# "I feel faint and crampy in my arms and legs"



## paccookie (Jul 10, 2009)

You are a medic on a medic/medic truck.  You are called non-emergency to a reported fall from a standing position at home.  Pt reported to be C/A/O.  Arrive on scene and find the pt's wife at the door saying, "I think his sugar dropped."  Pt is sitting on the couch, looking fatigued.  History of HTN, IDDM (poorly controlled), MI, right BKA, CHF.  Meds include Zaroxolyn, Lasix, Lisinopril, ASA, Coreg, Plavix, Digoxin.  Pt is C/A/O, but is a little slow to respond.  He seems tired, as though answering your questions requires great effort.  He states that he came home from work, ate lunch and gave himself 10 units of regular insulin.  Then he sat down on the couch and felt like he passed out.  And now you're here.  Wife is worried about his heart.  Skin is cold and diaphoretic.  Unable to palpate radial pulses.  Initial blood glucose is "high."  What's your next move?


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## WuLabsWuTecH (Jul 10, 2009)

Let's get him on high flow O2 and the monitor and start getting ready to go toward the hospital.  Take vitals and get another glucose check.  Since we didn't get a radial pulse, we might have low BP so hold off on the nitro until we get a BP.  Spike a bag and get ready for an IV.  Does he have allergies to meds?


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## daedalus (Jul 10, 2009)

Age of patient?

Lets sit this gentleman down on our gurney and get some O2 going while you revel his vital signs and glucometer, oximetry, BP, EKG. Lets also do a quick PE. HEENT, CV, pulm, and extremties. 

Treatment at this point: Empirical. Monitor, O2, IV insertion fearing possible further collapse.


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## Aidey (Jul 10, 2009)

Also a 12 lead.

I would also do serial blood glucose checks, probably every 5 minutes apart depending on transport time.


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## paccookie (Jul 10, 2009)

Pt is 58.  Monitor shows normal sinus rhythm at 70 bpm.  O2 sat initially 94%, now 100% on 4L.  BP is 84/50, very difficult to auscultate.  Lungs clear and equal, heart tones clear.  Trachea midline, no jugular venous distention.  Respirations 16 and non-labored.  No increased work of breathing, no hyperpnea, no retractions, no accessory muscle use.  Pt states that his chest pain is crampy and that his arms and leg hurt worse than his chest.  He says that his left leg is the worst and feels like it is folding up on him.  12 lead shows T wave inversion in leads I, AVF, V5.  Q waves in II, III, AVF, V5, V6.  No ST elevation or depression.  Repeat blood glucose is 594.  Capillary refill is sluggish and >3 sec.  Extremities are cold.  Your partner has established two IVs - an 18 gauge in the left AC and a 20 gauge in the right forearm.  You start fluids - one saline and one ringers.  

Wanna do anything else?  You are enroute to the hospital.  15 minute ETA.


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## mycrofft (Jul 10, 2009)

*High blood suger isn't first worry here.*

That's the slow killer, 15 min won't hurt more. Focus on ABC's. If allowed might get blood for 'lytes, but no time saver there. O2, EKG, assess for hidden bleeding, get hx before pt losses consciousness.
If possible, bring his meds including insulin along. Include any herbals and vitamins.


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## paccookie (Jul 10, 2009)

mycrofft said:


> That's the slow killer, 15 min won't hurt more. Focus on ABC's. If allowed might get blood for 'lytes, but no time saver there. O2, EKG, assess for hidden bleeding, get hx before pt losses consciousness.
> If possible, bring his meds including insulin along. Include any herbals and vitamins.



Airway is open and patent.  Pt is talking to you, answering questions.  LOC is improving, he appears to be waking up a bit now that he's in your truck.  He says the pain in left leg is worse, but the chest pain has improved (only med given is O2, normal saline and lactated ringers hanging).  Breathing 18/min, non-labored.  Lungs clear and equal.  Still no palpable radials.  Skin cold and clammy.  Pt no longer sweating.  No abdominal pain, no swelling, no rigidity, no mass, no guarding.  Pt states no nausea/vomiting.  Leg assessed, nothing out of the ordinary noted except for the cold, clammy skin.  Pt in position of comfort at this time - semi-fowlers.  History of HTN, IDDM (poorly controlled), MI, right BKA, CHF. Meds include Zaroxolyn, Lasix, Lisinopril, ASA, Coreg, Plavix, Digoxin.


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## Sasha (Jul 10, 2009)

Slight off topic but having to do with the scenario. Fluids are good for hyerglycemia, yes? Kind of dilute the concentration?


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## paccookie (Jul 10, 2009)

Sasha said:


> Slight off topic but having to do with the scenario. Fluids are good for hyerglycemia, yes? Kind of dilute the concentration?




Hyperglycemia severely dehydrates the body by causing a fluid shift into the vascular bed and out of the body via the kidneys.  That's the line of thinking I was on.  I was thinking he might have HHNKC since he did not have the typical increased respirations that you see with DKA.  

I hung fluids and watched his vitals.  On arrival to the ER, he had been given 500 cc normal saline and 700 cc lactated ringers.  BP was 70/44.  

