# 54yo female just discharged



## Rialaigh (Jul 1, 2014)

So I am going to pose a scenario with limited information starting. You may ask any and all questions you like. Please be detailed in the questions you ask, I can give you the answers to any and all questions you have regarding anything that I paint a picture about. I will be fairly quickly responsive today in giving answers and painting a picture. I am just curious as to how others would treat/not treat this patient.

Background Information - 

You work a very poor fairly rural area. There is a high incidence of drug and alcohol abuse as well as tobacco use. Violence is not very common. 

You are on a ALS truck, you are a paramedic with a EMT-B partner. You are dispatched priority 1 to a 54 year old female trouble breathing. Your response time is aproximately 20 minutes, you have no backup and no helicopter

Your community hospital is 20 minutes away P-1
Your PCI and stroke center is 30 minutes away P-1
Your level 1 trauma, neuro, etc... Center is 65 minutes away P-1


You are escorted into a clean looking mobile home by family, patient is found in back of home sitting on floor looking weak and appears in no/minor respiratory distress. PT appears to be on home O2 via nasal canula. Patient is being propped up by her sister. PT states she was in the hospital today and hands you her discharge paperwork. Hospital discharge paperwork states the patient was seen today, diagnosed with pyelonephritis, and discharged home with a prescription for Zofran, Norco, and Levaquin. PT states her side still hurts really bad and she feels worse then when she was discharged several hours ago. She states she has not taken any of her prescriptions since leaving the hospital. 




Go ---->


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## phideux (Jul 1, 2014)

Been there, done that, got the t-shirt.
The shot of Dilaudid they gave her in the ER wore off and she is in pain.
The boyfriend, or other family member already took and stashed for later, or sold her hydrocodone. Or, after buying beer and cigarettes, they can't afford the scripts.
I bet if you look up her record she has been in all the ERs, repeatedly, all the nurses and medics know her by name, and roll their eyes as she comes in.
Your company has a transport everyone policy, and she wants to go to a different ER than the one she left a few hours ago, so you load her up, stuff your EMT partner in the back and go.
Drop her off, they will give her another shot or 2 of Dilaudid, call the transport ambulance to take her home, again. Of course they can't take her home POV or call a cab, medicare/Medicaid won't buy gas or pay a taxi.
And hopefully they gave her enough Dilaudid so she will sleep through the night and you, the ER, and the transport ambulance guys don't have to worry about her again till your next shift.  :rofl::rofl:

Am I close????


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## TransportJockey (Jul 1, 2014)

Vitals, continue O2, small fluid challenge, consider Rocephin IV drip during transport, if vitals are telling of pain consider some pain management (50mcg of Fent should do nicely). Non-emergent transfer to closest ED if pt would like to go.


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## Brandon O (Jul 1, 2014)

Vitals to consider sepsis. Back to the same ED. Might get admitted this time.


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## Ewok Jerky (Jul 1, 2014)

Hard to tell whether this is a case of "the medicine isn't working" or pylo>sepsis.  Can we have vitals including temp and resp rate? Past medical Hx? Previously healthy? Freq UTIs? Was she admitted or just in the ED? Anything in the paperwork about her workup, CBC, u/a, Ultrasound, other imaging? Did she receive ABX in the hospital, which one?


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## OnceAnEMT (Jul 1, 2014)

phideux said:


> Been there, done that, got the t-shirt.
> The shot of Dilaudid they gave her in the ER wore off and she is in pain.
> The boyfriend, or other family member already took and stashed for later, or sold her hydrocodone. Or, after buying beer and cigarettes, they can't afford the scripts.
> I bet if you look up her record she has been in all the ERs, repeatedly, all the nurses and medics know her by name, and roll their eyes as she comes in.
> ...



Do you waste your time to judge all of your patients this way, or is there a further time-wasting selection process of who you're going to skimp on? I'll say it frankly, your attitude is despicable and I hold no pity for it or anyone who finds it humorous. You've burned out, or are deep in the process. You really, really should look into a way to switch things up and prevent this.

I want to know the vitals. If the 02 sat is low, replace the NC with an NRB. High temp really pushes us towards sepsis, perhaps further sepsis depending on where she was before. Ask if any drips or medications were administered while in the hospital. My guess is that nothing was on-boarded in the ED (which I disagree with by practice), and she was sent home expected specifically to take the antibiotic ASAP. That didn't happen. 

