# what's your take on this call



## knxemt1983 (Jan 10, 2009)

ok so here's a call I ran the other night, I got a couple questions that I'll have at the bottom.

we respond emergency to scene where fire was called out non-emergency for a lift assist. upon arrival elderly f pt is seated on bed. Fire medic reported that pt was on floor on their arrival and they got her in the bed. Unknown time down. front door was open when fire got there about 0230, and in a not so good area of town. house was warm, more like hot, clean with no abnormal finding. pt is not oriented to anything except for her first name. b/p 64/p, pulse is regular but ranged from 140 bpm down to about 40, and back up at varying times. only two meds that we could find were macrobid and atenolol. unknown medical hx. no trauma noted. pupils equal and pinpoint, grips equal no facial droop or slurred speech. once on the monitor it showed only what looked like artifact, it was fire's monitor so we thought maybe it was messed up, put her on our brand new machine, with same effect, 12 lead unattainable. tried moving leads from legs to abd, and shoulders the chest, and everything in between, with no change, hospital ekg did the same thing. lost radial pulses once we got int he truck, and my monitor v-fib alarm went off but it was still crap so I figure thats just the monitors mistake since the pt still had pulse and was conscious. clear breath sounds all around, 
gave her about 300 cc NS and got radials back but weak. called med control and asked doc what to do and he said titrate fluid to keep pulses and get there asap and to call back if I could get more info or something new developed. (honestly I was stumped, all I knew to do was o2, iv, and attempt ekg and vitals). hands were cold throughout so no pulse ox, but pt had pink core. 

end verdict as of now is hypothermia (oh yeah I used warm fluid, not hot warm per protocol) with a core temp of 90.2f. Doc said for some reason yet undetermined at my last check, her body is not "generating enough heat". I will check back in next shift and update the final Dx.

my questions are this:
1. why could I get no EKG tracing, was it the cold or could it be something else. One of the other medics said something about some people can't wear watches because of electromagnetic fields from their body, and maybe thats it, but that doesn't sound right to me but I'm no know it all

2. why would her body not be generating heat, what mechanism would cause that to happen?

3. I thought fluid was right to try, but we have hypotension protocol to use dopamine, but I didn't want to go that route with out knowing what her heart was doing. ended up that the doc comfirmed my thoughts but if no doc was available what would you have done to overcome the EKG obstacle or worked around it.

4. what more could I have done. I missed the hypothermia and know I should've thought of it with her age, low body mass, and in the floor on a cold night, I guess the hot house made me overlook it when it should've tpped me off to it (live and learn, I'll be aware of that from now on). thankfully we were gentle with here just because of her age. I'm a new medic and want to try and learn as much about these kind of calls as I can.

we did take her in emergency, and she did make it through the night alive and was in the bear-hugger warming device when I went off duty.


----------



## MSDeltaFlt (Jan 10, 2009)

knxemt1983 said:


> ok so here's a call I ran the other night, I got a couple questions that I'll have at the bottom.
> 
> we respond emergency to scene where fire was called out non-emergency for a lift assist. upon arrival elderly f pt is seated on bed. Fire medic reported that pt was on floor on their arrival and they got her in the bed. Unknown time down. front door was open when fire got there about 0230, and in a not so good area of town. house was warm, more like hot, clean with no abnormal finding. pt is not oriented to anything except for her first name. b/p 64/p, pulse is regular but ranged from 140 bpm down to about 40, and back up at varying times. only two meds that we could find were macrobid and atenolol. unknown medical hx. no trauma noted. pupils equal and pinpoint, grips equal no facial droop or slurred speech. once on the monitor it showed only what looked like artifact, it was fire's monitor so we thought maybe it was messed up, put her on our brand new machine, with same effect, 12 lead unattainable. tried moving leads from legs to abd, and shoulders the chest, and everything in between, with no change, hospital ekg did the same thing. lost radial pulses once we got int he truck, and my monitor v-fib alarm went off but it was still crap so I figure thats just the monitors mistake since the pt still had pulse and was conscious. clear breath sounds all around,
> gave her about 300 cc NS and got radials back but weak. called med control and asked doc what to do and he said titrate fluid to keep pulses and get there asap and to call back if I could get more info or something new developed. (honestly I was stumped, all I knew to do was o2, iv, and attempt ekg and vitals). hands were cold throughout so no pulse ox, but pt had pink core.
> ...




