Q segment. (i.e. prolongation between the end of P and QRS), BUT with First-degree AVB there is STILL always a P before every QRS (i.e. unlike the rest of the AV blocks, there are NO dropped QRS complexes). This is virtually the only thing that confirms the difference in lead-2 ECG. (assuming I don't have a full 12-lead).
> 
> By a light dose of zofran, I mean at around half of the normal recommended dose of 4mg IV, because of the fact that it's most likely a surgical case, in my opinion. With GI surgical cases, the gastric contents have to be dealt with somehow before surgical anesthesia is induced, to reduce the risk of intraoperative sepsis later down the road.



Are you a brand new medic? (Asking for a friend.)


----------



## Handsome Robb (Oct 25, 2016)

Why on earth would you half a dose of zofran? 

We routinely give people 18-16mg IV in two doses. 


Sent from my iPhone using Tapatalk


----------



## bakertaylor28 (Oct 25, 2016)

DEmedic said:


> Are you a brand new medic? (Asking for a friend.)



I'm still doing collegiate education.


----------



## bakertaylor28 (Oct 25, 2016)

Handsome Robb said:


> Why on earth would you half a dose of zofran?
> 
> We routinely give people 18-16mg IV in two doses.
> 
> ...



Obviously, you haven't read the FDA's dossage guidelines. The standard dose of Zofran in surgical cases is 4mg IV Q 4 Hours. See rxlist.com/zofran-injection-drug/indications-dosage.htm The reason for giving half the standard dose is because of the fact that you want it to wear off by the time a surgical consult rolls around, given the fact that it is statiscally likely to be GI obstruction, given the whole bile thing.


----------



## VFlutter (Oct 25, 2016)

bakertaylor28 said:


> Obviously, you haven't read the FDA's dossage guidelines. The standard dose of Zofran in surgical cases is 4mg IV Q 4 Hours. See rxlist.com/zofran-injection-drug/indications-dosage.htm The reason for giving half the standard dose is because of the fact that you want it to wear off by the time a surgical consult rolls around, given the fact that it is statiscally likely to be GI obstruction, given the whole bile thing.





bakertaylor28 said:


> First, the reason I would be careful to evaluate for first-degree AVB is that it can sometimes be mistaken as Sinus Bradycardia- with the difference being that First degree AVB involves a prolonged P-Q segment. (i.e. prolongation between the end of P and QRS), BUT with First-degree AVB there is STILL always a P before every QRS (i.e. unlike the rest of the AV blocks, there are NO dropped QRS complexes). This is virtually the only thing that confirms the difference in lead-2 ECG. (assuming I don't have a full 12-lead).
> 
> By a light dose of zofran, I mean at around half of the normal recommended dose of 4mg IV, because of the fact that it's most likely a surgical case, in my opinion. With GI surgical cases, the gastric contents have to be dealt with somehow before surgical anesthesia is induced, to reduce the risk of intraoperative sepsis later down the road.



Oh boy where to begin...

Obviously you have no experience working as a health care provider and have no factual basis for anything you are suggesting.There is absolutely no reason to reduce the dose of, or withhold, an antiemetic so that the patient is nauseous when the surgeon happens to wander by. That is even more ludicrous than not adequately treating pain to help the doctor diagnose.

"Hey Doc, this guy was nauseous on arrival but is much more comfortable after some Zofran and Compazine"
"What?!? How am i supposed to assess him?! Call me when the meds wear off and he is nauseous again so I can order a CT scan!"

Furthermore throwing up bile rarely a true bowel obstruction and is likely just from repeated vomiting on an empty stomach. What statics are you using?

Gastric contents causing intraoperative sepsis? What? I won't even touch that one.

Thank you for regurgitating that information about blocks however that does not really answer the question.


----------



## Handsome Robb (Oct 26, 2016)

bakertaylor28 said:


> Obviously, you haven't read the FDA's dossage guidelines. The standard dose of Zofran in surgical cases is 4mg IV Q 4 Hours. See rxlist.com/zofran-injection-drug/indications-dosage.htm The reason for giving half the standard dose is because of the fact that you want it to wear off by the time a surgical consult rolls around, given the fact that it is statiscally likely to be GI obstruction, given the whole bile thing.



Umm...yea not going to touch that with a 10 foot pole. 

There is absolutely zero reason to withhold antiemetic from a patient who is nauseous. The first thing a surgeon is going to do if they're nauseous is order an antiemetic. They don't want to be puked on anymore than we do. 


Sent from my iPhone using Tapatalk


----------



## dutemplar (Oct 26, 2016)

((blinks)) Given the current symptoms, release to Alpha (two EMT-Is, more or less) truck with instructions to monitor and transport non-emergent to RIAMS (medical, via ambulance triage).  Lethargic, but puking his guts out for hours, probably get a sending dose of Zofran 4mg.  Due to the lethargy, probably no opoid narcotics although I'd consider Penthrox inhalation an option for the Alphas to give while transporting without lights and woowoos.

