# 80 Year Old Female



## NYMedic828 (May 29, 2012)

80 year old female - Called for difficulty breathing.

Patient is in a clinic under care of a physician. 

MD states she is experiencing hypertension with shortness of breath and neck pain radiating to the left arm. They have administered O2 and acquired a 12 lead prior to our arrival.

Initial assessment:

Verbally responsive
Extremely cool, pale, diaphoretic.
Strong and regular radial pulse.
Labored but adequate regular respirations.

Vitals:
BP 250/146
HR 72
RR 16
Lungs clear all fields
BGL 230
ECG 3/12 NSR otherwise unremarkable.

Known history:
Diabetes.
Hypertension.


We move the patient to the vehicle.

Mental status declines, now painfully responsive eye opening only.

We establish IV access and initiate transport.

Patient vomits one time.

Patient becomes unresponsive.

Patient remains in unresponsive condition vitals unchanged until arrival at ER.

Head back to chest pain area, doctor calls for RSI intubation immediately.

Patient goes into SVT at 160bpm. BP drops to 130/72.

So, we originally were ruling her out as potential MI (NSTEMI) with the complaints that she went to the doctor's office for. But by arrival at the hospital, it seemed more along the lines of a bleed. Maybe both?

What do you guys think?


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## jjesusfreak01 (Jun 3, 2012)

Well, she wasn't progressing with a standard cushings reflex, if it was a bleed. Any change in respirations following the change in mental status? Did you happen to check pupillary size and response? 

I don't really want to try and diagnose a nSTEMI in the field, I would rather wait to see what the hospital gets with the CK/Troponin. 

I might also consider the possibility of a hypertensive crisis as the primary problem. It could lead to some of the other symptoms. 

A PE would be my last guess. It can be a precursor to a hypertensive crisis and might explain the strange cardiac progression.

PS: Was the change in vitals before or after the RSI?


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## Dwindlin (Jun 3, 2012)

I would have a high index of suspicion for a dissection.  This could also just be a hypertensive emergency.


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