# Traffic Collision



## daedalus (Oct 10, 2008)

I got stuck on an ALS interfacility transport the other day, coming out of a small hospital ER going to UCLA Medical Center. While my partner, the paramedic, was obtaining the history and report from a nurse, I read the run sheet from the crew that brought him in. The RN than told my partner that he and the MD had no idea what was going on with the guy and he was going to UCLA for a advanced testing and a diagnosis. After reading the run sheet, looking at the patient, and hearing the RN say this, The HOUSE theme music suddenly started playing in my head. It was a perfect case for Dr. House.

Details-

53 y/o male was driving on the freeway, and all of a sudden cut across all four lanes of traffic and slammed into the center divider. He has no allergies, takes various hypertension and hyperlipidemia medications, had a CABG six days prior to this accident, ate right before the accident, and was on his way home from lunch with a friend. He states he has no memory of the accident, and has been in a state of drowsiness for several hours after the incident. The RN says a few times he was difficult to arouse. A physical examination revealed an actively bleeding "zipper" scar from the medial sternotomy, that looked very fresh and had self removed steri-strips the day before. He was still difficult to arouse when we were preparing him for the transport. Blood sugar was 126, 12 lead EKG was apparently normal for him, Blood pressures were around 126-120/64-70. All other vitals were within normal limits except for a sat of 94 on 2 liters. No hx of COPD, smoking, or home use of O2.

Doctors were very concerned on why he lost consciousness on the freeway. This was all very cool to me. Any ideas?


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## rhan101277 (Oct 10, 2008)

I'll try.  He could have had a seizure even with past history.  Did he have any bite marks or bleeding from his tongue.


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## Sapphyre (Oct 10, 2008)

Sepsis?  Or maybe he threw a clot due to not enough heparin during the CABG?


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## Code 3 (Oct 10, 2008)

Possible aneurysm from CABG surgery or clot as mentioned above. This sounds like a cardiac output problem and could be the reason for LOC prior to accident.


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## KEVD18 (Oct 10, 2008)

lupus......


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## Sasha (Oct 10, 2008)

Code 3 said:


> Possible aneurysm from CABG surgery or clot as mentioned above. This sounds like a cardiac output problem and could be the reason for LOC prior to accident.



If bleeding out enough to cause a loss of conciousness wouldnt his bp be affected? Vitals all seem pretty normal to me


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## Code 3 (Oct 10, 2008)

Sasha said:


> If bleeding out enough to cause a loss of conciousness wouldnt his bp be affected? Vitals all seem pretty normal to me



Not bleeding out, persay. If his cardiac output is inefficient it could cause him to have a syncopal episode and crash. Remember, those vitals were taken while in the hospital and being prepared for an IFT -- not during the accident.


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## Bosco578 (Oct 10, 2008)

He is faking it.


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## daedalus (Oct 10, 2008)

KEVD18 said:


> lupus......



The Dx that fits everything from House's perspective! Haha.

I have no idea what happened to the guy. Seizures, Cardiac Output issues, all good guesses. I just thought it was interesting because of the bleeding surgical site and no apparent traumatic reason for it.


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## BossyCow (Oct 10, 2008)

Depending on how long before the surgery was, he could have had an encapsulated infection at the surgical incision that dehisced.


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## VentMedic (Oct 11, 2008)

Start with the basics since this is an interfacility transport and some data should be available:

Temperature spike? 

Meds:
Are any of the post-operative meds interacting with his regular maintenance meds? Pain? Anti-hypertensives?

Labs:
PT, PTT, Platelets, INR, H&H, WBC

Acid-Base?

Electrolytes, Anion Gap, Lactate

Renal function: Input/Output, BUN, Creatinine


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## Airwaygoddess (Oct 11, 2008)

*Post op hearts......*

To add along with Vent's assessment, Post up hearts are not to drive for at least 6 weeks due to the medications that they are taking and also for the lack of sleep which happens while in the hospital.  I would also look towards possible TIA's.


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## mycrofft (Oct 11, 2008)

*If this were House...*

Someone would pipe up with "Paraneoplastic Syndrome" whatever that is.
Not remembering the accident or the immediate prelude and being fuzzy thereafter is normal for a good old crash. Was this CABG done "on the gallop" or on cardiopulmonary bypass? ("Pump Head"?). TIA from a clot leading to vertigo or neuromuscular seizure event? Maybe he was driving with hs cell phone...


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## Melanie77 (Nov 12, 2008)

hm im not sure that could definitley go up for a debate


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## tatersalad (Nov 13, 2008)

sounds familiar to what happened with a buddy of mine. Ended up being a glioblastoma.


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