Do you have a copy of the ECG to post?  It sounds like the lack of aquisition could be due to either A: the way the heart conducted itself (some rhythms, though looking like artifact are indeed lethal dysrhythmias), or B: I've seen pts dry flaky skin and the condition of the electrodes not allow a good enough connection to get any reading at all. 

Add to that infection to the elderly can cause both unreadable ECG's and hypothermia.


----------



## 41 Duck (Jan 10, 2009)

1)  I think the suspicion you have regarding self-generated magnetic fields is well-founded.  This makes for great plot devices and for weird explanations on TV shows like GHOST HUNTERS, but I'd suspect it was more a conductivity issue due to condition of PT's skin.  

2)  There's a couple of disease processes that could cause lack of heat generation --but this is probably best directed at Rid.  I'd think it more likely that the PT couldn't retain heat generated due to physical condition, and would ask if her age exceeded her weight.

3) I'd go with the fluid as well, and omit any drugs without being able to confirm electrical activity.

4) Hypothermia is a weird thing, as it's subject to the PT's interaction with their environment--which may not have the same effect on the provider.  Like you said, the house was hot... trying to compensate for chronically feeling cold.  As far as what else you could have done... well, that'd all depend on recognizing the process at work... 

...and figuring out what you could do better next time, which is, essentially the thrust of this discussion, so I'd say you're doing all you can.


We all have calls we would like back to have another go at it.  Thank god for 'em... as these are the ones from which we learn.



Later!

--Coop


----------



## VentMedic (Jan 10, 2009)

This may have been shivering even if not readily visible to your eye. A 12-lead would have been imipossible. A 3 lead might have had some success. If we see total EKG artifact on a patient that comes in with an ROSC hypotermia protocol started, we know the sedation and paralytics are not adequate. 

The body loses heat through radiation, convection and conduction. Even if the room is very warm, contact with a cold surface will allow transference of heat through conduction. 

The pinpoint pupils can also indicate a medication, drug or neurological injury of either brain or spinal cord. The body's temperature regulating mechanism may also be affected. This can involve the hypothalamus or peripheral thermoreceptors.

Not all neuro disorders are cleared with hand squeezing or lack of facial droop.


----------



## reaper (Jan 10, 2009)

I did not notice in your post, did you get a BGL on her?


----------



## knxemt1983 (Jan 10, 2009)

reaper said:


> I did not notice in your post, did you get a BGL on her?



sorry bout that, yeah bgl was 124


----------



## knxemt1983 (Jan 10, 2009)

VentMedic said:


> This may have been shivering even if not readily visible to your eye. A 12-lead would have been imipossible. A 3 lead might have had some success. If we see total EKG artifact on a patient that comes in with an ROSC hypotermia protocol started, we know the sedation and paralytics are not adequate.
> 
> The body loses heat through radiation, convection and conduction. Even if the room is very warm, contact with a cold surface will allow transference of heat through conduction.
> 
> ...



yeah I was kinda thinkin toward basically shivering inside, but not a visible shaking outside. I tried to find other meds but had no sucess, but thats definitely a possibility. 

what other neurologic test would you suggest? I know the usuals like facial droop, grips, speech, arm drift, and mental status, but what others?


