# 45 yom, unknown medical problem



## abckidsmom (Jun 30, 2012)

1130 on a Tuesday, you're dispatched 3 dues away for an unknown medical problem.  Caller states pt wasn't acting right, and now has an altered mental status.  History of MI and HTN.

During your response, first responders arrive and upgrade the call to a cardiac arrest, then correct themselves and states that the patient is unresponsive with snoring respirations.

On arrival, you find the 45 yom unresponsive to painful stimulus, with fast, deep respirations, airway is clear, he accepts an NPA.  Skin is hot, red and sweaty...it's about 80 in the room, and a hot day.  You see a couple of scrapes on his elbows and the lateral side of one hand.  

Initial vitals:
P: 138
BP: 230/124
R: 32, deep, BBS clear
T: 99.8
SpO2:  86% RA
CBG: 164

You talk to the family, and they say they aren't too sure what happened, he'd been feeling weak and crabby all day, and was sitting in the chair when he stopped responding.  Some minutes later, after first responders were there, he somehow fell out of the chair.  The family present is the patient's mother, who is not a very good historian, and doesn't have many deatils.  She is able to fill you in on his PMH:

MI 2 years ago, with 4 stents placed
HTN, poorly controlled

Meds:
Clonidine 0.3 mg tabs QID
Simvastatin
Lisinopril 40 mg BID
Plavix

When you get him up on the stretcher, he regains consciousness enough to pull the NPA, yank at the oxygen mask, and generally be a little combative.  His gaze is empty, and he is aphasic.

In the ambulance the head to toe looks like this:

HEENT:  Pupils are 3 mm L/2 mm R, R facial droop, no JVD in high semifowlers, no trauma noted
Resp:  BBS clear and equal, respirations still deep and rapid, mild accessory muscle use
CV:  Skin warm and moist, no longer red.  Radial pulses are bounding.  BLEs mottled and dusky, cool and pulseless.  EKG Sinus tach, no ectopy, no signs of ischemia or infarct on 12 lead
Abd: Firm with ascites, no masses on palpation, liver is palpable well below the costal margin.  
GI/GU:  No incontinence, no reported GI complaints.
Extremities:  As noted, with mild abrasions to BUEs. No movement of RUE, pt is combative with LUE.

You're an hour from the closest hospital, 25 minute ETA of closest helicoptor.  You're on the truck today with your BLS partner, and the BLS first responders look at you and say "what do you need?"


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## VFlutter (Jun 30, 2012)

Any peripheral edema? Musty Odor to breath? jaundice?


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## abckidsmom (Jun 30, 2012)

ChaseZ33 said:


> Any peripheral edema? Musty Odor to breath? jaundice?



No peripheral edema, odor of ETOH on his breath, mild jaundice.  

Pts mother states that he has had "two beers" today.  Ah, the usefulness of "two beers..."


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## VFlutter (Jun 30, 2012)

abckidsmom said:


> No peripheral edema, odor of ETOH on his breath, mild jaundice.
> 
> Pts mother states that he has had "two beers" today.  Ah, the usefulness of "two beers..."



That was my next question haha pupils fixed at 3/2 or reactive? Heart sounds?


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## MassEMT-B (Jun 30, 2012)

Just kind of a shot in the dark you said there were abrasions, any recent history of a fall?


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## abckidsmom (Jun 30, 2012)

MassEMT-B said:


> Just kind of a shot in the dark you said there were abrasions, any recent history of a fall?



All the family can say is that he had no fall, just somehow fell out of his chair.  It may have been witnessed, but they are freaking out.


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## EMT91 (Jun 30, 2012)

The hypertension added to the right sided weakness and facial droop makes me think stroke or tia. However...I feel that is too simple.

Sounds like it might possibly be Acute Kidney Failure:
The Jauidice, AMS, the elbows, the fall could have been caused by the loss of sensation,,,I do not know.


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## NomadicMedic (Jun 30, 2012)

Blurred vision? Headache?

Oh that's right. He's aphasic. :/

Hypertensive crisis followed by a CVA? 

Ahhh...

