# Help understanding this one



## sdafbkfsdbkjdsf (Aug 27, 2013)

Called for a person sick not alert

  Arrive on scene and see a crowd running up the stairs to our pt, everyone around us was yelling and screaming. get up into the room and see an aprox 80 y/o F who looked like she was on the brink of death.

 I asked the family what happened and they said "she was fine 10 minutes ago."
I yelled the pts name and no response, i did a sternum rub and got a little moan out of her and that was it. Pt was very cool, dry, and non diaphoretic. Family again stated that she fell in the shower a couple days ago so she was currently taking tramadol, i look at her leg and saw a big abrasion to the left leg which look untreated. From all the hostility and yelling in the room i elected to take the pt out of the house and to work in the back of the truck for everyone's safety.

Assessment 
bp 90/60
P62 and dropping
RR 10
pupils- dilated but reactive
lung sounds -clear and equal bilaterally
bgl- all it read was low
Medications- tramadol, hydrocodone,omeprazole, zofran,sucralfate. Family said she only took the tramadol

i was able to obtain a 12 lead- see attachment

pt was then bagged and then given and npa , i don't know how but she still had a gag reflex and we do not carry RSI medications. me and fire tried for 3 ivs and then we went straight to IO i was able to giver he some d50 and the most fluids i was able to give through our short transport, i was going to give sodium bicarbonate and calcium due to the 12 lead but we arrived at the hospital.
What has me thinking about this call is that I learned that Hyperkalemia can be due to renal failure,tricyclic antidepressants , and DKA. But from what I know the pt did not have any of these and I don't know how she got into that rhythm.


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## blindsideflank (Aug 28, 2013)

you wanted to RSI a hypoglycemic patient?

how did her wound look untreated?

I had a person on tramadol with serotonin syndrome shaking so much she was mottled, cramping and becoming hyperkalemic, versed fixed her (not saying this is what you had). temp?

many other reasons to become hyperkalemic and that ecg is suspect but not diagnostic. hospital follow up?
i see a big qrs and a resulting big t wave, although it is peaked and ?symmetric?, wide and 1st degree block


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## sdafbkfsdbkjdsf (Aug 28, 2013)

Hospital had the drugs ready to RSI the patient before she coded, I believe it was way more than hypoglycemia.
The wound looked untreated or unkept because skin was peeling off, it was yellow, green,  and oozing a little
Hospital did the same thing I was going to do sodium bicarbonate, calcium, insulin, and d50 to try to narrow the complex.


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## blindsideflank (Aug 28, 2013)

occams razor says sepsis (and/or undiagnosed kidney problem) to me. but i dunno. 

you understand how metabolic acidosis causes free H+ to jump into cells and K+ will jump out?


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## sdafbkfsdbkjdsf (Aug 28, 2013)

Yeah sepsis came to my mind as well, it was just the story from the family saying she was normal today or 10 minutes ago that had me thinking it was something acute, but hey they could be lying. But also wouldn't she be hot, and diaphoetic if it were sepsis?. And about metabolic acidosis I read it a while back but I would love  a refresher if you don't mind.


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## Medic Tim (Aug 28, 2013)

lill91210 said:


> Yeah sepsis came to my mind as well, it was just the story from the family saying she was normal today or 10 minutes ago that had me thinking it was something acute, but hey they could be lying. But also wouldn't she be hot, and diaphoetic if it were sepsis?. And about metabolic acidosis I read it a while back but I would love  a refresher if you don't mind.



I cant remember the source... But I remember reading somewhere that around 1/3 of geri pts present normothermic or hypothermic


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## VFlutter (Aug 28, 2013)

I had a patient who kept getting pain meds from her PCP for leg pain and eventually got brought in for septic shock from osteomyelitis. 

And I do not really believe this patient dose not have more of a medical history. "I ain't got none of that but I ain't seen a doctor in 20 years"


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## DrankTheKoolaid (Aug 28, 2013)

Sounds like cold sepsis. Though the rapid onset of it is atypical. Unless she was sicker for longer then the family is letting on, knew about.


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## MSDeltaFlt (Aug 28, 2013)

Yeah, sepsis.  Probably threw an embolus somewhere important as well.  Geriatric female = osteoporosis until priven otherwise.  Add to that diabetes?...

When you hear hooves look for horses, not zebras.


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## sdafbkfsdbkjdsf (Aug 28, 2013)

Chase said:


> I had a patient who kept getting pain meds from her PCP for leg pain and eventually got brought in for septic shock from osteomyelitis.
> 
> And I do not really believe this patient dose not have more of a medical history. "I ain't got none of that but I ain't seen a doctor in 20 years"



I know what you mean, i bet she had a lot more medical problems, also I forgot to add she was rather skinny, and no other signs of obvious trauma besides the leg.


