# Scenario: Unresponsive Female



## Ridryder911 (Dec 23, 2006)

It is a bright, sunny but cold wintry day when you and your partner is dispatched in reference to an "unresponsive female". You and your partner discuss that it is unusual to have to respond to calls in this part of the "wealthy neighborhood". 

You arrive to the address, and pull up to the cobblestone driveway, you notice the rescue squad unit is already at the scene. The home, which your partner describes as a "mansion" is a multi story, with large 20 foot tall doors, and the "maid" greets you as enter toward the door. She informs you the patient is "upstairs" and in her broken English, describes the "husband not able to wake up the misses". The maid is obviously upset, with interruption of periods of crying and rapid Spanish. 

As you climb the "plush" carpeted stairs, your partner whom is very wise is counting the steps as you go toward the patient so you will know how many you will have to go down...but that will be later.

You enter a very large master bedroom and with several firefighters and an apparent concerned male, being questioned by one of the firefighters. You immediately assume that is  the spouse, and focus your attention to the patient. You see a female that appears to be in her upper mid 30's to 40'ish, laying supine, transverse across the bed. 

You hear the sound of oxygen being supplied as the "good firefighters" has applied oxygen at 15> lpm per NRBM. 

The squad Lt. gives you a brief hx. of Ms. Brown is a 41 y.o. female found by her husband approximately 15 minutes ago, and could not awaken her. He then notified 9-1-1. She has no major outstanding medical history other than re-current headaches for the past two weeks which was controlled with medication(s) recently. She is an avid jogger, and society personality. Very active in the community, and her husband is popular attorney. In which your partner "elbows you to inform of this, by seeing his recurring television ads" of describing.."I know what to do, let's sue !"..

IPHX: Last seen approximately three hours ago, last meal at that same time. Patient had described "not feeling well", but the thought dismissed since all the family had the "bug" type flu recently. 

Physical exam reveals an attractive 41 year-old female, that does not respond to verbal, or noxious stimulus. You note shallow respiration's, and vomitus from the patients mouth, you ask for a towel and for one of the firefighters to gather your equipment, including suction. 

?????


R/r 911


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## emtwannabe (Dec 23, 2006)

Any empty pill bottles or meds laying around? Possible OD or allergic reaction maybe?

Jeff


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## yowzer (Dec 24, 2006)

Aneurysm, maybe? Or overdose from the pain medication or recreational drugs? 

What are her vitals? Blood sugar? What are her eyes doing? What medications is she on?

Treatment: Load, go. BVM if she's not breathing too well, or, since this is the ALS forum, IV and consider intubation, especially since she's been throwing up. Give some narcan and see if that wakes her up a bit.


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## MICU (Dec 24, 2006)

It does sounds like an overdose, but I came to simillar scene with a 40 y.o lady that had an HY.

Could you give more data?
HR, BP, SpO2, gloc check, ETC


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## jeepmedic (Dec 24, 2006)

Vitals? what does the scene look like? How is she dressed? Check Blood Glucose.


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## islandgal (Dec 24, 2006)

You sure her name is Brown, not Von Bulow?


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## FF/EMT Sam (Dec 24, 2006)

I know I'm in the ALS forum, but oh well.  My first guesses are OD, allergic reaction, diabetic emergency, or possible CVA.  

--Clear the airway
--Call for ALS
--Make sure that the man "assumed" to be her husband actually is, and verify medical history if possible.
--If possible, try to ask the maid what she knows.  (It's a long shot, but worth trying.  Maybe the pt. and her husband have been arguing and the pt. told the maid something about hurting herself...)
--LOAD AND GO!!!!!
--Continue 15L of O2 via NRB or BVM, depending on the rate of respirations.
--Monitor vitals, with a new set every 5 min.  Get blood glucose reading.
--Treat any conditions found from the vitals, if possible. 


Questions for R/Rid:
--Any pill bottles in the room?
--Was she under any special stress?
--Any allergies?
--Any new medications?  If so, what?  How long had she been taking it?


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## jeepmedic (Dec 24, 2006)

Did she fall down the stairs? Head injury.


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## Ridryder911 (Dec 24, 2006)

The only other medical history was "she had not been feeling well", and c/o of headache and weakness and went to lie down. As discussed all immediate family members have had recent history of diarrhea, nausea for the past day and a half. Absent of recent trauma. Current medication(s) are Synthroid (old thyroid problems, Doxepin- migraine headaches, Ibuprofen- muscle aches & headache, Excedrin for Migraines, NyQuil type antihistamine ( last administration approx. 5 -6 hrs. ago. All the prescription bottles have pills remaining, no display of recent hx. of depression. Non-smoker, avid athlete (jogger, plays tennis at least twice a week)  

Initial examination:

41 year old female, appears to be well nourished, fit & tanned, well kept even in apparent illness. Approximately 64kg in weight.
*AVPU:* Patient is totally unresponsive to any stimulus, however; there is noted some muscle "twitching' in the facial area and slight in the extremities with stimulus.  

