# 65 year old female



## NomadicMedic (Sep 19, 2019)

It’s a warm day, about 85 degrees. You’re a paramedic with an EMT basic partner and you’re staffing an ambulance with all of the standard ALS stuff on board. 

You are dispatched to a sick person. It’s a bravo level, non emergent. 

You arrive on scene to a well kept single family home. A neatly dressed older woman meets you in front of the house and says,  “Hi. My sister had a colonoscopy and and endoscopy today, and now she’s not doing well. She’s laying inside, on the couch in the sun room.”

What would you like to know? 

(Let’s let the NEWER people play first!)


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## Old Tracker (Sep 19, 2019)

How are here breathing, respirations, and profusion?  Temp?  Pain?  LOC? Skin?  Pink warm and dry, or other?  History? Allergic to anything?

If she can talk, what is HER chief complaint?


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## NomadicMedic (Sep 19, 2019)

She’s laying on a couch, vomit in a garbage can next to her. Just bile.
Hot to the touch. Temp102.8.  No history other than IBS. Meds: Imodium, Zantac. NKDA. No pain. She relates she’s really  weak and nauseous


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## Carlos Danger (Sep 20, 2019)

When did she start feeling this way? Why did she have the EGD and colonoscopy done?

Edit: I don't think I count as newer, but someone's gotta get this going


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## Old Tracker (Sep 20, 2019)

I palpate her abdomen, what are my findings?


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## DesertMedic66 (Sep 20, 2019)

Vitals?


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## E tank (Sep 20, 2019)

How about a medical history,  physical exam, vitals and basic diagnostics? Medical case studies shouldn't be presented in a way that requires excruciating teasing out of standard initial observations. Those should be a given.


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## NomadicMedic (Sep 20, 2019)

Old Tracker said:


> I palpate her abdomen, what are my findings?



Soft and non tender.


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## NomadicMedic (Sep 20, 2019)

E tank said:


> How about a medical history,  physical exam, vitals and basic diagnostics? Medical case studies shouldn't be presented in a way that requires excruciating teasing out of standard initial observations. Those should be a given.



 OK fair enough. No history except for irritable bowel syndrome. She’s had gastric distress, reflux and diarrhea for the past several years. With no definitive diagnosis. 

 Basically, she has no  acute complaints aside from general weakness and nausea ... and the majority of the physical exam is unremarkable except for the fact that she’s particularly weak and her mucosa is dry. 

 Vital signs are as follows. Sinus tach at 118. Radial pulses are strong and regular. Respiratory rate is 16. Lungs are clear to auscultation bilaterally.
 Blood pressure is 134/68.  She’s warm to the touch and a temporal thermometer gives you a reading of 102.8°.

 And the reason I was teasing this out, was usually one person asks for everything and nobody else ever gets a chance to do any critical thinking. But I gave you the basic presentation, ask away… I’m happy to answer anything


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## Old Tracker (Sep 20, 2019)

Sounds like she may possibly have a bowl infection and might be septic.


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## Carlos Danger (Sep 20, 2019)

E tank said:


> How about a medical history,  physical exam, vitals and basic diagnostics? Medical case studies shouldn't be presented in a way that requires excruciating teasing out of standard initial observations. Those should be a given.



It’s the EMS way.


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## silver (Sep 20, 2019)

What procedure was actually done? Was it under sedation or was she intubated?


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## E tank (Sep 20, 2019)

Remi said:


> It’s the EMS way.


I'm trying to forget.....

As the particulars of an EGD and colonoscopy might be obscure to anyone that hasn't witnessed them, they can be done in a very elegant and gentle manner or as though a 900 # gorilla is doing it. That's one consideration in the differential. The other is that, as someone mentioned, they require in most cases anything from light sedation to general anesthesia depending on the circumstances. 

Unless the lady has been hanging out in the sun and has sequela from that, she's having a systemic inflammatory response to something.


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## SpecialK (Sep 22, 2019)

What if we move her out of the sun and look again in 10 minutes, what do we see?

Does she have any history of h hypertension? Wait 15 minutes and repeat get blood pressure?


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## NomadicMedic (Sep 22, 2019)

silver said:


> What procedure was actually done? Was it under sedation or was she intubated?



All I got was an EGD and colonoscopy. Performed under sedation. No clue as to the agent used


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## silver (Sep 22, 2019)

This is going slow, so...

History of events today leading up to her laying on the couch in the sun? Did she bowel prep prior? Has she tolerated oral fluids after recovering? Peeing? Prior anesthetic history? Family anesthetic complications? 

Real exam?  Is her abdomen benign? Any focal neurologic findings or rigidity?

Move to cooler environment, IV fluids.


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## NomadicMedic (Sep 22, 2019)

She did the typical bowel prep yesterday. Procedure was this morning at the local scope shop. Vomits any fluid. Vomits crackers. No previous issues with any sedation that she knows of. Abdomen is soft and non tender. Blood glucose is 96. Not making much urine. Peeled a bit since coming home. Just a few drops. 

So, we all agree on fluids? Anything else...


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## NomadicMedic (Sep 22, 2019)

SpecialK said:


> What if we move her out of the sun and look again in 10 minutes, what do we see?
> 
> Does she have any history of h hypertension? Wait 15 minutes and repeat get blood pressure?



