# Dispatched to assault. Really?!



## Shrimpfriedrice (Jan 25, 2013)

Dispatched to an assault.

Onscene crew finds "a little person", female in back of cab. Driver sts she was talking to him a short while ago, paid her fare and was about to exit the cab when she sat back in seat.

Pt awake and unresponsive
Ctc: unremarkable
Little amount of dried blood notesd at corners of mouth
Driver dns seeing and type of tremors.

Pt's pilates instructor on scene.

Pt is 42yo, no dcapbtls throughout.

Go!!!


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## firecoins (Jan 25, 2013)

Take them to hospital


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## Tigger (Jan 25, 2013)

Shrimpfriedrice said:


> Dispatched to an assault.
> 
> Onscene crew finds "a little person", female in back of cab. Driver sts she was talking to him a short while ago, paid her fare and was about to exit the cab when she sat back in seat.
> 
> ...



How is someone awake and unresponsive?


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## Shrimpfriedrice (Jan 25, 2013)

Apologies! I meant responsive to painful stimuli..
Tried to edit after rereading but i dont have the option anymore

And while ur input is welcomed u may want to look up the difference between unconscious and unresponsive!


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## Clare (Jan 25, 2013)

So she basically has an altered level of consciousness.

What do your investigations reveal? For example ECG, blood sugar, physical exam.

What is dcapbtls?


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## EpiEMS (Jan 25, 2013)

Clare said:


> What is dcapbtls?



DCAP-BTLS is a silly mnemonic that "they" try to drill into BLS providers. It stands for Deformities, Contusions, Abrasions, Punctures/Penetration, Burns, Tenderness, Lacerations, Swelling, is intended to remind providers what to check for in trauma patients during a trauma assessment. Not that it's really necessary to have an mnemonic for this stuff.

For the OP, there is a fair number of possible causes for this patient's presentation. What's the patient's BGL? What's a more detailed HEENT exam show? BP?


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## Aidey (Jan 25, 2013)

Tigger said:


> How is someone awake and unresponsive?



Easy. Eyes open and no one is home. Not uncommon in absence seizures, or the postictal phase.


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## Shrimpfriedrice (Jan 25, 2013)

Vitals:

Hr: 92
R: 18
Bp: unattainable ( 1st and 2nd attempts made by both emts and 1 medic using child cuff ) last attempt made by medic with adult cuff revealed questionable 240/p

Bgl: 86
O2 : 99 while on 15lpm via nrb
+ PERRLA
12 lead no abnormalities

Contact made with pt's mother who sts no pmh, no meds, nkda that she is aware of


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## Aidey (Jan 25, 2013)

Seizures secondary to increased ICP due to her CSF shunt becoming occluded.


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## NomadicMedic (Jan 25, 2013)

Dried blood at her mouth... Did she bite her tongue? And why was she on 15 LPN of o2 on a mask? Was she hypoxic or displaying an obvious increase in work of breathing?


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## JPINFV (Jan 25, 2013)

Assault?

Was there any tennis balls around?


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## Summit (Jan 25, 2013)

Blood came from where?
You suspect super duper htn?
Altered level of consciousness?
Must suspect Suspect postictal after sz 3* CVA 2* super duper htn.

Now get a real BP to adjust that focus?


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## Veneficus (Jan 25, 2013)

Aidey said:


> Seizures secondary to increased ICP due to her CSF shunt becoming occluded.



You laugh, my first neurosurg assist was an emergent repair of a CSF shunt for a guy who decided to defend his girlfriend's honor and got hit in the head during a bar fight. 

He is in a vegetable garden now.


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## Aidey (Jan 25, 2013)

I wasn't laughing, that was a serious guess.


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## JPINFV (Jan 25, 2013)

Veneficus said:


> You laugh, my first neurosurg assist was an emergent repair of a CSF shunt for a guy who decided to defend his girlfriend's honor and got hit in the head during a bar fight.
> 
> He is in a vegetable garden now.




Sounds like he was a Sontaran.


/Dr. Who reference.