* A* Your experienced partner removes the pillow where on of the firefighters placed under head and rolls a towel under the neck to maintain the airway, With the other towel the maid gives you, wipe clear, thick oral secretions. 
*B:* After the head is tilted, noted increase in depth of tidal volume, however still shallow and slow.  

There is no obvious gross trauma, such as bleeding or bruising noted. 

Vital signs: BP 80/42, P-156, R/r 10-12 ... 

Actions and possible Dx. ?

R/r 911


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## jeepmedic (Dec 24, 2006)

What is the blood glucose level? Could be dehydration.


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## Ridryder911 (Dec 25, 2006)

Glucose is 128 mg/dl, skin has good retraction/turgor, mucus membranes slightly dry, tongue non-furrlowed. 

Your partner slides a 16 french nasal trumpet into her (which side should he attempt 1'st?) & suctions the oral cavity and reapplies the oxygen per NRBM.

Still noted some defasculatating facial movements (twinges) with any major stimulus.

R/r 911


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## jeepmedic (Dec 25, 2006)

Well at this point I am thinking Dehydration. But I am still unsure as to why the unresponsiveness. So, OPA if no gag then Intubate,oxygenate and check Cardiac monitor.then transport to ED.


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## emtwannabe (Dec 25, 2006)

Npa's should always be in the pt's right nostril unless otherwise compromised-the bevel side to the septum.

Jeff


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## Ridryder911 (Dec 27, 2006)

You and your partner decide to hold off intubating at this time since she is breathing and moving a patient down stairs can be tricky.. 

Physical exam reveals :

41 year old caucasian female that appears to be fit, tan and toned. She is unresponsive to stimulus as described with some fasculating movements of the facial area and arms. 
HEAD:Normal cephalic. Pupils are 1-2 mm brisk to respond. Negative "dolls eye", sclera clear as well as conjutiva is pink, with absence of petechiae (no smothering at least). Oral cavity while suctioning noted mallampati grade II, veneer coverage over all dental, uvula mid-line with absent of swelling of the posterior pharynx. Absent of rhino & otorrhea.
NECK: Trachea mid-line, JVD measurable @ 2-3 cm MCL/supine position, respectfully. Absent of carotid bruits, grade +1 carotid pulse, noted "old incision scar" sternal notch area. 
CHEST: Quickly exposed, no noted trauma, absent of bruising, chest normal appearance, with possible breast enhancement. Bi-lateral symmetry, lung sounds clear bi-lateral without adventitious sounds, heart tones clear to auscultation with S1/S2 and APMI noted @ 4'th ICS/MCL. 
ABDOMEN: Flat, absent of trauma, soft, palpable all quadrants, old incision scar in lower right hypochondriac region, bowel sounds not assessed. 
Pelvic: quick scan revealed no gross trauma and no incontinence of bowel or bladder. 
 EXTREMITIES: Upper extremities again toned muscular, absent of any signs of trauma, grade +1 radial pulse, absent of clubbing, edema, or cyanosis. Well manicured nails, and absent of palmer rash and mottling. Capillary refill approximately 4 seconds. 
 POSTERIOR[/b]: Absent of trauma, lumbar/sacral normal alignment. 

Initial ECG reveals  







Pulse oximetry: With wave form noted capturing pulse is 98% with oxygen NRBM, and EtCo2 is 32mm/hg and noted normal square wave forms are noted. 

You & your partner agree simultaneously, without verbal discussion to establish an IV. You see a great basilic vein and get a 18g in and establish a saline lock, and your partner whom wants to demonstrate his great skills establishes a 14g in the left A/C. A isotonic solution of Normal Saline is established at a wide open rate to bolus infusion of at least a liter. 
The patient is securely strapped and immobilized to a LSB, and gently carried through the mahogany trimmed door ways and down the stairs. Where the stretcher is awaiting. .. You prepare your patient into the EMS unit.

??? 

R/r 911


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## AnthonyM83 (Dec 28, 2006)

Ridryder911 said:


> You arrive to the address, and pull up to the cobblestone driveway, you notice the rescue squad unit is already at the scene. The home, which your partner describes as a "mansion" is a multi story, with large 20 foot tall doors, and the "maid" greets you as enter toward the door. She informs you the patient is "upstairs" and in her broken English, describes the "husband not able to wake up the misses". The maid is obviously upset, with interruption of periods of crying and rapid Spanish.