The ER hung more fluids as soon as my bags were gone.  I never had a chance to go back and check on him, but I did peek in as we were going by his room with another patient.  He had another couple of bags hanging and his BP was still in the double digits, although he was still C/A/O.  I know he was still in the ER the next morning, but I'm not sure if they had admitted him yet.  I expected him to go to the ICU.


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## Flight-LP (Jul 10, 2009)

Yes sasha, a 20cc/kg bolus followed by an infusion in the ball park of 10ml/kg/hr is indicated.

Was it truly T wave inversion, or did you possibly have a "U" wave present? Sounds as if your patient is hypokalemic (cramping and fatigue are two classic signs). Zaroxolyn is a powerful thiazide diuretic, combined with Lasix, the potentiation could be fatal. I'd keep the fluids going, preferrably with LR for the Ca+ and K+ additives.

Inquire about urine output, pt. should be putting out a significant amount. If not, you probably have an electrolyte / fluid shift and need to address the dehydration issue.

As you cannot really differentiate DKA vs. HHNK efficiently in the field, I would not recommend Insulin administration.

Fluids, adding a colloid or pressor if refractory to the inital bolus, continuous EKG monitoring, and O2 as indicated is the best treatment. Add to the mix an expeditious transport and you are good to go!


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## paccookie (Jul 10, 2009)

Flight-LP said:


> Yes sasha, a 20cc/kg bolus followed by an infusion in the ball park of 10ml/kg/hr is indicated.
> 
> Was it truly T wave inversion, or did you possibly have a "U" wave present? Sounds as if your patient is hypokalemic (cramping and fatigue are two classic signs). Zaroxolyn is a powerful thiazide diuretic, combined with Lasix, the potentiation could be fatal. I'd keep the fluids going, preferrably with LR for the Ca+ and K+ additives.
> 
> ...



Very well could have been U waves.  If so, they were very pronounced.  I didn't copy the 12 lead, wish I had.  They are scanned in once the secretary processes the calls for billing, so I may be able to get a copy in a few days.  I wasn't familiar with Zaroxolyn until I looked it up in the drug guide, but I came to the same conclusion regarding the hypokalemia.  That's why I hung LR and had it as wide open as it would go.  We don't do insulin in the field, so that's not a concern.  I gave dopamine some thought since his BP was very hard to hear.  Didn't do it in the field though.  I wanted to give the fluids a chance to work first and honestly we got to the hospital a bit quicker than I expected.  Between rechecking vitals and lung sounds and the monitor and asking him questions, it was a busy trip.  He did report increased urine output, but said that he normally had a high urine output due to the diuretics.  He said he hadn't worked outside in the heat that day or done anything strenuous.  He ate lunch and drank water with his lunch.  He was still C/A/O on arrival and had no changes on the serial 12 leads.  As I said, he did report a lessening of the cramping pain in his arms.  

I'm hoping I can check up on him when I go in again on Sunday.  If he's still there.  They usually keep hyperglycemics for several days, so I guess we'll see.


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## Aidey (Jul 11, 2009)

Flight-LP said:


> Was it truly T wave inversion, or did you possibly have a "U" wave present? Sounds as if your patient is hypokalemic (cramping and fatigue are two classic signs). Zaroxolyn is a powerful thiazide diuretic, combined with Lasix, the potentiation could be fatal. I'd keep the fluids going, preferrably with LR for the Ca+ and K+ additives.



This is what I was thinking also.


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## Ridryder911 (Jul 11, 2009)

All the symptomology sounds like Hyperosmolar Hyperglycemic Nonketotic Syndrome, or HHNS except the hx. of acute phase. I have been fortunate as to dx. several of these in the field setting as many will present the general malaise and flu like symptoms. 

I usually rehydrate as well and another tool is to use is EtCo2 as I have seen severe DKA that have went passed the Kussmaul and actually have shallow respiration's. One can assess their EtCo2 level as another valuable assessment. 

I am also concerned with the patients medication(s). There is a lot of side effects that can be associated with each other and of course any electrolyte imbalance can alter them or could be caused by the medication itself. Digoxin has several s/e other than just the yellow haze that most Paramedics can only remember as a s/e. ECG changes can definitely be attributed to a potential Dig imbalance as well as electrolyte changes (the chicken or the egg question). Also  the patient was on Plavix and CoReg which itself is asking for potential problems. 

As addressed diuretics and although Lisinopril is a nice med that helps spare K+, the Lasix will definitely expel it. In which I did not read that he was on Potassium supplement. 

The patient is what most internist call a "train wreck". Fortunately, they will get a full panel of lab, and can narrow it down from there. 

I concur with the others K+ and Ca+ will be given with as soon as the base line is achieved. I would imagine a K+ cocktail (potassium cocktail, consisting of 50 mL of 50% dextrose in 500 mL of 5% dextrose, 9.8 g of sodium lactate, 2 g of calcium gluconate) to save the kidneys. Although, one would not think of additional glucose, one has to remember the sodium pump theory and how potassium is moved. 

R/r 911


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