About seeking info relating to lab results in discharge paperwork, very good suggestion. However, at least in the ED I'm at, our discharge papers don't include lab results or imaging or really anything other than laymen-worthy wording and prescriptions. Those results would only be included if manually entered by the physician or nurse. Otherwise they could only be obtained through a medical records release request. 

Let's see some vitals!


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## abckidsmom (Jul 1, 2014)

Brandon O said:


> Vitals to consider sepsis. Back to the same ED. Might get admitted this time.




Ding ding ding. We have a winner.


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## Rialaigh (Jul 2, 2014)

beano said:


> Hard to tell whether this is a case of "the medicine isn't working" or pylo>sepsis.  Can we have vitals including temp and resp rate? Past medical Hx? Previously healthy? Freq UTIs? Was she admitted or just in the ED? Anything in the paperwork about her workup, CBC, u/a, Ultrasound, other imaging? Did she receive ABX in the hospital, which one?



You feel for a radial pulse, skin is dry and warm but not abnormally so. Radial pulse feels about 100. Respiration rate is about 22 with no obvious distress. Initial O2 saturation shows 57%. Initial BP is 83/46, patient is still sitting in floor leaning against her sister. Patient states her O2 sat always stays between 55%-65% and 57% is pretty much normal for her. Patient does not appear in much respiratory distress. Patient states she just feels a little weaker than earlier and is breathing slightly worse then when she was at the hospital

Past medical history includes HTN, Diabetes, Several TIA's, several cardiac caths with stints placed, stints placed in each leg, unknown on PE's, COPD, Ephysema, CHF

 Patient states no recent illness, she has battled with UTI's in the past and has them several times a year. 

She was just seen in the ER at the small community hospital earlier today and discharged home. Paperwork from discharge has no lab values or imaging studies included in it. Patient received Dilaudid and Phenergan IM and PO norco prior to leaving.


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## Anjel (Jul 2, 2014)

Can we get a temp on her? A 12 lead and a BGL 

Start an IV and start a bolus to see how the BP responds.


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## Brandon O (Jul 2, 2014)

beano said:


> Hard to tell whether this is a case of "the medicine isn't working" or pylo>sepsis.



Agreed, and I'd be a bit skeptical that anything has changed bigtime since the discharge if it was really a few hours ago (especially if she looked low-risk enough that they discharged her in the first place), but even then clearly she's not capable of adequate followup and self-care.


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## Rialaigh (Jul 2, 2014)

Anjel said:


> Can we get a temp on her? A 12 lead and a BGL
> 
> Start an IV and start a bolus to see how the BP responds.



Temp is 99.0 Tempanic, 

12 lead shows as below at a total rate of around 80 now. Repeat BP  is 92/53. BgL is 442. IV access is unobtainable after blowing 2 22's and a 24, her vasculature is very poor and she has no identifiable EJ locations. 

*EDIT: This is not the actual ECG. It is from a case on Dr. Smith's ECG Blog. See the case here*


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## Anjel (Jul 2, 2014)

Bigeminey... nice. 

I would up her o2 and transport to probably whatever hospital she wanted. I would probably push a little toward the one with a little more capability than the community hospital.


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## TransportJockey (Jul 2, 2014)

Rialaigh said:


> Temp is 99.0 Tempanic,
> 
> 12 lead shows as below at a total rate of around 80 now. Repeat BP  is 92/53. BgL is 442. IV access is unobtainable after blowing 2 22's and a 24, her vasculature is very poor and she has no identifiable EJ locations.
> 
> *EDIT: This is not the actual ECG. It is from a case on Dr. Smith's ECG Blog. See the case here*


SubClavian or IO access.


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## Rialaigh (Jul 2, 2014)

So lets say you get IV access, whats the plan? any medication? assuming her BP is hanging out in the 80-90/40 range...transport decisions?


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## TransportJockey (Jul 2, 2014)

Rialaigh said:


> So lets say you get IV access, whats the plan? any medication? assuming her BP is hanging out in the 80-90/40 range...transport decisions?