The best part about reading this scenario is that I HAPPENED to have just clicked on a random song on my playlist and it was "Tour of the Kingdom"...this majestic instrumental with trumpets and violins...great background for the mansion intro...like a movie scene.


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## AnthonyM83 (Dec 28, 2006)

Can we find out from husband what those scars are from? All cosmetic surgery?


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## DT4EMS (Dec 28, 2006)

The synthroid and scar may play a role. Her having a headache may also. Her end title CO2 seems a little low for a person that is so active and her respiratory effort was "shallow" upon intitial assesment.

Her rhythm is tachy...... of an atrial nature. It is hard for me to see it real well. ( I am getting old I guess).

The Excedrin may pose a risk as well. 

I worked a "suspicious" death a couple years ago where it was an unknown OD. The pateint took some excedrin, had what appeared to be a seizure and died.

I am excited to see how this turned out.


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## Ridryder911 (Dec 28, 2006)

You are right her rate is between 140 & 150, and her EtCo2 is a little low. So your partner assists with a BVM until you can intubate her. Her surgical history : thyroidectomy X 5yrs ago (hence -synthroid), cholecystectomy (gallbladder X 3 yrs ago). 

The fire guys load the cot, and you enter the side door to gain access to the head and turn on the oxygen, your partner quickly prepares equipment to intubate. As he is attempting intubate her says : Wow! She was slobbery now her mucosa is 'way too dry.. that's weird? " & asks for some lube. The firefighter (whom works with you part time) says.. you might want to look at this as well!..(pointing to the monitor)  







You quick assess her, and she does have a pulse..(Intubation has not been performed yet)... ??? Her husband yells from the front of the cab.. I think she said .."She could not get rid of that headache"......

R/r 911


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## DT4EMS (Dec 28, 2006)

Well......time to say "Dang" and start working with the VT........ she still has a pulse and it looks monomorphic.......cardiovert at 100.........

Was her skin abnormally warm? I'm thinking funky CVA type stuff is possible with the thyroid hx and headache.........especially since she took the Excedrin. (This is in my H's and T's) while we work this!


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## AnthonyM83 (Dec 28, 2006)

Ridryder911 said:


> The fire guys load the cot, and you enter the side door to gain access to the head


Wait, stop right there. You had me going with the mansion and Spanish housekeeper (did we interview her, btw?), but the fire guys actually loading a patient for us? That'll be the day...


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## Ridryder911 (Dec 28, 2006)

Good catch.. of course your partner's sphincter tone just went up 3 notches, thinking he might have induced this when he started to intubate. You set the defib on synch and watch the ..."blep"...shock!.. This is what you have on the monitor..






You reassess her and and no change in LOC , pulse is now about 54, blood pressure is 70/40. You notice each time you touch the patient increasing fasciculations and tremors occur.. 

You ask the husband how bad was the head ache? He described that she said it what was really bad, but did not appear any worse than usual..


?????
R/r 911


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## Ridryder911 (Dec 28, 2006)

P.S... Her skin is now appearing to be more flush like in appearance....

R/r 911


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## Airwaygoddess (Dec 28, 2006)

Well I would like to take a stab at it, intracranial bleed or brain stem rupture.


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## Guardian (Dec 29, 2006)

Some thoughts…the fact her pupils are equal, normal sized, and negative “dolls eyes” without signs of seizure makes me not want to go down the road of CVA, intracranial bleed, etc…but it’s possible, especially in weird cases like this.  With her age, VT, and the fact she’s been lying in a bed the last few days because of migraine or sickness, I want to say PE but that doesn’t really account for ALOC in the beginning.  I think dehydration was a good guess…I’m inclined to think it’s a problem with electrolyte imbalance.  It’s possibly encephalitis or meningitis and it could definitely be an overdose of some sort, I just don’t know what…


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## FF/EMT Sam (Dec 29, 2006)

My guesses are now dehydration, intracranial bleed, or accidental OD.

I showed this thread to a paramedic where I work.  Her response: "This patient is just f'ed up!!"


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## DT4EMS (Dec 29, 2006)

Let's start pacing her.

How is her skin temp? Is it elevated?

I wouldn't rule out something funky around the brainstem. The fasiculations and tremors could be coming from an internal temperature regulation problem as well.

Again, working on H's and T's............

Ooohhhh give me more!!


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## Ridryder911 (Dec 29, 2006)

First of all... All excellent posts and suggestions. This was an intentional  hard case I had.... 