My guess is gonna be sepsis. Do you have a lactate meter on board?


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## VFlutter (Jun 30, 2012)

EMT91 said:


> The hypertension added to the right sided weakness and facial droop makes me think stroke or tia.



My first thought too, but it would expect the patient to be bradycardic and have irregular respirations with increasing ICP. The pulseless lower extremities Is very interesting along with the suspected hepatomegaly and jaundice. I think it will end up being a cluster of multisystem problems. I am trying to think how hepatic encephalopathy would present, it may explain the Neuro and liver problems mixed with pre-existing HTN and maybe a little ETOH abuse mixed in


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## Aidey (Jun 30, 2012)

Sounds like he has portal hypertension. Encephalopathy, a HTN crisis, or CVA/TIA are the 3 main things that come to mind.


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## NomadicMedic (Jun 30, 2012)

Aidey said:


> Sounds like he has portal hypertension. Encephalopathy, a HTN crisis, or CVA/TIA are the 3 main things that come to mind.



Yep. And which one kills him first?


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## VFlutter (Jun 30, 2012)

Stupid Ipad


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## VFlutter (Jun 30, 2012)

n7lxi said:


> Yep. And which one kills him first?


 My guess would be the impending herniation from a massive SAH or cerebral edema


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## STXmedic (Jun 30, 2012)

Yeah, but that's too obvious for a scenario  I like Chase's theory of hepatic encephalopathy.

Has the patient been feeling ill or acting different lately? Temp? EtCO2?

Combative, S/S of brain injury, AND interfering with treatments? Somebody just bought themselves a tube 

I'm assuming you aren't going to be nice enough to give us blood work?  Chem panel, LFT, nothin'?


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## VFlutter (Jun 30, 2012)

How is that tube going to effect his ICP......I'm guessing heavy on the meds


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## EMT91 (Jun 30, 2012)

PoeticInjustice said:


> Yeah, but that's too obvious for a scenario  I like Chase's theory of hepatic encephalopathy.
> 
> Has the patient been feeling ill or acting different lately? Temp? EtCO2?
> 
> ...



This is true. However, the Peripheral edema is missing...did you catch any smells from the feet?


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## VFlutter (Jun 30, 2012)

EMT91 said:


> This is true. However, the Peripheral edema is missing...did you catch any smells from the feet?



True but she did state that the lower extremities were cold, mottled and pulseless. So something seems to be going on


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## EMT91 (Jun 30, 2012)

ChaseZ33 said:


> True but she did state that the lower extremities were cold, mottled and pulseless. So something seems to be going on



For sure lol.....

Did you get a second or third set of vitals?


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## STXmedic (Jun 30, 2012)

ChaseZ33 said:


> How is that tube going to effect his ICP......I'm guessing heavy on the meds



Not as dramatically as him fighting you treating him. Vec, fent, and versed should work nicely. Now he's not fighting, and you can control his airway and breathing.


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## abckidsmom (Jun 30, 2012)

EMT91 said:


> The hypertension added to the right sided weakness and facial droop makes me think stroke or tia. However...I feel that is too simple.



Probably too simple. 



> Sounds like it might possibly be Acute Kidney Failure:
> The Jauidice, AMS, the elbows, the fall could have been caused by the loss of sensation,,,I do not know.




Not renal failure.  



n7lxi said:


> Blurred vision? Headache?
> 
> Oh that's right. He's aphasic. :/
> 
> ...



Lactate is 1.8.  




ChaseZ33 said:


> My first thought too, but it would expect the patient to be bradycardic and have irregular respirations with increasing ICP. The pulseless lower extremities Is very interesting along with the suspected hepatomegaly and jaundice. I think it will end up being a cluster of multisystem problems. I am trying to think how hepatic encephalopathy would present, it may explain the Neuro and liver problems mixed with pre-existing HTN and maybe a little ETOH abuse mixed in



How might hepatic encephalopathy present?

How might ETOH abuse come into this situation?




Aidey said:


> Sounds like he has portal hypertension. Encephalopathy, a HTN crisis, or CVA/TIA are the 3 main things that come to mind.



