# Errr?



## Shishkabob (Jan 22, 2011)

Another unit is dispatched for a middle aged lady with stroke-like symptoms.  Upon their arrival, they declare to dispatch that the patient is a "yellow patient" and request a second ambulance, so you check enroute.

On arrival, you walk up to the homes front door and find the other ambulance crew in with the patient.  The other medic relays that the original call was for stroke like symtpoms, found the patient unconscious, and when he felt a pulse, it was brady in the 40s.  After hooking her up to the EKG, he deemed it sinus-bradycardia with no ectopy, started a 20g in the hand and gave 0.5mg atropine.  HR rose and pt opened her eyes.

The patient starts screaming that she's in a "crap" load of pain, but wont say where.  pt wont answer any further questions including her age, and quickly loses consciousness.  (Family is of no use for some odd reason) Everyone quickly moves her to the cot and out to the MICU.  You ride along with the other medic while headed to the closest hospital (a level II 20 minutes away) code-3, your partner follows code-1 (non-emergent) in the second ambulance.  It's you and 2 other Paramedics in the back.


What do you want to know?


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## clibb (Jan 22, 2011)

With 20 min to the hospital, I would had probably called for a chopper.


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## Smash (Jan 22, 2011)

clibb said:


> With 20 min to the hospital, I would had probably called for a chopper.



Just to watch the Whirly Bird?  What possible advantage can helicopter transport offer when road transport is only 20 minutes? Or are you joking? Sorry if you are, I'm a bit slow today. 

I'd like to know... Everything else.


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## Shishkabob (Jan 22, 2011)

clibb-- Call to liftoff is 7 minutes for our helo, and flight to our location would be about 10.  They would had to have auto-launched on the outset of the call.  Just be happy it was 20 and no the usual 45+... otherwise the chopper WOULD have been launched.


Smash-- Initial stuff on outset of transport

Pt would regain conciousness for about 15-20 seconds at a time, complain of very sharp pain, and go right back out.  No changes in EKG during lapses.

EKG post atropine shows sinus rhythm on the 4 lead, rate of ~70.

BP of ~103/54

SPo2 86% on RA wth RR at 14.  NRB put on at 15lpm, increasing to 90%.  Malampatti 3,  negative 3-3-2 view.  

ETCo2 ~45

BGL 131.

No hx gathered from family other than pt drinks.


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## clibb (Jan 22, 2011)

Due to the brady and episodes of LOC and in consciousness I'm thinking Cushing's Triad due to stroke.
Regular Respirations and the BP is making me think otherwise. Please let us know what the diagnosis is!

Oh and yeah, I was kidding about the chopper launch.


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## truetiger (Jan 22, 2011)

What does your physical exam find? 12-Lead? Lung sounds?


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## Shishkabob (Jan 22, 2011)

Well, as I said, we transported with 3 Paramedics in the back.

Family wasn't of much help at the house, but denied any trauma/blows to the head, and the patient was found laying her her bed.  Pupils would go pinpoint each time she went unconcious, however, be reactive when she was 'with it'.

She got 4mg of Zofran (one of the times she woke up she said she was going to throw up), 100mg Thiamine and 2mg Narcan.  Neither Narcan nor Thiamine helped with her mental status.


Each time she woke up, she'd look around for a bit then start screaming she was in pain, and finally I was able to elicit that it was near her right shoulder, though no trauma was noted there.

Her respirations would routinely go from "ok" and satting 95%, to crappy and satting 85%.  We ended up keeping a BVM over her mouth and just doing it for her when it got crappy.  We contemplated RSI, but felt it was better just to get to the hospital as her coherent points were somewhat predictable and she was doing ok with her own airway.  Lung sounds were clear.

12-lead showed ST-depression in I, aVr, V2, V6 and ST-elevation in III, V1 and V4.  (Yeah...odd)  Had 2 IVs started, drew blood for test from one of them.  


At the hospital, they ran labs on our blood draws and we found out they activated the cath lab for her for an MI.  Never found out anything beyond that.




It was just an odd, odd call.


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## Melclin (Jan 23, 2011)

I would have thought cardiogenic shock. 

Any chance you could post the 12 lead?


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## Smash (Jan 23, 2011)

Melclin said:


> I would have thought cardiogenic shock.
> 
> Any chance you could post the 12 lead?



I would have thought fulminant liver failure.  Patient is a drinker, is "yellow", obtunded (cerebral edema), gets pinpoint pupils when GCS drops (pressure on pontine region from cerebral edema) has right shoulder pain (referred pain) and arrythmias are not uncommon with the various electrolyte and metabolic derangements that come with hepatic failure.  I'm guessing that infarct is not out of the realms of possibility either, but ECG changes are not at all contiguous, which would make me suspicious that they are nothing to do with a primary cardiac problem.

Any follow up possible on this one Linuss?


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## Veneficus (Jan 23, 2011)

Good call on the thiamine. She may have been too far gone for it to work though.

At some point the damage is permanant at thiamine will not help the existing condition but may stop it from getting worse.

Sugeested reading the pathology of:

Wet beri beri 

and 

Dry beri beri.

from a big thick book.


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## Melclin (Jan 23, 2011)

Smash said:


> I would have thought fulminant liver failure.  Patient is a drinker, is "yellow", obtunded (cerebral edema), gets pinpoint pupils when GCS drops (pressure on pontine region from cerebral edema) has right shoulder pain (referred pain) and arrythmias are not uncommon with the various electrolyte and metabolic derangements that come with hepatic failure.  I'm guessing that infarct is not out of the realms of possibility either, but ECG changes are not at all contiguous, which would make me suspicious that they are nothing to do with a primary cardiac problem.
> 
> Any follow up possible on this one Linuss?



I thought yellow was some kind of time criticality thing :blush:

That does change things somewhat. ALF makes much much more sense if the pt is actually yellow. The pulse pressure is pretty good for cardiogenic shock too. The changes in resp pattern probably make more sense if its encephalopathy I suppose. 

What was her temp Linuss?
Any Asterixis? 

Does encephalopathy present with short alterations in conscious state like that? I picture her GCS dropping to 3 and coming back to 14 like a minute later..GHB style.

Wouldn't an improvement in conscious state with atropine point towards the conscious state being cardiogenic?

As far as the ECG goes, whether or not there was elevation in this lead or that lead can be up for interpretation, hence my wanting to see it myself. Not to make any inferences about Linuss's ECG skills, but I've done a few jobs where the ECG didn't make any sense on description but was clearly interpreted by another set of eyes (ie, not mine ).


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## Melclin (Jan 23, 2011)

Veneficus said:


> Good call on the thiamine. She may have been too far gone for it to work though.
> 
> At some point the damage is permanant at thiamine will not help the existing condition but may stop it from getting worse.
> 
> ...



Which, upon inspection of a big "thick" electronic book, accounts for the activation of the cath lab because of raised troponin. Awesome. I'm totally using that one to look smart in front of some other students one day


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