# Unresponsive person



## StCEMT (Aug 21, 2017)

Dispatched for 69 y/o F in a nursing home. Only helpful notes say poss stroke, unconscious and that she is breathing. 

Arrive on scene to find pt supine in bed. Eyes partially open, but pt not responsive to any stimuli during initial assessment. Airway patent, breathing a bit shallow rate approx. 14, pulses strong and rapid. 

Once on the monitor...pulse 140 sinus tach, bp 171/108, 88% room air trended down to 82% quickly, BGL 163. Around now the pt begins to have small tremors in her face, right hand, right foot.

After initial assessment staff bring sheet with Hx that includes dementia, seizures, and CVA. They say she is usually alert, ambulatory, and able to talk with staff. (There was a med list, I will go on and say I've forgotten what they were since I only skimmed it very quickly during the 4 minute drive). Last known well time given by staff was 1230 (its about 1650 now).


----------



## VentMonkey (Aug 21, 2017)

Sit her upright and perform basic airway maneuvers. Does she take any sort of adjuncts such as an NPA or OPA?

Is she febrile, and what are her breath sounds. Supplemental O2 delivery of the high-flow variety. Is she tracking?

Given her hx, I'm dropping a lock and reaching for the Versed. I'd like my EMT to be at the ready with suction as well. In my experience, small tremors almost always precipitate a grand mal seizure. I would probably also ask the staff if her tremors are what her "seizures" normally look like.

@StCEMT what happens next?

Edit: an updated code-status on this patient would be my first priority TBCH.


----------



## DesertMedic66 (Aug 22, 2017)

Exactly what Vent said. Sit her up, get her on some oxygen. I’d also toss in checking a BGL.

Edit: with the Hx of dementia I’d want another look at the med list to look for medications that may cause EPS.


----------



## StCEMT (Aug 22, 2017)

NPA works. Afebrile, temperature tab looks to be at the 98 mark. 15lpm bumps up O2 sat to an >94%. BGL was 163. Pt is a full code. Tremors appeared to last for 30-40 seconds.

@VentMonkey. Next was a quick trauma check. Purple discoloration noticed from upper chest upto the neck. Pt had a rightward gaze, pupils were unequal at approx. 3 & 5mm. No obvious bruising or signs of a fall noted.


----------



## EpiEMS (Aug 22, 2017)

StCEMT said:


> Purple discoloration noticed from upper chest upto the neck. Pt had a rightward gaze, pupils were unequal at approx. 3 & 5mm.



Interesting. At the moment, can we get a 12-lead? Also, quick q - was the pulse nice and regular, or was it..A-fibby? Response to the versed?

Some random ramblings:
Anisocoria suggests some sort of intracranial pathology. (I would have guessed it was precipitated by a fall, too.) 
Purple discoloration, combined with the dyspnea I'm thinking pulmonary embolism (patient has signs of one, possibly two parts of Virchow's triad & the cyanosis)? 

I guess I'm having trouble squaring the circle here - are there multiple pathologies at work? Or am I way off base?


----------



## StCEMT (Aug 22, 2017)

EpiEMS said:


> Interesting. At the moment, can we get a 12-lead? Also, quick q - was the pulse nice and regular, or was it..A-fibby? Response to the versed?
> 
> Some random ramblings:
> Anisocoria suggests some sort of intracranial pathology. (I would have guessed it was precipitated by a fall, too.)
> ...


12 lead showed sinus tach consistently between 130-140. Pulses we're strong.

That is the question if the day, I am going to follow up this weekend. I wanted to see what questions y'all asked and what diffs got thrown out until then.


----------



## VentMonkey (Aug 22, 2017)

StCEMT said:


> I wanted to see what questions y'all asked and what diffs got thrown out until then.


Given the history, and presentation leading to an underlying neurological etiology, I'm treating for seizure prophylaxis, and making a patent airway with adequate oxygenation, and ventilation my top priorities.

Just like in P-school, all of the other side notes, or "nice-to-knows", as we would call them such as a possible PE I cannot do any about directly therefore a neuro workup is where my focus lies. 

I used to tell my interns that you can perform every test in your pocket, and most likely will in the beginning, but none of that will fix this patient. Once you get your bearings you'll begin to focus more on one primary, treat it, then question a secondary at the ED. You'll also realize just how limited a medic is regardless of their toolbox. At least I did, and that's where I learned that the value of differentials comes with time, as does knowing where it fits in to a paramedics assessment.


----------



## E tank (Aug 22, 2017)

Med list? Bruising might suggest a blood thinner and a reason not to place an NPA.


----------



## EpiEMS (Aug 22, 2017)

E tank said:


> Med list? Bruising might suggest a blood thinner and a reason not to place an NPA.


Curious - if they're on an anticoagulant, should that push PE further down the list of DDx?


----------



## E tank (Aug 22, 2017)

EpiEMS said:


> Curious - if they're on an anticoagulant, should that push PE further down the list of DDx?


 
It would be unusual for someone that was therapeutic on a blood thinner to embolize something. But having it on their med list doesn't mean they've been taking it appropriately or at all. 

But since you brought up the scenario, if a patient were to have an intracardiac thrombus that he was being treated for with blood thinners, it isn't outside the realm of possibility that, if the clot were unstable, it could embolize. 

But, at the end of the day, it doesn't matter. You'll treat what you see.


----------



## EpiEMS (Aug 23, 2017)

E tank said:


> But, at the end of the day, it doesn't matter. You'll treat what you see.