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## Aidey (Jan 25, 2013)

JPINFV said:


> Sounds like he was a Sontaran.
> 
> 
> /Dr. Who reference.



Groan


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## Shrimpfriedrice (Jan 26, 2013)

n7lxi said:


> Dried blood at her mouth... Did she bite her tongue? And why was she on 15 LPN of o2 on a mask? Was she hypoxic or displaying an obvious increase in work of breathing?



Its easy to say why is she on o2 with all the info placed nicely right before you. Now ask yourself someone presents as ams, u have no history, non verbal, no glucometer or pulse oximeter bls. What do u do?


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## Shrimpfriedrice (Jan 26, 2013)

Aidey said:


> Seizures secondary to increased ICP due to her CSF shunt becoming occluded.



Nice guess, pt brought into er after many attempts to get a bp, reading was 280/150! Pt has massive intracranial hemorrhage after following up next day.


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## FLdoc2011 (Jan 26, 2013)

In these sort of cases I would ask for a good neuro exam.  And what was her GCS?


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## Handsome Robb (Jan 26, 2013)

Shrimpfriedrice said:


> Its easy to say why is she on o2 with all the info placed nicely right before you. Now ask yourself someone presents as ams, u have no history, non verbal, no glucometer or pulse oximeter bls. What do u do?



Without signs of hypoxia or respiratory distress you don't give high flow o2, that's for sure. Were there any indications in the physical exam that she was hypoxic/hypoxemic? From what you described it doesn't sound like it. If CVA is high on your list of differentials high flow isn't a very good choice. Hyperoxygenation can cause more harm than good in these patients. There's a reason low flow o2 is the standard for CVA care. The whole "just load the blood up with o2 so there's a chance more o2 will slip past the clot" idea doesn't hold any water. 

Not trying to be an *** but in the future you'll get better responses to your scenarios with more detailed information and better structure to them. 

I'm having a hard time understanding why it was so difficult to get a BP on this patient... her being a "little person" isn't a good reason. Hypotensive then sure that makes sense, not hypertensive though.


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## Shrimpfriedrice (Jan 26, 2013)

FLdoc2011 said:


> In these sort of cases I would ask for a good neuro exam.  And what was her GCS?



Gcs :10


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## Handsome Robb (Jan 26, 2013)

Shrimpfriedrice said:


> Gcs :10



Can you break it down for us, please? Lots of combinations can reach a total of 10.


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## Shrimpfriedrice (Jan 26, 2013)

FLdoc2011 said:


> In these sort of cases I would ask for a good neuro exam.  And what was her GCS?





Shrimpfriedrice said:


> Gcs :10





Robb said:


> Without signs of hypoxia or respiratory distress you don't give high flow o2, that's for sure. Were there any indications in the physical exam that she was hypoxic/hypoxemic? From what you described it doesn't sound like it. If CVA is high on your list of differentials high flow isn't a very good choice. Hyperoxygenation can cause more harm than good in these patients. There's a reason low flow o2 is the standard for CVA care. The whole "just load the blood up with o2 so there's a chance more o2 will slip past the clot" idea doesn't hold any water.
> 
> Not trying to be an *** but in the future you'll get better responses to your scenarios with more detailed information and better structure to them.
> 
> I'm having a hard time understanding why it was so difficult to get a BP on this patient... her being a "little person" isn't a good reason. Hypotensive then sure that makes sense, not hypertensive though.



If i gave a bp right away it would defeat the purpose. And isnt hyperventilation indicated in rising icp? Not that it was done here. And i never said we couldnt get a bp because she was a little person i was simply building the senario. And its not just me if both emts, medics and hospital staff have trouble have trouble getting a bp.

And as i said before without all that info given to u nicely how can i make a cva call ruling out other things o2 would be indicated for?


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## Handsome Robb (Jan 26, 2013)

Your grammar is really difficult to understand, bud.

I'm not asking to be spoon-fed.

Vitals are generally part of the initial assessment, so generally they're presented in the beginning of the scenario...