I'm a little different than most because I'll stabilize the best I can on scene and then transport to a fixed wing. I'd do a lactate level, chem panel, flyid bolus then possibly a levo drip. Ill expand more when I'm not on my phonE


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## Rialaigh (Jul 2, 2014)

TransportJockey said:


> I'm a little different than most because I'll stabilize the best I can on scene and then transport to a fixed wing. I'd do a lactate level, chem panel, flyid bolus then possibly a levo drip. Ill expand more when I'm not on my phonE



Sounds good, from the bit of research I have done I am getting the idea that most medical professionals are getting away from trying to convert the rhythm as long as it does not deteriorate into full blown Vtach, Im wondering if a Levo drip and then Amio or lido would be indicated or if we are looking to correct an electrolyte imbalance possibly causing the problem. If my transport time were lets say an hour I am trying to figure out how I treat this patient if she continues to deteriorate.


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## MonkeyArrow (Jul 2, 2014)

Was a 12 lead taken at the hospital? Is a interpretation or copy of it in the d/c papers?


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## Carlos Danger (Jul 2, 2014)

Rialaigh said:


> Sounds good, from the bit of research I have done I am getting the idea that most medical professionals are getting away from trying to convert the rhythm as long as it does not deteriorate into full blown Vtach, Im wondering if a Levo drip and then Amio or lido would be indicated or if we are looking to correct an electrolyte imbalance possibly causing the problem. If my transport time were lets say an hour I am trying to figure out how I treat this patient if she continues to deteriorate.



It's hard to come up with a decent plan for a complicated patient like this without having a better history and seeing them with you own eyes. So, all I can add is a couple thoughts:

This is a complex patient with many interrelated comorbidities. The short of it is that it sounds like a brewing sepsis is aggravating her other problems. But again, it's hard to know without more info. I'd like to see a CBC and ABG.


Does she have a pneumonia? Was a CXR done in the ED?


I find it hard to believe that her Sp02 is "normally" in the 50's. Is that with a good pleth?


I would start with a fluid bolus and some high flow oxygen. I'm guessing that would lessen both her dyspnea and the ectopy. If it doesn't I'd try a small dose of glyco or atropine to see if that helps.


I would not use antiarrythmic unless she starts to have runs of VT.


I would also avoid norepi if at all possible, due to it's pro-arrythmic effects.


Getting an IO now vs. waiting until she worsens clinically is a judgement call; good arguments can be made for either approach but I'd lean towards doing it now.


Sometimes the best thing to do is just drive to the hospital. Even a small one with limited capability can usually handle patients like this.


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## Brandon O (Jul 2, 2014)

I think you have to treat this as urosepsis until proven otherwise. Volume load, abx if you have them, go. This is consistent with the hypotension, lethargy, infectious focus, hyperglycemia, etc. No fever, but hey.

Cardiac may be number 2, and you could argue for going 10 minutes further to the PCI facility. Ectopy is pretty appropriate for sepsis. (Let's stop talking about "converting" it...) However...

Try to find the J-point in each lead. Confused? Before I thought it was bigeminy, perhaps with Sgarbossa-type changes, but nope, those all seem to be SINUS beats. Every other P wave is being lost in the big T waves, which is why it's so hard to find those J-points. In other words, it looks like an intermittent RBBB every other beat.

With that said I don't THINK there are any clear ischemic changes, but that is not a normal rhythm and certainly may suggest a cardiac etiology.

The recalled sat is clearly spurious.


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## Christopher (Jul 2, 2014)

This ECG looked so much like a Dr. Smith ECG I googled it just to see. I guess you guys use the same machines 

(btw Google says this is "RBBB" when you search by image)



Brandon O said:


> Try to find the J-point in each lead. Confused? Before I thought it was bigeminy, perhaps with Sgarbossa-type changes, but nope, those all seem to be SINUS beats. Every other P wave is being lost in the big T waves, which is why it's so hard to find those J-points. In other words, it looks like an intermittent RBBB every other beat.



Nah, looks like bigeminy; R-R's are long-short-long-short-long-short.


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## Brandon O (Jul 2, 2014)

Christopher said:


> Nah, looks like bigeminy; R-R's are long-short-long-short-long-short.



So are you not buying those P waves?


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## Christopher (Jul 2, 2014)

Brandon O said:


> So are you not buying those P waves?



Perhaps PACs? I dunno, can't be simple 1:1 with the R-R's. 3:2 is the only option, but I can't march that scenario out.