Indeed! Just wanted to check if my (very, very high level) thoughts on the physiology (if you can even call my ramblings "physiology") were appropriate.


----------



## StCEMT (Aug 23, 2017)

@VentMonkey I like it and agree with your points. Calls like this are good learning moments for newer medics like me in terms of overall management. We didn't waste time, scene to hospital was 30ish minutes, but there are some things I could have done better to make things smoother. The toolbox may be limited for us, but the tests (at least what we did) are valuable. Biggest thing is I now know I need to tell this hospital to have more prepared in advance, I usually am brining people like this to the level 1 which has everything laid out and are ready for quick, aggressive treatment if needed and they have more than once immediately intubated people I have brought in just because they prepare better.

@E tank there were no blood thinners that I saw on the sheet, but I don't remember the list off the top of my head anymore.


----------



## zzyzx (Aug 24, 2017)

Aspiration pneumonia/sepsis. It's always aspiration pneumonia when you're living in a SNF.

Above all, clarify the code status. Get the family contact info and bring it to the ER. This patient should never get intubated or end up in an ICU.


----------



## EpiEMS (Aug 24, 2017)

zzyzx said:


> This patient should never get intubated or end up in an ICU.



One would hope...I am not so convinced, though.

As far as sepsis secondary to aspiration pneumonia, that makes sense - certainly meets SIRS criteria.


----------



## StCEMT (Aug 24, 2017)

zzyzx said:


> Aspiration pneumonia/sepsis. It's always aspiration pneumonia when you're living in a SNF.
> 
> Above all, clarify the code status. Get the family contact info and bring it to the ER. This patient should never get intubated or end up in an ICU.


Don't agree or disagree, but for the sake of discussion....why is sepsis your first go to and what makes you think his patient shouldn't be intubated?


----------



## zzyzx (Aug 24, 2017)

StCEMT said:


> Don't agree or disagree, but for the sake of discussion....why is sepsis your first go to and what makes you think his patient shouldn't be intubated?



For an altered patient in a nursing home, infection/sepsis would be at the top of my differential. Since this patient is also a little hypoxic, they may well have pneumonia. Aspiration pneumonia is common in elderly patients with dementia.

Of course, there are many other reasons for why this patient could present with increased confusion.

Why no intubation or ICU care? Well, what is her quality of life? If she has a good quality of life, then the next question to ask if intubation and an ICU stay will have a realistic chance or making her better. Most people will say that when they get to the point near the end of their lives where they can no longer recognize their loved ones, they will not want any medical care to prolong their lives. If the patient's family wanted "everything done," she would probably wind up in an ICU for a while, maybe a very long while, and most likely not get better.


----------



## VFlutter (Aug 24, 2017)

Sounds like either a primary neuro insult or seizure activity secondary to something medical. Could have been postictal. 

IRRC gaze preference towards the side of weakness is usually seizure vs stoke being contralateral . Or something like that.


----------



## E tank (Aug 24, 2017)

zzyzx said:


> Aspiration pneumonia/sepsis. It's always aspiration pneumonia when you're living in a SNF.
> 
> Above all, clarify the code status. Get the family contact info and bring it to the ER. This patient should never get intubated or end up in an ICU.



How can that determination possibly be made at this point in the scenario? The patient is usually alert, ambulatory and able to have conversations with the staff. There isn't even a firm diagnosis and the patient is being relegated moribund? You make a lot of speculative assumptions and generalizations about how people want to live and die when there is nothing at all to substantiate those notions at all in this scenario.

My bias would be to err toward saving her life, short any specific directive by her or the family in the face of a devastating illness or injury. Like someone pointed out, she could just be post ictal for pete's sake.


----------



## zzyzx (Aug 25, 2017)

As I stated in my post, there are many reason why this patient could be presenting the way she is. 

With all due respect, if you worked in an ICU, I think you would have a better understanding of why it would most likely not be in this patient's best interests to be on a vent in an ICU.


----------



## E tank (Aug 25, 2017)

zzyzx said:


> As I stated in my post, there are many reason why this patient could be presenting the way she is.
> 
> With all due respect, if you worked in an ICU, I think you would have a better understanding of why it would most likely not be in this patient's best interests to be on a vent in an ICU.



For what its worth, I do critical care every day I work, an that includes putting people on ventilators as well as giving therapies meant to avoid having to put people on ventilators. Just pointing that out because I don't think we've met. 

 Again, I'm at a loss to know how it is a foregone conclusion what's in this patient's best interests before anyone knows what is going on, beyond a conscientious diagnostic workup and supportive care until definitive conclusions are made. I wouldn't be ready to let her die just yet.


----------



## VFlutter (Aug 25, 2017)

I am a huge advocate for palliative care and deferring intubation if possible until a conversation with family can be had. Even if the family knew the patient would not want to be prolonged on life support once they are on it many have a difficult time withdrawing care. Having said that, in my experience, the majority of families request aggressive care unless there was a written DNR regardless if they know the patient would not want it. in EMS treat the patient to the standard of care and let things play out in the ICU with the physicians and palliative care specialist. If they can survive on Bipap or a NRB then that is great but if they need intubation then do it. How do you know this isn't a reversible disease process? Maybe she missed her Keppra dose the past few days and is hyponatremic. I do not see anything that would make me assume she is end of life or futile. She was ambulatory and at her baseline prior to this incident.


----------



## StCEMT (Aug 29, 2017)

Followed up today. Turns out it was simply status, nothing else funky neuro going on.


----------