A person with a list of 3 differentials!  Woot!  Can you expand it any more?



PoeticInjustice said:


> Yeah, but that's too obvious for a scenario  I like Chase's theory of hepatic encephalopathy.
> 
> Has the patient been feeling ill or acting different lately? Temp? EtCO2?
> 
> ...



As you're pulling out of the driveway, the wife hops in the front seat, so you start all over with her on the history.  The only additional info you get from her is that he's been on vacation, and has been extremely motivated about getting long-term projects around the house that he's been putting off done.  He's been in a good mood until last night and today he has been feeling like crap.  No real specific symptoms, just "sick."


So, you decided to transport by ground because you know as well as the next guy that you can beat the helicoptor to the hospital, even though it's going to be an eternity until you get there.

He remains hypertensive and tachycardic for another 40 minutes, desatting off of oxygen at 4 liters.  No real change in his condition, until you cycle the cuff one time and this is the new set of vitals:

BP 108/58
HR 134
RR 22
SpO2 98 (4L)

Mental status remains unchanged, assessment also basically unchanged.

When you call the hospital, what are you going to say?  You're headed for a community hospital with a full range of services except trauma, and the university medical center is an additional 15 minutes away.  Do you want to change the destination?

You still have 20 minutes left in this ride when you got this set of vital signs.  There are 2 closer hospitals you're planning to drive past in order to get to the one you've chosen.  Do you want to pull into one of them?

Is this guy gonna die today?


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## EMT91 (Jun 30, 2012)

abckidsmom said:


> Probably too simple.
> 
> 
> 
> ...


The renal failure was just a guess with the s/s. I knew stroke TIA would be too simple lol. Can someone explain this:
Lactate is 1.8.  
?


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## NomadicMedic (Jun 30, 2012)

EMT91 said:


> The renal failure was just a guess with the s/s. I knew stroke TIA would be too simple lol. Can someone explain this:
> Lactate is 1.8.
> ?



A serum lactate of 4.0 or greater is a marker that may indicate sepsis.


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## EMT91 (Jun 30, 2012)

n7lxi said:


> A serum lactate of 4.0 or greater is a marker that may indicate sepsis.



Perhaps you could PM me and explain Serum Lactates?


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## NomadicMedic (Jun 30, 2012)

EMT91 said:


> Perhaps you could PM me and explain Serum Lactates?



Or you could feel free to google it.


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## VFlutter (Jun 30, 2012)

Hmm maybe some kind of excessive catecholamine dump that finally broke? Or he is bleeding or 3rd spacing fluid somewhere. Abdomen distended / worsening ascietes?


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## abckidsmom (Jun 30, 2012)

ChaseZ33 said:


> *Hmm maybe some kind of excessive catecholamine dump that finally broke?* Or he is bleeding or 3rd spacing fluid somewhere. Abdomen distended / worsening ascietes?



You are on to something here... Where could an apparent alcoholic get this prolonged altered mental status and catecholamine dump?


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## VFlutter (Jun 30, 2012)

abckidsmom said:


> You are on to something here... Where could an apparent alcoholic get this prolonged altered mental status and catecholamine dump?



delirium tremens? However symptoms
Usually don't develop until 2-3 days after the last drink and he drank "a few" today


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## STXmedic (Jun 30, 2012)

Does the wife know of any recent weight-loss?


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## abckidsmom (Jun 30, 2012)

ChaseZ33 said:


> delirium tremens? However symptoms
> Usually don't develop until 2-3 days after the last drink and he drank "a few" today



The history from the family was ridiculous.  

When we put him on the CT scanner table, I was giving report to the Chief of Neurology of this hospital.  Midday on a Tuesday and all, the gang was all available.  One of the staff members said, "He looks post-ictal," and that was like a spotlight shining on the guy for me.

This is not my first time following Todd's Paresis down the path of stroke alert, and yet, I totally fell for this dude.  He was very convincing, and I think the hypertension really helped a lot.  