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## sdafbkfsdbkjdsf (Aug 28, 2013)

But lets just say her only medical hx was just the leg trauma, how would sepsis make you hyperkalemic?


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## VFlutter (Aug 28, 2013)

lill91210 said:


> But lets just say her only medical hx was just the leg trauma, how would sepsis make you hyperkalemic?



Metabolic Acidosis. However, it usually only a slight bump in serum potassium unless it is a very acute change in Ph.


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## Handsome Robb (Aug 28, 2013)

How about a bleed? Fell in the shower two days prior... 

That looks like a LBBB with a 1AVB. Doesn't really scream hyperK to me. 

I didn't see a hx of DM or hypoglycemia so that's odd, hypoglycemic episodes are generally medication related.

Septic patients usually present with hyperglycemia as well, not hypo not to say it isn't possible.

Any changes in mentation after the D50? What was her spo2%? Any signs of hypoxia? 

I'd also be tempted to try some naloxone before I intubated her. Tramadol is a synthetic opiate and responds to naloxone. She also takes hydrocodone...With the family how you described them i wouldnt trust a whole lot they say. She's got respiratory depression and ALOC. I'd cover my bases before jumping right to tubing her.

Any beta blockers? I don't see any listed but then I thought you said there were more meds. That'd explain the low HR, lack of ability to compensate. Or she's already decompensating but with an acute onset I doubt that's the case. 

Could be a GI bleed...she's got a hx of ulcers just from looking at her meds.


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## sdafbkfsdbkjdsf (Aug 28, 2013)

I wasn't able to get the time frame of when she fell in the shower due to  the family screaming, crying, and acting hostile. trust me I tried to get as much information as I could.


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## sdafbkfsdbkjdsf (Aug 28, 2013)

and yes the hypoglycemia did catch me off guard. Will make a very interesting case study , ill try all that I can do to get something from the hospital. All the doctor told me was they were just trying to narrow the complex.


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## Carlos Danger (Aug 28, 2013)

lill91210 said:


> But lets just say her only medical hx was just the leg trauma, *how would sepsis make you hyperkalemic?*



Sepsis = altered metabolism = excess acid (hydrogen cation) production.

Hydrogen cations are positively charged and in higher than normal concentrations, they diffuse into cells along the concentration gradient.  

Potassium is also positively charged, and exists in high concentrations inside the cells.

What do two positive charges do? Repel each other. The hydrogen ions force potassium ions out of the cells, and serum potassium levels rise.

Sepsis can also cause renal insufficiency, which can contribute to increased K levels, since the kidneys aren't able to excrete excess K.

The actual physiology of why acid is produced during sepsis and how the ions move into and out of the cells is pretty complex, but that's the down and dirty of it.


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## sdafbkfsdbkjdsf (Aug 28, 2013)

You are absolutely right in trying narcan, I was thinking drug overdose in some sort I was looking for the pinpoint pupils and saw nothing but hey it's worth a shot, after the d50 she was able to take more deeper breaths than the shallow ones she was taking, but still the same gcs of 5 and no change in the monitor. And really I don't remember the spo2 I'm sorry about that one.


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## abckidsmom (Aug 28, 2013)

lill91210 said:


> But lets just say her only medical hx was just the leg trauma, how would sepsis make you hyperkalemic?



Fall with an unknown down time leads you to suspect rhabdomyolysis in elderly people too.  Also hyperkalemia.


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## usalsfyre (Aug 28, 2013)

Sepsis, with a wound that looks like that and the actions you describe I'm suspicious of elder neglect as well.

House was wrong (and a quack but that's another discussion). Patients rarely lie I've found. CAREGIVERS OTOH....


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## abckidsmom (Aug 28, 2013)

usalsfyre said:


> Sepsis, with a wound that looks like that and the actions you describe I'm suspicious of elder neglect as well.
> 
> House was wrong (and a quack but that's another discussion). Patients rarely lie I've found. CAREGIVERS OTOH....



Agree there.


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## sdafbkfsdbkjdsf (Aug 28, 2013)

Neglect never crossed my mind, with the whole crowd around it looked like she was well liked they were all yelling asking if she was okay and that she felt cold, it was a low income apartment complex and not many have access to the best heath care. But I know she did go to the doctor because of the prescribed medication of tramadol.


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## abckidsmom (Aug 28, 2013)

lill91210 said:


> Neglect never crossed my mind, with the whole crowd around it looked like she was well liked they were all yelling asking if she was okay and that she felt cold, it was a low income apartment complex and not many have access to the best heath care. But I know she did go to the doctor because of the prescribed medication of tramadol.



At some point. Not necessarily with this fall. 

Also, neglect doesn't always comes from a place of malice. Sometimes it's plain old ignorance.


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## chaz90 (Aug 28, 2013)

And sometimes crowds and loud yelling obscure true apathy towards the patient while indicating concern that someone has called the authorities...


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