----------



## knxemt1983 (Jan 10, 2009)

41 Duck said:


> 1)  I think the suspicion you have regarding self-generated magnetic fields is well-founded.  This makes for great plot devices and for weird explanations on TV shows like GHOST HUNTERS, but I'd suspect it was more a conductivity issue due to condition of PT's skin.
> 
> 2)  There's a couple of disease processes that could cause lack of heat generation --but this is probably best directed at Rid.  I'd think it more likely that the PT couldn't retain heat generated due to physical condition, and would ask if her age exceeded her weight.
> 
> ...



her body weight actually was about equal to her age. she was 88 and weighed maybe 90 lbs. So she was at risk for hypothermia anyway. yeah I hope rid will chime in, I know it was probably just a conduction issue from being on the floor, but the heat being so high could indicate something going on before the fall, or it could just be that it was a cold night and she weighed 90 lbs. The possibility of a disorder that could cause that severe of hypothermia though has me curious, even if it had nothing to do with her issue.


----------



## knxemt1983 (Jan 10, 2009)

MSDeltaFlt said:


> Do you have a copy of the ECG to post?  It sounds like the lack of aquisition could be due to either A: the way the heart conducted itself (some rhythms, though looking like artifact are indeed lethal dysrhythmias), or B: I've seen pts dry flaky skin and the condition of the electrodes not allow a good enough connection to get any reading at all.
> 
> Add to that infection to the elderly can cause both unreadable ECG's and hypothermia.



I do have a copy, but have no way to scan it here, I will see if I canuse the scanner at work to get it on here when I go back on monday.

yeah the rythm worried me, I kept a close eye on her pulse (cartid pulse that is) to make sure at least she kept circulating. that combined with the low b/p is why we ran hot, I didn't wanna waste any time not knowing what was nehind the artifact.

I tried everything I could to clean the skin, new electrodes, the physio guy told us at our last in service to try cleaning the skin with alcohol then scrubbing it with a 4x4, but that didn't change anything


----------



## knxemt1983 (Jan 10, 2009)

thanks for all the replies guys, keep em comin.


----------



## artman17847 (Jan 10, 2009)

1) Her hypothermia was possibly due to a problem with her endocrine system, mainly something wrong with the hypothalmus that is responsible for regulating the body's temp.

2) Do you take temps as a regular part of your vitals. If not may want to add it to your regular vitals check.


----------



## reaper (Jan 10, 2009)

Also remember that elderly folks have a hard time regulating body temp. That is why their houses are usually very warm inside. Then on top of that she laid on a floor for unknown time. That let conduction drain her body heat.

BTW- I asked before but didn't see an answer. Did you get a BGL on her? What was it?


----------



## bonedog (Jan 10, 2009)

What was the Rx count, atenolol can cause cold extremities along with of course brady arrythmias and hypotension.
Perhaps she has developed "cold sepsis" from her UTI, if so, I imagine you will be looking at the postmortem.
What site did you use for your temp?
The electronic thermometers used peripherally are notoriously unreliable, good old mercury, rectal, might give you a better idea.

It would be interesting to find out it was a hypothalmus infarct.


It is unique to see when they start re-warming bypass patients and the cold patient begins to sweat. Fooling the master gland....


----------



## knxemt1983 (Jan 10, 2009)

artman17847 said:


> 1) Her hypothermia was possibly due to a problem with her endocrine system, mainly something wrong with the hypothalmus that is responsible for regulating the body's temp.
> 
> 2) Do you take temps as a regular part of your vitals. If not may want to add it to your regular vitals check.



I usually don't because our company has really sucky thermometers, and they take like 5-6 min sometimes, and are inaccurate as can be. I think I will add it, I may even look into my own thermometer.