Turns out, this guy left work on Friday, knowing he was taking a week or two for vacation and intending to quit drinking.  He had one last weekend of fun, and stopped drinking Sunday night.  He was feeling bad on Monday afternoon, and Tuesday morning was entering DTs.  He had a seizure (called back the first responder to get a coherent description now that he wasn't shaking in his boots anymore, and he totally witnessed a seizure.

So, they admitted him for medically supervised detox, kept him on some benzos, and the theory goes that he will live happily ever after, except for his poor shriveled up, ammonia-poisoned brain.

So, all this to say, that's why you don't typically stroke alert people who have confirmed seizure activity.

He would have needed the head CT anyway, she said self-protectively.    I don't think the Chief of Neuro minded much, he was really surprised when the CT came out with no big bleed.  

I just wanted to share this one because I felt like the clues were there the whole time, but I missed them in the face of the glaring signs pointing at CVA.  I learned how important it is to explore all the differentials, not just the one you really think it is.


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## DPM (Jun 30, 2012)

I'm thinking Seizure. Especially after the "It's Cardiac Arrest, no wait it's resp. arrest, well no he's breathing now but etc etc" at the beginning.

Any family history?


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## STXmedic (Jun 30, 2012)

:rofl:

Good scenario, Dana! Thanks! Todd's paresis is a new one for me


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## NomadicMedic (Jun 30, 2012)

Good scenario. Thanks for sharing.


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## abckidsmom (Jun 30, 2012)

PoeticInjustice said:


> :rofl:
> 
> Good scenario, Dana! Thanks! Todd's paresis is a new one for me



I first saw it in a 16 month old 27 week gestation NICU grad who was developing a seizure disorder.  That sweet girl became a twice weekly frequent flier for us, and she was down on the left during her post-ictal time almost every time.  

The first time, I tried to alert her, and the hospital refused, but offered no explanation.  It was a steep learning curve, but I learned my lesson then.

Apparently it didn't stick.


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## abckidsmom (Jun 30, 2012)

PS They were going to refer him to vascular for those nasty looking legs.  No immediately theories were coming up to explain that red herring.


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## MadMedic (Jun 30, 2012)

Great scenario!  Todd's Paresis is new for me too and will be sharing that with all my co-medics.  I'm also going to use this for training.  

As I read it I was first thinking Stroke, then DT's, thinking 2 beers were not enough for this guy.  But some how i missed the seizure all together.

Thanks again for this one, everyday is a learning day, and I learned something today!


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## EMT91 (Jun 30, 2012)

Honest to God, I was really thinking seizure but ruled it out due to it not being witnessed. I was thinking---->Acute Renal Failure----->caused a absent seizure------>fell from chair----->got bruised.


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## Aidey (Jun 30, 2012)

Where did you get acute renal failure from?


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## EMT91 (Jun 30, 2012)

Aidey said:


> Where did you get acute renal failure from?



http://www.nlm.nih.gov/medlineplus/ency/article/000501.htm

The symptoms fit at places. Also, one of my instructors said she found a guy with ETOH breath who had kidney failure.


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## Aidey (Jun 30, 2012)

What symptoms in the first post made you personally think that?


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## EMT91 (Jun 30, 2012)

Aidey said:


> What symptoms in the first post made you personally think that?



BP: 230/124
weak and crabby all day
he somehow fell out of the chair
mild abrasions to BUEs
odor of ETOH on his breath, mild jaundice.

ARF lists HTN, AMS, tiredness (could be described as being weak) breath odor, and seizures.


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## Aidey (Jun 30, 2012)

Why the abrasions? 
Jaundice is caused by liver failure, not renal failure. 
Renal failure usually causes the breath to smell like ammonia, not alcohol.


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## EMT91 (Jun 30, 2012)

Aidey said:


> Why the abrasions?
> Jaundice is caused by liver failure, not renal failure.
> Renal failure usually causes the breath to smell like ammonia, not alcohol.