Since this location is on outskirts of town, you have a return trip to the hospital of 15 minutes .. dependent on time and traffic. 

You quickly review the assessment and hx. again.. attempting to narrow this complex situation. You again quickly ask the husband how much vomiting, diarrhea.. etc. He informs you he didn't think that she had than many episodes, but she told him that her head was hurting her and she was going to take some more of her headache medicine. Being the astute Paramedic you are, reviewing the unusual fasciculations, cardiac ectopi, and sudden B/P you as well initially assume neuro or dehydration, but so severe? You ask how if she was on any other headache medication and he informs you that she was not, she used to be on Imitrex but was not on effective. So they placed her on this one which appeared to work "a bit better". 

You look at the medicine and note that the headache medication is  Doxepin ? Not being familiar with this you pull out your handy-dandy pocket field guide & look it up. 

BINGO !... It now makes sense!.. Doxepin is a tetracycline antidepressant that is widely used for migraines.... tetracycline/anticholinergic poisoning!. ..Neuro irritability (fasciculations) initially salivation now dry.. slightly erythematous flushed skin, arrhythmia's tachy to wide complexes.. she apparently self medicated herself additionally and with the additional antihistamine from NyQuil and caffeine and dehydration she has made herself a life threatening cocktail. As well she is very petite and low body mass and excellant metabolism does aid in absorption  of medication . 

You immediately establish fluid resuscitation and initiate a Dopamine drip at 6-8 mcg/kg/min as well drop a large oral gastric tube with irrigation of saline. You note some small pill fragments on return ... 

ECG remains as noted but you do see some attempts of conversion with occasional sinus beats. Her pressure with fluids and Dopamine has reached 82/58 and her respiratory rate has increased a little. 

You arrive in the ED and the ER Doc agrees with your speculation. A serum level is drawn as well as tox screen and cardiac profile and the usual other routine lab's. The patient is placed on ventilator and radiography films are taken as well as an emergency brain to pelvic CT scan. 

You had to respond to another call but able to return about 2 hrs later. 

The patient is being packaged and prepared for transfer to ICU. 

The Doc personally comes to talk to you and pats you on the back and congratulate you on a job well done!. Her lab's is a train wreck with BUN and anion gap horrible showing severe dehydration. As well, her tox level initially was high but not severely dangerous.. but as the physician describes along with the other factors potentiated the tetracycline.  CT is negative as well as cardiac markers .. except her CPK probably due to your cardioversion.

She was placed in the unit for consideration for emergency dialysis but due to severe dehydration was postponed. She regained consciousness about 8 hours later and ventilator was discontinued the next morning. She was rehydrated and discharged three days later, of course a change in medication. ..lol

Lesson learned... when one hears hoofsteps..don't always assume it is horses.. it might be zebras!
Multiple indications for medications can be confusing, i.e. NTG for esophageal spasms, Haldol for headaches.. etc.. Not only can trauma/medical patients can have multiple problems, medical patients can as well. Sometimes it appears they attempt to "test" our capabilities all the time.  

Again, good going guys! Great responses.. !

R/r 911


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## DT4EMS (Dec 29, 2006)

Dang............

So not only did she have the medication problem but the electrolytes were out too. 

I started going away from the dehydration because initially her skin turgor was good and mucosa wasn't that dry.

Another awesome post Rid!


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## Airwaygoddess (Dec 29, 2006)

antidepression medication strikes again!:wacko:


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## Guardian (Dec 29, 2006)

Another great post, thanks.

I'm going to go brush up on tetracycline/anticholinergic poisoning...lol.

Great point about medical pt's having multiple problems.  I had a MI pt the other day who just happened to have a seizure while I was asking him about his CP...first seizure in 2 years...lol, maybe i just have that effect on people.


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## Ridryder911 (Dec 29, 2006)

There used to be a saying (don't know ow true or accurate) Called the 50% Rule. 50% of the Tetracycline O.D.'s are asymptomatic and out of those 50% are fatal. 

I know this one of the few poisoning we do irrigation and NG tubes or "Code Blue/Big Bertha" tubes on. We irrigate with about a gallon and a half of saline, then place Actidose w/sorbitol be sure to have a bathroom facility nearby. 

Let us put it this way, it cleans them out from one end to another. 

R/r 911


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## Guardian (Dec 30, 2006)

In this case, would you have considered giving NaHCO3 in the field or at all because of the dysrhythmia (VT)?


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## macinfire (Dec 30, 2006)

Doxepin also a good antihistamine......may be used for hives, etc...low dose


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