That is assuming I don't look at the guy and go "Oh schnikies..."  But based on the rest of the assessment, and stable BP, blood glucose, etc...

..as far as halving the dose, if it's going surgical - I'm betting that his gastric contents are already pretty emptied from the current amount of reported puking, and nothing an NG tube can't resolve perioperatively.  Similarly, we stopped withholding pain meds on general abdominal pain about two decades ago.  First thing the hospital will do is take the nausea and pain away.  Especially while he's uncomfortable and can't lie still for a CT scan and all that happy stuff.  Likewise, with his pain I would be dancing around the heart rate/ level of consciousness a little bit and not wanting to outright put him to sleepyville for the ride, and any potential downward spiral in the back of a box.  Non-emergent transport that although I want this dude to get there, he likely doesn't need the rougher ride bouncing up and down getting there pushing the pain, and adding motion sickness to the deal.


----------



## Akulahawk (Oct 26, 2016)

bakertaylor28 said:


> Obviously, you haven't read the FDA's dossage guidelines. *The standard dose of Zofran in surgical cases is 4mg IV Q 4 Hours*. See rxlist.com/zofran-injection-drug/indications-dosage.htm The reason for giving half the standard dose is because of the fact that you want it to wear off by the time a surgical consult rolls around, given the fact that it is statiscally likely to be GI obstruction, given the whole bile thing.


This drug can also be administered this way: 8mg q 8 hours, or potentially in even greater doses for certain reasons. You really don't want to go "light" with this stuff. It's much better to stop the nausea. I'm not that worried about blotting out nausea even in potential surgical cases. Bile isn't exactly a specific indicator of GI obstruction. Presence or absence of nausea at the time of exam isn't going to change the ED MD's decision as far as getting a surgical consult. Since this guy has a relatively slow HR, I want to know if he's got a long QT. If he does, then Zofran is contraindicated. 

What's this patient going to get from me? Likely 4 mg Zofran and a nice, easy ride in to the ED. What am I also going to ask about? Has the patient been taking marijuana for a long time or has there been a recent increase in daily usage? I've seen this more than a few times... Any chance that the patient gets relief by taking very hot showers?


----------



## SpecialK (Oct 26, 2016)

I have no idea what is wrong with this guy's tummy.

I require no further information to decide he needs to go to the hospital.  I can't leave him, or refer him to somebody, in the community.

Ambulance is the most appropriate transport method.

Basic care: IV, IV ondasetron, analgesia (IV morphine, then oral paracetamol. ibuprofen and tramadol).  

No lights or siren.


----------



## dutemplar (Oct 26, 2016)

SpecialK said:


> Basic care: IV, IV ondasetron, analgesia (IV morphine, then oral paracetamol. ibuprofen and tramadol).



I almost overlooked that since we primarily use it for modest trauma, i.e.: fractures, but IV paracetamol here would be a viable option if he's at risk of puking the pills up.


----------



## Summit (Oct 26, 2016)

I agree with other posters that there is zero reason to withhold zofram unless this person has a really long QTc.

Hypothyroid yet 100 pounds of unintended weight loss is actually potentially one of the most alarming findings here for this person long term.

One could come up with a very long list of possible causes for n/v... cancer, drugs, ileus, intussusception, long long list. This patient needs a thorough medical workup.


----------



## TF Medic (Oct 26, 2016)

bakertaylor28 said:


> I'm still doing collegiate education.


Have you been solely responsible for an ALS patient?

I don't mind anybody responding, but I think it should be clarified whether you have any experience before espousing about surgical consults and the like.

For the others, I agree that a full house load of narcs likely isn't the bset choice, but that wasn't my decision at the time. Thanks for the discussion.


----------



## StCEMT (Oct 26, 2016)

I have no idea what could cause this. Potential OD or misdosed meds? Some other problem we cant see? Don't know. I would at least give 4mg of Zofran. Not sure I would rush to treat the bradycardia with anything since he seems to not have any symptoms other than lethargy. I might run it by a doc once he hit 30's, but if he still is mentating fine and has no other signs, then I still wouldn't be jumping to treat right away. Definitely would be watching this dude very closely and asking a bunch of questions to try and find some information that might be pertinent.


----------



## bakertaylor28 (Oct 26, 2016)

StCEMT said:


> I have no idea what could cause this. Potential OD or misdosed meds? Some other problem we cant see? Don't know. I would at least give 4mg of Zofran. Not sure I would rush to treat the bradycardia with anything since he seems to not have any symptoms other than lethargy. I might run it by a doc once he hit 30's, but if he still is mentating fine and has no other signs, then I still wouldn't be jumping to treat right away. Definitely would be watching this dude very closely and asking a bunch of questions to try and find some information that might be pertinent.



The most common causes of vomiting bile that are consistent with abdominal pain are GI obstruction, Gastroenteritis, and Food Posioning. 
with the least probability being assigned to a drug OD. 