----------



## knxemt1983 (Jan 10, 2009)

reaper said:


> Also remember that elderly folks have a hard time regulating body temp. That is why their houses are usually very warm inside. Then on top of that she laid on a floor for unknown time. That let conduction drain her body heat.
> 
> BTW- I asked before but didn't see an answer. Did you get a BGL on her? What was it?



bgl was 124, I did forget to put it in the original post. the way she presented made me instantly think bgl issues, just off first impression


----------



## knxemt1983 (Jan 10, 2009)

bonedog said:


> What was the Rx count, atenolol can cause cold extremities along with of course brady arrythmias and hypotension.
> Perhaps she has developed "cold sepsis" from her UTI, if so, I imagine you will be looking at the postmortem.
> What site did you use for your temp?
> The electronic thermometers used peripherally are notoriously unreliable, good old mercury, rectal, might give you a better idea.
> ...



atenolol was right on track where it should have been, but the macrobid was a week old and empty, she had a three week script. I looked for a med planner but couldn't find one either. . the sepsis could definitely be possible. the ed reported the temp to me, our thermometers are only the old school oral ones.


----------



## crotchitymedic1986 (Jan 11, 2009)

1.  Monitors not working was probably due to electrical interfernce in the house, unless they continued to fail in the truck -- then could be an electrical disturbance in the truck.

2.  Probably diagnosis:
    1. Sepsis
    2. Brain injury or brain tumor
    3. Endocrine issue

With the fluctuations in B/P and pulse, I would be more likely to guess the brain injury or tumor.


----------



## knxemt1983 (Jan 11, 2009)

crotchitymedic1986 said:


> 1.  Monitors not working was probably due to electrical interfernce in the house, unless they continued to fail in the truck -- then could be an electrical disturbance in the truck.
> 
> 2.  Probably diagnosis:
> 1. Sepsis
> ...



disturbances on the monitor were present on three different monitors, one inside the house and outside, one in the truck, and the one in the ed. All showed the same thing so interference from anything other than the pt is pretty much out, only theing she had on was a night gown. 

best explanation I've came up with so far is like stated above in a couple posts, maybe she was shivering internally without external tremors or something. I;m still kinda stumped


----------



## CH47Doc (Jan 12, 2009)

Did I read this correctly?

*b/p 64/p,* pulse is regular but ranged from 140 bpm down to about 40, and back up at varying times. only two meds that we could find were macrobid and atenolol.

BP is 64 palp?

atenolol overdose?


----------



## DrankTheKoolaid (Jan 12, 2009)

*re*

My guess would be septicemia secondary to the UTI that she is/was on the Macrobid for.  Which would explain the hypotension, and the -lol beta blocker would explain the no increase in HR even though her pressure had fallen.  The macrobid may not have covered the microorganism that caused the infection in the first place, especially if it wasn't cultured and followed up on.

  As to the ECG tracing you probably caught her at the end of her compensating abilities and she was no longer visibly shivering from her septic hypothermia.  Though she was still having small muscle fasiculations which were not visible to the eye.

    Fluid therapy for sure, as dopamine is not going to be very effective is she is fluid depleted.  Can squeeze the pipes and increase pump rate, but if theres no fluid to move it would be ineffective


Corky


----------



## piranah (Jan 12, 2009)

possible she was septic and that had effected her ability to control her temp(say an infection had gone to her brain)..along with her weight and being on the floor....i would done the same,fluids(warm) and the tracing was prolly the shivering....did you by any chance get ahold of the labs from the er?


----------



## knxemt1983 (Jan 12, 2009)

CH47Doc said:


> Did I read this correctly?
> 
> *b/p 64/p,* pulse is regular but ranged from 140 bpm down to about 40, and back up at varying times. only two meds that we could find were macrobid and atenolol.
> 
> ...



thought about that, pill count was right on for atenolol. I thought maybe if she had been taking it and not excreting it correctly maybe she had built up toxicity to it.


----------



## knxemt1983 (Jan 12, 2009)

piranah said:


> possible she was septic and that had effected her ability to control her temp(say an infection had gone to her brain)..along with her weight and being on the floor....i would done the same,fluids(warm) and the tracing was prolly the shivering....did you by any chance get ahold of the labs from the er?