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## KellyBracket (Jul 2, 2014)

Truly asking here - why isn't this an example of "STEMI-seen-in-PVC?" The ST elevation in the PVCs in lead II exceeds 25% of the preceding S wave.

E.g. http://hqmeded-ecg.blogspot.com/2009/11/stemi-best-seen-in-pvc.html

EDIT: Never mind, I just figured out how to Google image search. Dr Smith's explanation: http://hqmeded-ecg.blogspot.com/2013/10/polymorphic-ventricular-tachycardia.html


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## Rialaigh (Jul 2, 2014)

Christopher said:


> This ECG looked so much like a Dr. Smith ECG I googled it just to see. I guess you guys use the same machines
> 
> (btw Google says this is "RBBB" when you search by image)
> 
> ...



This ECG was not the actual ECG, just basically exactly like it, I had trouble getting a quality scan so I just searched for something that would get the gist across.


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## Rialaigh (Jul 2, 2014)

This was an actual patient I had on Sunday. I transported to the community hospital she was discharged from, our transport time was around 15 minutes and I did not drill her en route. Her BP's hung out around 90/50 with no trouble breathing (beyond what was normal for her) on 4L on a nasal canula. As far as I know  her chest Xray just showed chronic disease with no acute disease. I am curious about the highly diminished breath sounds on the left. Not sure on her lab work but when she called for EMS she had not been home from the hospital for more then 3 hours. I am wondering if this patient had some renal and electrolyte imbalances either associated with infection or separate and just happened stance. Or if the infection was causing a decrease in heart efficiency which was causing some acute CHF with and cardiogenic shock.

I'm curious if you have this patient in your care in *excess of an hour *are we hanging a pressor if non responsive to fluid therapy? Do any hospitals near you use Adenosine as a reset for this type of rhythm with hemodynamic changes? would anyone contemplate elective cardioversion with some ketamine or the like for comfort? Does anyone have experience pacing over PVC's if the heart rate drops low enough with hemo instability? 

 Do we have a high enough suspicion that antiobiotics and fluid are going to fix this underlying rhythm before it deteriorates or her BP drops to low or is this something that needs to be dealt with outside of fixing the possible sepsis?


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## Christopher (Jul 2, 2014)

Rialaigh said:


> This ECG was not the actual ECG, just basically exactly like it, I had trouble getting a quality scan so I just searched for something that would get the gist across.



It's ok. I have an uncanny knack for remembering tracings...


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## KellyBracket (Jul 2, 2014)

Rialaigh said:


> \...
> Do any hospitals near you use Adenosine as a reset for this type of rhythm with hemodynamic changes? would anyone contemplate elective cardioversion with some ketamine or the like for comfort? Does anyone have experience pacing over PVC's if the heart rate drops low enough with hemo instability?
> 
> Do we have a high enough suspicion that antiobiotics and fluid are going to fix this underlying rhythm before it deteriorates or her BP drops to low or is this something that needs to be dealt with outside of fixing the possible sepsis?



If it's sepsis, it's fluids, antibiotics, pressors, intubation, and source control (e.g., if it's an infected gallbladder it gets yanked or drained, if a PICC looks like the source, it gets pulled...).

If this ECG is a fair representation of what you saw, then no specific therapy is indicated. Bigeminal PVCs are a stable rhythm, and it takes a fair stretch of the imagination to picture them causing a problem. So, no to adenosine/cardioversion/pacing/amio/what have you.

The apparently stable and chronic severe hypoxemia makes me wonder if the patient has pulmonary fibrosis of some sort. (Not cystic fibrosis, different.) I wonder, however, if the preliminary diagnosis of pyelo is correct. The presentation may have evolved, even over 3 hours.


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## BlogAuthor (Jul 3, 2014)

*You stole this from my blog without attribution*

This case is stolen from Dr Smith's ECG Blog:
From my case of polymorphic VT.  I would post the link but this site will not let me.

*EDIT: This ECG is from a case on Dr. Smith's ECG Blog. See the case here*


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## Brandon O (Jul 3, 2014)

KellyBracket said:


> Truly asking here - why isn't this an example of "STEMI-seen-in-PVC?" The ST elevation in the PVCs in lead II exceeds 25% of the preceding S wave.



My doubt is because the STE in some leads seems to be an artifact -- those aren't the actual J points. If you measure off the QRS via the narrowest leads and use that to look at the rest, there's little ST change if any -- the bizarre T waves seem to be a result of what looks, to me, like buried P waves.