NOTE: I am a basic, so forgive me if I am not the brightest lol
The abrasions I got from the easy to bruise idea, a stretch but yeah.

http://medical-dictionary.thefreedictionary.com/jaundice 
that mentions Kidney failure as a possible cause 

The breath...well I never knew what it made the breath smell like, all I knew is that in one case one of my instructors told our class, she smelt alcohol and ironically enough:
"So, they admitted him for medically supervised detox, kept him on some benzos, and the theory goes that he will live happily ever after, except for his poor shriveled up, ammonia-poisoned brain. "


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## mycrofft (Jul 1, 2012)

Stray shots:

ALCOHOL ON BREATH: so many people with other aromatics including diabetic acetone (DKA) and petroleum distillates have been identified as "ETOH on breath" that law officers and forensic health providers cite "alcohol-like odor" or "scent reminiscent of alcohol". Be careful.

ETOH DETOX: having many years of interesting observation subjects (arrested while drinking, so we had a confirmed date and time of last drink, followed by Q 4 hr vitals and frequent count/other observation), I can make these generalizations:
1. If the liver is working and the pt has no other contributing conditions or toxins, clinical detox (elevated BP, elevated pulse, complaints of abdominal distress, feeling jittery, sleeplessness) progressing to physiologic detox (tremor including areas not likely to have pseudo tremors, diarrhea, nausea/vomiting) starts within 48 hrs. 

2. If the liver is not working well (evidenced by labs), the benzos for detox don't take effect promptly and seem to build in the bloodstream. I've seen pt's crash apparently from Valium OD on Day 4 post ETOH and the best we could ever figure out was the valium we kept pushing was not being activated by the liver, nor was it being excreted.


Focal paresis postictal! I need to remember that. I'll still teach by basic First Aiders to continue with their FAST eval for stroke, though.


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## EMT91 (Jul 1, 2012)

mycrofft said:


> Stray shots:
> 
> ALCOHOL ON BREATH: so many people with other aromatics including diabetic acetone (DKA) and petroleum distillates have been identified as "ETOH on breath" that law officers and forensic health providers cite "alcohol-like odor" or "scent reminiscent of alcohol". Be careful.
> 
> ...


 So, my Renal Failure Idea was not a bad idea, per se?


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## Veneficus (Jul 1, 2012)

abckidsmom said:


> You're on the truck today with your BLS partner, and the BLS first responders look at you and say "what do you need?"



A CT scan.

depending on the results of that, a neurosurgeon or neurologist with some mannitol, steroids, and Tpa.


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## Aidey (Jul 1, 2012)

EMT91 said:


> NOTE: I am a basic, so forgive me if I am not the brightest lol
> The abrasions I got from the easy to bruise idea, a stretch but yeah.
> 
> http://medical-dictionary.thefreedictionary.com/jaundice
> ...




Jaundice is caused by a build up of bilirubin in the blood stream.  Bilirubin is a component of hemoglobin which is the part of the red  blood cell that allows the cell to carry oxygen. Red blood cells have a  life span of about 3-4 months and when they die the bilirubin in them is  released, processed in the liver and excreted as a waste product.  Bilirubin is the reason urine is yellow, feces are brown, and bruises  turn yellow. Your body is constantly excreting bilirubin because red  blood cells die all of the time.  

There are several conditions that cause abnormal red blood cell  breakdown and kidney damage. Those patients can develop jaundice along  with kidney failure, due to the extra bilirubin being released from the  red blood cells and building up. I'm pretty sure those conditions are  what the link was talking about. Look up hemolytic uremic syndrome, and  that should explain it pretty well. It also is possible to run into  patients who have both renal and liver dysfunction because they are just  all around unhealthy people. 

Chronic kidney failure actually causes anemia. The kidneys produce  erythropoietin, which is a hormone that tells the bone marrow to make  more red blood cells. When the kidneys fail, they stop producing epo,  and thus the patient becomes anemic. Less red blood cells means less  hemaglobin which means less bilirubin. As far as I know, jaundice is not  a normal side effect of non-hemolytic kidney failure. 


The very short version is that when you see jaundice, think liver, not kidneys.