I;m back on tonight so if I can get a transport that wants to go back to the same ed then I'll get a good follow up report on her


----------



## knxemt1983 (Jan 12, 2009)

Corky said:


> My guess would be septicemia secondary to the UTI that she is/was on the Macrobid for.  Which would explain the hypotension, and the -lol beta blocker would explain the no increase in HR even though her pressure had fallen.  The macrobid may not have covered the microorganism that caused the infection in the first place, especially if it wasn't cultured and followed up on.
> 
> As to the ECG tracing you probably caught her at the end of her compensating abilities and she was no longer visibly shivering from her septic hypothermia.  Though she was still having small muscle fasiculations which were not visible to the eye.
> 
> ...



that is the same track I'm thinking now, probably septic from uti, and not having visible shivering.


----------



## ksEMTbabe (Jan 12, 2009)

My first thought with the temp regulation problem coupled with the pinpoint pupils was that she has some sort of neurologic dysfunction - possibly related to her hypothalamus?  That would explain the hypothermia and since the hypothalamus also controls some autonomic functions it could have an effect on her cardiac rhythm. You also mentioned that she was very thin... undernourishment in the elderly can cause a significant decrease in the working cells of the hypothalamus. Just a thought, maybe I've just been watching too many episodes of House


----------



## knxemt1983 (Jan 12, 2009)

verdict form the ED is lung ca, coupled with the hypothermia, and cardiac tamponade. once she was warmed with the bear hugger the EKG became clearer. The doc agrees that it must've been internal shivering w/o external signs.


----------



## VentMedic (Jan 12, 2009)

knxemt1983 said:


> verdict form the ED is lung ca, coupled with the hypothermia, and cardiac tamponade. once she was warmed with the bear hugger the EKG became clearer. The doc agrees that it must've been internal shivering w/o external signs.


 
How much fluid did they tap with a pericardial centesis?

That could also explain part of the EKG if the caridac tamponade gave low volts and electrical alternans.


----------



## DrankTheKoolaid (Jan 13, 2009)

*re*

Wow thats a bummer for sure.

Corky


----------



## CH47Doc (Jan 13, 2009)

VentMedic said:


> How much fluid did they tap with a pericardial centesis?
> 
> That could also explain part of the EKG if the caridac tamponade gave low volts and electrical alternans.



coulda just did antibiotics depending on how far along it was.


----------



## lizhiniatsos (Jan 13, 2009)

...you guys and gals are good! Along with all of the aforementioned items the thought did cross my mind that she could've sustained a head injury secondary toa  fall (found on the floor...right?) thereby causing neurologic deficits....
anyway...sad news on the true nature of her problem....and great care on your part~


----------



## knxemt1983 (Jan 13, 2009)

VentMedic said:


> How much fluid did they tap with a pericardial centesis?
> 
> That could also explain part of the EKG if the caridac tamponade gave low volts and electrical alternans.



that's pretty much exactly what the problem was. I don;t know how much fluid was removed though, the doc that did it wasn't there so I just talked to one of the ed nurses who was not the pt's nurse


----------



## knxemt1983 (Jan 13, 2009)

lizhiniatsos said:


> ...you guys and gals are good! Along with all of the aforementioned items the thought did cross my mind that she could've sustained a head injury secondary toa  fall (found on the floor...right?) thereby causing neurologic deficits....
> anyway...sad news on the true nature of her problem....and great care on your part~



yeah I went through all kinds of ideas. bgl, fall and head injury, overdose of something unknown, stroke, I was leaning toward some type of dysrythmia while I was on the call, but couldn't tell what it was. After the call I came up with and was helped with some stuff by you guys, and have learned alot from this call, thanks for all your all's help in thinking through this one.

thanks for the compliment, it means alot with me being only a 6 month paramedic, I can tell I have learned alot since school was out and that I still have an enormous amount to learn throughout the rest of my career.


----------