Hyperventilation is different from hyperoxygenation. Increased ventilatory rate does not equal increased FiO2. There's lots of arguments about hyperventilation in patients with suspected increased ICP.  Usually it's something you want to be doing with a definitive airway and ETCO2 monitoring to titrate to a desired ETCO2, generally ~30mmHg.


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## RustyShackleford (Jan 26, 2013)

Your sentence structure is so god awful, it is difficult to follow what you're saying.  If it takes a paramedic on scene to get a bp, god help you.


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## NomadicMedic (Jan 26, 2013)

The CLs are now paying close attention to this thread. 

Everyone take a deep breath before you post.


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## FLdoc2011 (Jan 26, 2013)

Shrimpfriedrice said:


> Gcs :10



Was a full neuro exam done? 

What all was done prehospital?

And throwing high flow O2 on is not hyperventilating.


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## epipusher (Jan 26, 2013)

Aidey said:


> Easy. Eyes open and no one is home. Not uncommon in absence seizures, or the postictal phase.



a doa may have their eyes open. so awake yet unresponsive?


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## NomadicMedic (Jan 27, 2013)

epipusher said:


> a doa may have their eyes open. so awake yet unresponsive?


No matter how you slice it, awake does NOT equal "dead with eyes open"


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## JPINFV (Jan 27, 2013)

"Spontaneously opens eyes" and "eyes are open... but not moving" are not the same thing.


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## Melclin (Jan 31, 2013)

Shrimpfriedrice said:


> Its easy to say why is she on o2 with all the info placed nicely right before you. Now ask yourself someone presents as ams, u have no history, non verbal, no glucometer or pulse oximeter bls. What do u do?



I agree with you in the absence of reliable pulse oximetry. However, you posted an SpO2 when mentioning the O2...So you must have had oximetry. Maybe you didn't originally have oximetry and a second responder brought it. We were not to know this, which is part of the reason why reasonably detailed information in the OP is important. 

To expand on the clinical side of this issue, it is not obvious why O2 would be applied despite an adequate SpO2, altered conscious state or not. I would argue that the application of O2 in situations where any serious illness _may_ be 'possible' is no longer the standard of care in the absence of documented hypoxaemia or other reason for supplemental O2. This may be a learning opportunity for you in that the standard of care might differ from your original education and/or protocols. I assume the whole reason you came to a forum like this was to expand your knowledge beyond a protocol book. 

Have I misunderstood something?



Shrimpfriedrice said:


> If i gave a bp right away it would defeat the purpose. And isnt hyperventilation indicated in rising icp? Not that it was done here. And i never said we couldnt get a bp because she was a little person i was simply building the senario. And its not just me if both emts, medics and hospital staff have trouble have trouble getting a bp.
> 
> And as i said before without all that info given to u nicely how can i make a cva call ruling out other things o2 would be indicated for?



I understand that it is difficult to present a scenario in writing while trying to capture the difficulty of a stressful situation and prioritising assessments and treatments. However, simply saying, "person with x"...go, doesn't work too well in my experience. Given a scenario like this, it is reasonable to assume that people will be asking for the results of at least a rough primary survey, vitals, an assessment of conscious state, pulse oximetry, monitoring, BGL, some kind of secondary survey or physical exam as well as a focussed neuro exam of some sort and further info about the event and her medical hx. Few providers would omit these things.

A set of vitals is not a mystery. Its not like someone will cleverly ask for a BP, it then reveals the nature of the illness and everyone thinks, "Oh gee, I wish I'd thought to take a BP". There are certain investigations that can be reasonably assumed given that we are to some extent all on the same page as far as basic pt assessment goes. I might suggest that this information be provided in the original presentation in future.


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## Handsome Robb (Jan 31, 2013)

Melclin said:


> A set of vitals is not a mystery. Its not like someone will cleverly ask for a BP, it then reveals the nature of the illness and everyone thinks, "Oh gee, I wish I'd thought to take a BP". There are certain investigations that can be reasonably assumed given that we are to some extent all on the same page as far as basic pt assessment goes. I might suggest that this information be provided in the original presentation in future.



Well put.


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