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## EMT91 (Jul 1, 2012)

Aidey said:


> Jaundice is caused by a build up of bilirubin in the blood stream.  Bilirubin is a component of hemoglobin which is the part of the red  blood cell that allows the cell to carry oxygen. Red blood cells have a  life span of about 3-4 months and when they die the bilirubin in them is  released, processed in the liver and excreted as a waste product.  Bilirubin is the reason urine is yellow, feces are brown, and bruises  turn yellow. Your body is constantly excreting bilirubin because red  blood cells die all of the time.
> 
> There are several conditions that cause abnormal red blood cell  breakdown and kidney damage. Those patients can develop jaundice along  with kidney failure, due to the extra bilirubin being released from the  red blood cells and building up. I'm pretty sure those conditions are  what the link was talking about. Look up hemolytic uremic syndrome, and  that should explain it pretty well. It also is possible to run into  patients who have both renal and liver dysfunction because they are just  all around unhealthy people.
> 
> ...


Normally, I do think liver. I do not know why, but something just told me Kidneys. My instructor told us When you hear hoofs, think horses not zebras. . But was my thought process way off or do you see where I was coming from?


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## Aidey (Jul 1, 2012)

The horse in this case would be the liver, not the kidneys.


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## EMT91 (Jul 1, 2012)

Aidey said:


> The horse in this case would be the liver, not the kidneys.



I know. But was my thought process way off or do you see how I arrived at renal?


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## DPM (Jul 1, 2012)

EMT91 said:


> I know. But was my thought process way off or do you see how I arrived at renal?



Renal isn't a bad guess, and is partly correct. It's just that it is most likely Renal failure / disease secondary to Liver Failure (and probably renovascular hypertension  / Renal Stenosis too).


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## Aidey (Jul 1, 2012)

EMT91 said:


> I know. But was my thought process way off or do you see how I arrived at renal?



I think the best way I can put it is that I don't understand how you arrived at renal without stopping at hepatic first.



DPM said:


> Renal isn't a bad guess, and is partly correct. It's  just that it is most likely Renal failure / disease secondary to Liver  Failure (and probably renovascular hypertension  / Renal Stenosis  too).



How is renal partly correct?


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## DPM (Jul 1, 2012)

I should re-phrase that. The PT undoubtedly will have Kidney problems if they have Liver failure and uncontrolled hypertension. Atherosclerosis that is severe enough to require x4 cardiac stents is easily enough to start blocking up the delicate renal vasculature. 

It isn't a Kidney issue that is causing the majority of our PT's problems, I was just pointing out that his seizure and liver failure aren't the only problems we're seeing evidence of.


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## Melclin (Jul 1, 2012)

I'm familiar with Todd's paralysis but it didn't occur to me either. I've only every heard of Todd's in relation to partial motor seizures, and then with the caveat that the longer it goes on for, the less likely it is to be Todd's doing. 

I think it would have been irresponsible not to call this in as a stroke. Bleed was highest on my list and I think it should be high enough on most people's list to warrant a stroke alert. 

I don't look at stroke alerts as being a diagnosis of stroke on my part, I look at them as the recognition of the fact that the patient needs an emergent CT scan and neuro attention.


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## abckidsmom (Jul 1, 2012)

Melclin said:


> I'm familiar with Todd's paralysis but it didn't occur to me either. I've only every heard of Todd's in relation to partial motor seizures, and then with the caveat that the longer it goes on for, the less likely it is to be Todd's doing.
> 
> I think it would have been irresponsible not to call this in as a stroke. Bleed was highest on my list and I think it should be high enough on most people's list to warrant a stroke alert.
> 
> I don't look at stroke alerts as being a diagnosis of stroke on my part, I look at them as the recognition of the fact that the patient needs an emergent CT scan and neuro attention.



Looking at him retrospectively with the thought of that witnessed by a "healthcare provider" seizure, this whole story changes.  I think this just shows how important the history is, and how obnoxious it is when you can't get the information you need out of the people on the scene.  

It's great that they turned him on his side to keep his tongue from occluding his airway, but other than that, the first responders actually got in the way on this one.  The patient's mom, at the hospital, said something like, "I thought it might have been a seizure, but that guy didn't know, so I wasn't sure."

Awesome.