She doesn’t have any history at all aside from the IBS that she was getting scoped for. Again.


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## NomadicMedic (Sep 22, 2019)

I started an IV, 4mg of zofran. 500ml of normal saline.  Captured a 12 lead for grins.


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## Peak (Sep 23, 2019)

Street medic assessment/plan (I understand some of this has already been answered):

Airway/ENT: Patency, secretions?
Breathing/respiratory: Rate, depth, quality, breath sounds?
Circulation/cardiac: BP, quality of peripheral and central pulses, cap refill, cardiac sounds?
Neuro: AVPU, NIHSS?
GI: Onset of nausea, appearance of emesis any any bowel movements, abdominal sounds, palpation, percussion (typanic vs dull), liver edge, intake since discharge?
GU: Color/quality/quantity of urine that has been produced, CVA tenderness?
Skin/Lymph: Skin quality, brusing, any other visual abnormality, any palpable lymph nodes?
MS: general strength, tone?
Consitutional/endocrine: Fever history, chills, appetite?

Allergies, medical history, surgical history, travel in the past 3 weeks, daily medications (including those that were held or she has not taken), OTC/Rx'd meds since discharge, supplements, implants, anesthesia history (including any family history of anesthesia reactions), vaccination history?

BGL, EKG, capnography, vitals.

DDX:
I think that this patient is more likely to have an uncommon complication given the previous responses. With what seems to be a benign GI palpation/exam I doubt she has a perforation or infection. Therefore without a good infection source I doubt the patient is septic, I think that the fever may be from being somewhat poikilothermic older person or more likely from a more serious etiology; I would consider flu or other viral infection but she doesn't seem to fit with that disease profile.

I think that this patient is either having an atypical MH presentation or another cause of acute renal failure (be it from NSAIDs, other nephrotoxic medications, hypotension during the procedure, or whatever else).

Treatment: two large bore IVs, aggressive IV fluid management, consider antiemetics favoring those with less proclivity towards zofran due to the already present profound dehydration (in fact in this patient I would favor giving a small dose of ativan), foley if I suspect bladder distension, rapid transport to a center that stocks dantrolene and has CRRT capability.

Hospital course:
Patient needs to be rapidly assessed and differentiated for MH, sepsis/infection, and acute renal failure. CBC, CMP, gas/lactate, CRP, Procal, blood cultures, troponin UA/culture, respiratory viral panel, serial EKGs. Imaging is necessary but we need to consider that if we give contrast that we will probably damage her kidneys. Portable CXR and KUB, POC ultrasound (specifically looking at the kidneys, liver, and bladder), consider MR/CT based on initial labs and bedside imaging.

Admission and further treatment based on ED course, will probably need a CHCT at some point.


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## Carlos Danger (Sep 27, 2019)

So what was going on with her?


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## NomadicMedic (Sep 28, 2019)

the doc said said she was septic and had an MI. I gave her fluid and Zofran to treat her symptoms.  In the last few minutes of transport she started to be come confused. Coded in the ED, worked for 45 minutes and pronounced.


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## Tigger (Sep 28, 2019)

What did you call that EKG?


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## NomadicMedic (Sep 28, 2019)

New onset LBBB. She had no history.


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## E tank (Oct 1, 2019)

echo would tell a lot...PE is the go to dx short of anything else....


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## T1medic (Dec 12, 2019)

Hyperkalemia would be my guess. The previous day prep along with the current diarrhea plus the stomach bile leads me towards this. 
I may completely off here but id say that 12 lead is also indicative of hyper k+. Wide complex tachycardia yet not fast enough to be v-tach (see Amal Mattu). 
Most people tunnel to the "peaked t-waves" for hyper k+ but the v-tach mimic is seen when serum potassium levels get to the 8-9 mEq/L levels. 

This could explain why she arrested. 

My teatment would be A-B-C-D Albuterol, Bicarb, Calcium, Diuretic (Lasix). Would start with the bicarb and calcium first. 


Like I said. I could be way off, just my random thoughts.


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## wcspa (Mar 17, 2020)

want2savelives said:


> Hyperkalemia would be my guess. The previous day prep along with the current diarrhea plus the stomach bile leads me towards this.
> I may completely off here but id say that 12 lead is also indicative of hyper k+. Wide complex tachycardia yet not fast enough to be v-tach (see Amal Mattu).
> Most people tunnel to the "peaked t-waves" for hyper k+ but the v-tach mimic is seen when serum potassium levels get to the 8-9 mEq/L levels.
> 
> ...



While your management for hyperkalemia is correct, the inference of diarrhea and vomiting leading to hyperkalemia is not. Volume losses from the GI tract, i.e. vomiting and diarrhea, lead to hypokalemia -- not hyperkalemia.


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## VFlutter (Mar 17, 2020)

Remi said:


> So what was going on with her?



Whatever it is....blame Anesthesia 🤷‍♂️


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## Peak (Mar 17, 2020)

VFlutter said:


> Whatever it is....blame Anesthesia 🤷‍♂️


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## Carlos Danger (Mar 17, 2020)

VFlutter said:


> Whatever it is....blame Anesthesia 🤷‍♂️


You would never believe how true that actually is.


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