# Mini Scenario



## Anjel (Oct 13, 2011)

It's 1330 and you are sitting in the truck on a nice Tuesday. 

The radio goes off and you know exactly who it is for. So you head on over to your next pick up. 

You arrive at the house of one of your patients. 76 y/o female. She goes to dialysis T-Th-S so you know her well. Her husband meets you at the door and says "Oh she isn't doing well today". 

You walk in to find pt laying in bed. Pt is A&Ox2 and confused. She is normally x4. Her cheeks are swollen and she is slurring her words. 

You ask how she is and she replies she is in a lot of pain. 10/10. After poking and proding some more. Mainly it is her left side and breast that is hurting. She had a breast biopsy done 2 days prior and found out today that it was negative for any cancer. 

So you look around some more and find on her left side LLQ a 2in by 4 in raised rough area of skin. In the middle of the area is a blister that looks like it opened and now the skin is starting to become necrotic. 

You look some more and find 2 more areas like that on her inner thighs. When you go to move the pt you find one more on her back side/hip/flank area that is approx 8x10 inches and completely necrotic. 

You took this pt to dialysis 2 days prior and none of these were present at this time. Husband states they started yesterday and are spreading. 

Vitals:

BP: 150-90
P- 76
R- 16
Skin- Warm dry
Pupils- pearl
Altered mental status

Previous medical history- End stage renal disease, vascularitis(sp?) in the legs requiring multiple surgeries. She has been on dialysis for about 2 years now. She has anxiety and depression. 

Sooo....Anyone have any idea what is going on with my patient? What would you do treatment wise if anything? This isn't supposed to be a what would you do kind of thing. Just want to know what you think is happening.


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## IRIDEZX6R (Oct 13, 2011)

I'd suspect VRSA/MRSA Staph infections and take full iso precautions, they spread quickly and are very similar to what you described. Any hx of dm? Other than that I'd transport in a posistion of comfort and suspect sepsis. Possibly cover sores with a 4x4. I'd do a full med assessment though, just because the AMS is an extremely quick onset if you just saw her two days prior... but I guess being on dialysis and being old, her immune system is already compromised which explains how rapid it spread.


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## Anjel (Oct 13, 2011)

No history of DM. 

It's not MRSA or VRA. 

while you are assessing in the truck you notice another tiny blister starting on her left arm. 

Pt is screaming on pain because of the sore on her bottom. 

Pt becomes more and more dillusional. Daughter shows up as you are pulling out and states the have.been giving her Vicodin ES every hour for pain.


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## foxfire (Oct 13, 2011)

Kinda Sounds like a allergic reaction, to what not sure. Vicodin every hour?  that sounds a bit much.
what does ES stand for though? forgive me , my brain is still tanking  up on coffee.
how long had she been receiving the Vicodin? 
position of comfort, establish IV tko. 
was there any problems during or after the last dialysis ? 

i am scratching my head about this one.


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## Sasha (Oct 13, 2011)

Nevermind.

Sent from LuLu using Tapatalk


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## abckidsmom (Oct 13, 2011)

I would strongly suspect necrotizing fasciitis or Stevens johnson syndrome and take her a hospital with a burn unit.


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## Anjel (Oct 13, 2011)

foxfire said:


> Kinda Sounds like a allergic reaction, to what not sure. Vicodin every hour?  that sounds a bit much.
> what does ES stand for though? forgive me , my brain is still tanking  up on coffee.
> how long had she been receiving the Vicodin?
> position of comfort, establish IV tko.
> ...



Vicodin extra stength sorry.

And she had dialysis on saturday problems started after that


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## mycrofft (Oct 13, 2011)

*In any event, she needs to be seen and diagnosed at a facility.*

Do the lesions exhibit redness? Is there palpable induration and is it limited to the roughened area? By necrotic, I presume you mean an open ulcer with pale devitalized edges and a reddened floor; do you mean that, or something else, like blackened or dried -out or leaking green ichor?
Pain in a lesion with "blister" sort of suggests herpes (shingles) except they tend to present as crops of tiny vesicles on a reddened and _burning/painful_ segment of a dermatome. 
Treat as infectious, see if dialysis wants her in this state or if they want her hospitalized.


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## AlphaButch (Oct 13, 2011)

I'd want to r/o Calciphylaxis (since MRSA/VRA has been r/o).

Going full BSI.


/imagery too strong, should not come to EMT life until after lunch.


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## Anjel (Oct 13, 2011)

AlphaButch said:


> I'd want to r/o Calciphylaxis (since MRSA/VRA has been r/o).
> 
> Going full BSI.
> 
> ...



You sir, are correct. 

Pt had calciphylaxis from long term dialysis. 

She is still in the hospital and it doesn't look like she is going to make it.

I just couldnt believe how fast it was spreading. She was transported to our local level 1 trauma center.


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## Anjel (Oct 13, 2011)

Picture can be found here

http://en.m.wikipedia.org/wiki/Calciphylaxis


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## redcrossemt (Oct 13, 2011)

Anjel1030 said:


> Pt had calciphylaxis from long term dialysis.



Thank you for this interesting post.


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## AlphaButch (Oct 13, 2011)

The complication isn't that rare anymore with the rise in long term dialysis patients.


/this mini scenario ruined my lunch due to recollections of a patient with the same problem. First time I saw this in a patient it scared the beejeebus out of me, the picture you linked isn't bad Anjel. I was a fresh EMT just a few months in, doing a SNF to ER transport - looked more like 
Image - Not safe for weak stomachs - Internet Journal of Internal Medicine

gave me nightmares for a week.

Trauma I can handle. Something that looks like a flesh eating virus kinda spooks me, so I had to learn more about it to be able to sleep at night.


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## Anjel (Oct 13, 2011)

Ya thats what the one on her butt looked like.


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## mycrofft (Oct 13, 2011)

*FIeld tx/Rx?*

It shows purpura then breakdown/breakthrough, no reddened bed. I'm not seeing the blister. Excellent portal for infection and it was progressing to fast...


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## Anjel (Oct 13, 2011)

The blistering was more like the skin spreading and ripping apart. Not a true blister. 

I wasnt too sure how to describe it


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## mycrofft (Oct 13, 2011)

*And I WAS hungry for supper....*

:sad:....


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## Anjel (Oct 17, 2011)

And she passed away :-(

It all happened so fast.


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## Fish (Oct 18, 2011)

Gnarly


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