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## VFlutter (Jul 1, 2012)

Wouldnt you expect a seizing patient to have slightly elevated lactate levels? They have a lot of muscle activity during an apnic state which would result in anaerobic metabolism and an increase in lactate? Just my thinking


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## Melclin (Jul 1, 2012)

abckidsmom said:


> Looking at him retrospectively with the thought of that witnessed by a "healthcare provider" seizure, this whole story changes.  I think this just shows how important the history is, and how obnoxious it is when you can't get the information you need out of the people on the scene.
> 
> It's great that they turned him on his side to keep his tongue from occluding his airway, but other than that, the first responders actually got in the way on this one.  The patient's mom, at the hospital, said something like, "I thought it might have been a seizure, but that guy didn't know, so I wasn't sure."
> 
> Awesome.



Yeah good information to have but if I had a pt acting strangely with unilateral neuro symptoms who then has a seizure, I'd be more worried about a bleed, not less. 

I don't think that knowledge would have changed anything for me other than to increase my index of suspicion for a bleed, but perhaps I'm wrong. How would it have changed your management or you handover other than adding the info?


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## EMT91 (Jul 1, 2012)

Aidey said:


> I think the best way I can put it is that I don't understand how you arrived at renal without stopping at hepatic first.
> 
> 
> 
> How is renal partly correct?



You are right. I am not sure how I skipped that link. The other symptoms were there and being that my knowledge only so far lol.


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## blindsideflank (Jul 1, 2012)

I still think itsa bleed... No, but I was convinced too, especially if this was a call and I wasn't aware of a "tricky" scenario.
Subdural is the thought that comes to mind, add the meds (plavix I think) etoh, vitals and findings.


So with a bp/map that high and a high heart rate is it suggestive of not elevated icp? Vs say a bradycardia


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## DPM (Jul 1, 2012)

blindsideflank said:


> So with a bp/map that high and a high heart rate is it suggestive of not elevated icp? Vs say a bradycardia



Hypertension, bradycardia and irregular breathing / widening pulse pressure would have made me think increased ICP. All we had was hypertension, which was borderline hypotension after the 2nd set of vitals...

It's a great scenario though, and I didn't know about Todd's until now. Ironically, I thought seizure before we got into the S/S... then the numbers came along and started to confuse me!


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## abckidsmom (Jul 1, 2012)

blindsideflank said:


> I still think itsa bleed... No, but I was convinced too, especially if this was a call and I wasn't aware of a "tricky" scenario.
> Subdural is the thought that comes to mind, add the meds (plavix I think) etoh, vitals and findings.
> 
> 
> So with a bp/map that high and a high heart rate is it suggestive of not elevated icp? Vs say a bradycardia



This was a real call. They are all potentially tricky scenarios.


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## Handsome Robb (Jul 1, 2012)

blindsideflank said:


> I still think itsa bleed... No, but I was convinced too, especially if this was a call and I wasn't aware of a "tricky" scenario.
> Subdural is the thought that comes to mind, add the meds (plavix I think) etoh, vitals and findings.
> 
> 
> So with a bp/map that high and a high heart rate is it suggestive of not elevated icp? Vs say a bradycardia




Bleed is a thought but there's only one side of the three-sided triangle that makes up Cushing's triad and some could argue there are no signs with a Hx of HTN and non-compliance with medication. Then with the second set of vitals there are no signs of increased ICP.

People generally say HTN is part of Cushing's but technically it is a widened pulse pressure by an increase in the systolic pressure. The diastolic will increase as well but not nearly as much as the systolic. The body is trying to increase cerebral perfusion pressure while attempting to keep Intracranial pressure down hence the increase in systolic rather than diastolic. 

I learned something new today. Todd's paresis is a new one, or I just missed it in class. Both are viable options.


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## FLdoc2011 (Jul 1, 2012)

NVRob said:


> Bleed is a thought but there's only one side of the three-sided triangle that makes up Cushing's triad and some could argue there are no signs with a Hx of HTN and non-compliance with medication. Then with the second set of vitals there are no signs of increased ICP.
> 
> People generally say HTN is part of Cushing's but technically it is a widened pulse pressure by an increase in the systolic pressure. The diastolic will increase as well but not nearly as much as the systolic. The body is trying to increase cerebral perfusion pressure while attempting to keep Intracranial pressure down hence the increase in systolic rather than diastolic.
> 
> I learned something new today. Todd's paresis is a new one, or I just missed it in class. Both are viable options.