Also, as Dr. Smith notes, the alternating narrow beats lack matching ST/T changes (or in some leads even appear to be deflected opposite). So it's a bit hard to draw a pattern here.



Rialaigh said:


> This ECG was not the actual ECG, just basically exactly like it, I had trouble getting a quality scan so I just searched for something that would get the gist across.



I understand the tendency to cut corners when it comes to educational purposes -- probably everybody has thrown an image into a PowerPoint that they found on Google -- but please try to understand that for situations like this, there are people who make their livelihood and/or have dedicated hundreds of hours of their lives to producing free online medical content. Most of the time they don't mind its reuse, especially if they don't make money on it, but I think using it without attribution is always upsetting... for the same reason as when someone plagiarizes an essay -- they're passing off your work as their own, even if unintentionally. Just attribute your sources, even when using things for mere illustration, and that usually does the trick.



Rialaigh said:


> This was an actual patient I had on Sunday.
> 
> I'm curious if you have this patient in your care in *excess of an hour *are we hanging a pressor if non responsive to fluid therapy? Do any hospitals near you use Adenosine as a reset for this type of rhythm with hemodynamic changes? would anyone contemplate elective cardioversion with some ketamine or the like for comfort? Does anyone have experience pacing over PVC's if the heart rate drops low enough with hemo instability?



In general I would say that a rhythm like this should never be cardioverted, whether chemically or electrically. It would not be indicated. There's no reentrant pathway to interrupt, and it's organized so if you "reboot" there's little reason to think you'll end up with anything different. Transcutaneous pacing wouldn't be appropriate either as it's not a bradycardia.

I could be wrong but I doubt the hypotension and lethargy are due to the rhythm. (They could be due to a shared underlying cause such as MI.) It is at least regular and at a decent rate.

Question: what was the sat while in your care?


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## Rialaigh (Jul 5, 2014)

I would like to apologize for my use of the EKG image with permission or attributing the work to the author. The rest of the scenario information was mine from a call ran very recently. I was looking for a EKG that represented what I saw and just grabbed the first one that looked good. I again would like to say I am sorry and will use this as a learning opportunity. 


During  the patient contact time her O2 sat never came above 62% for me, good waveform with minimal trouble breathing. I kept her on a nasal canula at 4L, Really her only complaint during transport was her flank pain and generalized weakness.


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## BlogAuthor (Jul 6, 2014)

Thanks for the apology.  Totally accepted!!
Steve Smith


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## NomadicMedic (Jul 6, 2014)

Dr Smith, I know I speak for all of us (including the moderators) when I say we'd love to have you post more and share cases with us.


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## Brandon O (Jul 6, 2014)

Rialaigh said:


> During  the patient contact time her O2 sat never came above 62% for me, good waveform with minimal trouble breathing. I kept her on a nasal canula at 4L, Really her only complaint during transport was her flank pain and generalized weakness.



If accurate, this would be absolutely the lowest sat I've ever heard of in a patient with no respiratory complaints. Not sure the literature on this but it's certainly impressive...


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## Rialaigh (Jul 6, 2014)

Brandon O said:


> If accurate, this would be absolutely the lowest sat I've ever heard of in a patient with no respiratory complaints. Not sure the literature on this but it's certainly impressive...



Yeah, we have picked this lady up multiple times and she is just a ticking time bomb. The irony (if you can call it that) is that she never calls for a respiratory complaint. It's always weakness, falls, stroke symptoms, abd pain, back pain...etc...etc..etc..

Everytime out there have had trouble getting anything over 62-65% tops. Hospital gets the same sats and she always comes back with a midly elevated CO2 on her ABG but nothing to call home about.


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## Brandon O (Jul 6, 2014)

Rialaigh said:


> Everytime out there have had trouble getting anything over 62-65% tops. Hospital gets the same sats and she always comes back with a midly elevated CO2 on her ABG but nothing to call home about.



Normal pO2 on the ABG or no?


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## Rialaigh (Jul 6, 2014)

Brandon O said:


> Normal pO2 on the ABG or no?



high 70's if I recall correctly, nothing ever was real crazy...Its just weird though, perfect wave form on the SPO2, good radial pulses, warm hands...same thing over and over


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