On the Flip SIde, excessive vomiting alone without any other cardiac influences is usually going to cause Sinus Tachycardia, and, in the extreme,  perhaps A-Flutter/A-Fib/SVT If the patient is presdisposed to any of those. It usually DOESN'T cause brady-arrhthmias, which tend to indicate CNS depression. However, this can't be hard-coded as a rule, either.


----------



## bakertaylor28 (Oct 26, 2016)

TF Medic said:


> Have you been solely responsible for an ALS patient?
> 
> I don't mind anybody responding, but I think it should be clarified whether you have any experience before espousing about surgical consults and the like.
> 
> For the others, I agree that a full house load of narcs likely isn't the bset choice, but that wasn't my decision at the time. Thanks for the discussion.



For the record, I'm in year 2 of a 4-year med program. That means I have cleared ACLS credentials. Years 2 and 3 are internship and year 4 crosses over into residency. I can GUARANTEE you the first thing the ER doc is going to do is get an abdominal CT or MRI looking for obstruction- because bile with abdominal pain practically lay it out on the table that your most likely dealing with GI obstruction, Gastroenteritis, Food Poisoning, or more rarely a drug OD.  The thing is that they will be looking and thinking on the terms of the worst case scenario- which is GI obstruction, and ruling that out first. 

We can (probably) safely rule out the drug thing because of the fact that if my mind serves me correctly, at least one of the regular drugs that were mentioned was a Trycyclic antidepressant- which is going to cause a prolonged QT interval that rapidly degrades to Torsades as that is the classic trycyclic OD syndrome.


----------



## Handsome Robb (Oct 26, 2016)

I'll toss a DDx out there. Cyclic vomiting syndrome. Presents with abdominal pain and intractable vomiting and nausea. He's had this same thing before and has not been diagnosed. A blockage is a possibility but if he's been having normal BMs it'd be odd for him to have a spontaneous blockage, especially for his age. 

I'd be willing to bet he's bradycardia from increased catalog tone secondary to the vomiting and the pain, yes pain can cause bradycardia.

Give the kid some zofran, potentially som metoclopramide if the zofran doesn't resolve his wretching and some fentanyl for his pain. If you're truly worried about him bradying out because of the narcotics then ketamine is another option. 


Sent from my iPhone using Tapatalk


----------



## Akulahawk (Oct 26, 2016)

bakertaylor28 said:


> For the record, I'm in year 2 of a 4-year med program. That means I have cleared ACLS credentials. Years 2 and 3 are internship and year 4 crosses over into residency. I can GUARANTEE you the first thing the ER doc is going to do is get an abdominal CT or MRI looking for obstruction- because bile with abdominal pain practically lay it out on the table that your most likely dealing with GI obstruction, Gastroenteritis, Food Poisoning, or more rarely a drug OD.  The thing is that they will be looking and thinking on the terms of the worst case scenario- which is GI obstruction, and ruling that out first.
> 
> We can (probably) safely rule out the drug thing because of the fact that if my mind serves me correctly, at least one of the regular drugs that were mentioned was a Trycyclic antidepressant- which is going to cause a prolonged QT interval that rapidly degrades to Torsades as that is the classic trycyclic OD syndrome.


Keep adding to the differential Dx list. Given the recent, rapid weight loss, you could add intestinal parasites to the list and you might also consider the possibility of CA. None of the drugs this patient takes are known to be a TCA. Bupropion (Wellbutrin) is an antidepressant but it is not a TCA. It has no known interaction issues with ondansetron. 

Oh, and unless the ED has a dedicated MRI machine, the EDMD isn't going to use the MRI machine for this when a CT scan is much faster and should be able to yield at least as much info about a bowel obstruction as the MRI will.


----------



## Summit (Oct 26, 2016)

Akulahawk said:


> Keep adding to the differential Dx list. Given the recent, rapid weight loss, you could add intestinal parasites to the list and you might also consider the possibility of CA.


And in the setting of hypothyroid with a presentation that suggests that excessive hormone replacement is not present.... it's super concerning for CA. Parasites is a good thought though...

Acute abdomen is probably the hardest medical workup there is.



> Oh, and unless the ED has a dedicated MRI machine, the EDMD isn't going to use the MRI machine for this when a CT scan is much faster and should be able to yield at least as much info about a bowel obstruction as the MRI will.


Agree with this 100%


----------



## Akulahawk (Oct 26, 2016)

Summit said:


> And in the setting of hypothyroid with a presentation that suggests that excessive hormone replacement is not present.... it's *super concerning for CA*. Parasites is a good thought though...
> 
> Acute abdomen is probably the hardest medical workup there is.
> 
> ...


That's why I listed it. A sufficiently bad parasite infection could also cause similar issues though IIRC there'd be a distended belly and there's no mention of that here and IIRC there's no mention of an abdominal exam per se here either, just symptoms.


----------