Just want to point out that you shouldn't discount a potential bleed just because you don't have Cushing's triad or other signs of ICP.    We get a lot of bleeds transferred in regularly and the vast majority don't exhibit that triad, I'll see it only occasionally when SHTF and they're about to herniate.  Part of this is also probably more true in older patients who naturally have some degree of cerebral atrophy and hence more space in their cranium for blood. 

 It's good to know the textbook presentation and all these "traids" but just remember that things can present differently in different people.  Never say never.


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## Handsome Robb (Jul 1, 2012)

Sorry had to run to a call.

Cerebral perfusion pressure = MAP - ICP

MAP = [(2xdiastolic) + systolic] / 3

While increasing the diastolic would increase the MAP much quicker it would also boost your ICP much faster as well.


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## Handsome Robb (Jul 1, 2012)

FLdoc2011 said:


> Just want to point out that you shouldn't discount a potential bleed just because you don't have Cushing's triad or other signs of ICP.    We get a lot of bleeds transferred in regularly and the vast majority don't exhibit that triad, I'll see it only occasionally when SHTF and they're about to herniate.  Part of this is also probably more true in older patients who naturally have some degree of cerebral atrophy and hence more space in their cranium for blood.
> 
> It's good to know the textbook presentation and all these "traids" but just remember that things can present differently in different people.  Never say never.



Agreed. Sorry, shouldn't have put that as an absolute.


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## mycrofft (Jul 1, 2012)

abckidsmom said:


> Looking at him retrospectively with the thought of that witnessed by a "healthcare provider" seizure, this whole story changes.  I think this just shows how important the history is, and how obnoxious it is when you can't get the information you need out of the people on the scene.



Didn't Gregory House MD tell us that for years?


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## blindsideflank (Jul 3, 2012)

NVRob said:


> Bleed is a thought but there's only one side of the three-sided triangle that makes up Cushing's triad and some could argue there are no signs with a Hx of HTN and non-compliance with medication. Then with the second set of vitals there are no signs of increased ICP.
> 
> People generally say HTN is part of Cushing's but technically it is a widened pulse pressure by an increase in the systolic pressure. The diastolic will increase as well but not nearly as much as the systolic. The body is trying to increase cerebral perfusion pressure while attempting to keep Intracranial pressure down hence the increase in systolic rather than diastolic.
> 
> I learned something new today. Todd's paresis is a new one, or I just missed it in class. Both are viable options.



Right, that's why I raised the question about bp/map...

Also, I know this was a real Call and they can be tricky. I meant bleed was the top for the differential and I suspected that it would turn out to be something else or he wouldn't bother posting it as it would present as much of a learning opportunity.


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## LgLuigiman (Jul 5, 2012)

I'm surprised that Todd's Paresis is so new to everyone. I'm going to guess most people learned about it, but just not by that name. Looking back in the textbook (assuming most of you used the big orange Emergency Care and Transportation of The Sick and Injured), I found that postictal hemiparesis is actually a key term (page 576 if we need to get specific). They just don't use the actual words "Todd's Paresis". I'm gonna bet this rings more of a bell for most people.


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## shiroun (Jul 18, 2012)

I know I may be wrong on this, and you guys do have more experience with it.

However, it almost seems like he had symptoms of CO poisoning. The hot red and sweaty is what links that to me. Maybe heat stroke? What was he doing prior to sitting down and having a couple of beers? If he'd over-exerted himself, come inside and had a few beers, maybe he just had a severe orthostatic hypotension? It would explain his scrapes. He's sitting down, goes to grab a couple more beers, stands up and is out for the count. If he'd been sitting for a really long period of time, and banged his head good enough, it could potentially cause a disrupted heart rhythm, right? That would explain the loss of a pulse by first responders (that or human error, take your pick).


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