# Just looking for some thoughts on this call the other day.



## RanchoEMT

ALS Ambulance and ALS Fire Engine arrive on scene at the same time to residence for a reported "Diff Breather". At front door is reporting party(patient's daughter) directing crew into the kitchen. Crew enters kitchen to find 57 year old male lying left lateral in mild to moderate distress. Patient is awake and tracking. Patient is able to answer questions and states "I had trouble breathing in, I passed out and went down to the floor. Its never happened before." 
Daughter reports "He was playing racket ball earlier and has had a gradual onset of difficulty breathing since playing. Patient has no medical Hx, no allergies and no meds. 911 was called when patient passed out about 10 minutes ago and started shaking. Patient started to wake up when EMS arrived."
Patient denies any other pain/Discomfort, nausea/Vomitting, no other complaints
------Initial Assessment---------------------------
GCS=E4,V5,M6(15) Pulse(Carotid Only)=132 Weak/Irregular  
Automated Blood Pressure=Unreadable   Manual Blood Pressure=UnReadable.
Respirations= 30/min and Shallow  SPO2=94% RA
Lung Sounds=Clear BiLaterally
Skins= Cyanotic, Moist, Cool.    Pupils= PERRL.    Cap Refill= Below 2 Sec.
ECG=A-Fib w/o Ectopy    12-LEAD=Non-Stemi.
-----------------------------------------------------
Administered oxygen NRB, SPO2=94% NRB
IV 18G left AC NS Flowing
Positioned Patient Semi-Fowler's

Patient states- "Thanks guys your the best....PAUSES..... I think im getting worse"

At this point patients skin color from clavicle level up turns blue. Patient passess out and pupils dilate fully. Patient goes into PEA Arrest. At this time a newly presenting stiff mass has become visible at patients epigastric area.  ACLS is started. ET-Tube is placed. Patient transported code3 to the hospital where rescusitation efforts are later stopped.


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## Aidey

Sounds like a pulmonary embolism except for the "stiff mass" business. Can you elaborate? 

And why 15lpm NRB?


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## DesertMedic66

Aidey said:


> Sounds like a pulmonary embolism except for the "stiff mass" business. Can you elaborate?
> 
> And why 15lpm NRB?



Why not the NRB?

spo2 is at 94% with shallow resperations at 30/min and the patient has cyanosis.


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## SoCal911

Like a rigid abdomen? Please elaborate?


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## RanchoEMT

Aidey said:


> Sounds like a pulmonary embolism except for the "stiff mass" business. Can you elaborate?
> 
> And why 15lpm NRB?


When we sat patient up he said his statement, passed out, a clear distinction of dark blue skin color from clavicle up could be scene. The rest of the body remained pale white. We had his shirt still up from the twelve lead and noticed at this time a mass form about fist-size in the patient's epigastric area. Fire medic felt it and said it was stiff. Layed patient back down for cpr and it dissipated.



Aidey said:


> And why 15lpm NRB?


Iunno, I think fire threw it on, dont remember. This all happened very quickly. Almost immediately following initail vital signs. Why do u ask? CPAP?


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## SoCal911

Sounds like an internal bleed out. All the symptoms fit.


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## SoCal911

Or an insane aneurysm


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## RanchoEMT

SoCal911 said:


> Sounds like an internal bleed out. All the symptoms fit.



What about the blue from clavicle up? Why would this happen? The reported seizure like activity reported from the daughter(i might have down played that) initially in the OP.  he was GCS15, but looked kinda postictal. Smelled incontinant.


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## DesertMedic66

Aidey said:


> Sounds like a pulmonary embolism except for the "stiff mass" business.



Based on my limited knowledge I would say I agree with a possible PE. 

My mother had a PE and all her symptoms area exactly the same as what has been described except for the stiff mass and luckily the PEA.


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## RanchoEMT

firefite said:


> Based on my limited knowledge I would say I agree with a possible PE.
> 
> My mother had a PE and all her symptoms area exactly the same as what has been described except for the stiff mass and luckily the PEA.



Dark Blue from clavicle up too??? I stress the clavicle up b/c there was such a visible distinction between skin colors superior/inferior to the clavicle line.


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## DesertMedic66

RanchoEMT said:


> Dark Blue from clavicle up too??? I stress the clavicle up b/c there was such a visible distinction between skin colors superior/inferior to the clavicle line.



No, luckily she didn't have that.


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## beefaroni

Well why did you sit him up if he had clear l/s and only a carotid pulse at 132? Sounds smart..


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## DesertMedic66

Supertampon5 said:


> Well why did you sit him up if he had clear l/s and only a carotid pulse at 132? Sounds smart..



Position of comfort?


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## RanchoEMT

Supertampon5 said:


> Well why did you sit him up if he had clear l/s and only a carotid pulse at 132? Sounds smart..



I didn't my medic did. But i think that gets into the subjective vs. objective do i position patient in a way that will help what i think is going on or what the patient is telling me is wrong??? I assume u mean why raise the head above the heart with a 'probably' low bp... Again i can only assume it was to see if patients subjective complaint of "difficulty breathing" was elevated with the positioning.


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## RanchoEMT

RanchoEMT said:


> I didn't my medic did. But i think that gets into the subjective vs. objective do i position patient in a way that will help what i think is going on or what the patient is telling me is wrong??? I assume u mean why raise the head above the heart with a 'probably' low bp... Again i can only assume it was to see if patients subjective complaint of "difficulty breathing" was elevated with the positioning.



This may or may not of been what killed him. I'm aware.


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## firetender

RanchoEMT said:


> This may or may not of been what killed him. I'm aware.


 
What killed him was the disease entity. You were there to make sure someone tried.


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## Handsome Robb

I doubt anything you guys did killed him. 

I agree with the PE. If it was a PE positioning wouldn't really matter. 

The discoloration almost sounds like traumatic asphyxiation but I don't see how this would be the case in the scenario you presented.


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## Aidey

*facepalm* I bet $10 the guy had an umbilical hernia totally unrelated to anything going on. That is the only thing I can think of that would be in that spot and would show up when sitting up and disappear when lying down. 


And when was the last time anyone heard of a patient with an SpO2 of 94% and non-localized cyanosis?


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## mycrofft

Googling "supraclavicular cyanosis" raises it as a symptom of blunt force trauma cardiac tamponade. Not sure about blunt trauma (sidebar: would CPR count as blunt trauma and how does blunt trauma cause "cardiac tamponade"?....), but similar mechanisms tend to create similar signs and symptoms, and cardiac tamponade can be caused by a number of mechanisms.
I don't think raising the head somewhat (30 degrees) killed anyone. Fowler's can improve respiration and decrease related anxiety. If BP was that delicate turning a corner rapidly could have done it, or tipping the litter as the pt was removed out from the ambulance.


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## bw2529

mycrofft said:


> would CPR count as blunt trauma



Depends on which side of the lawsuit you are on.


I kid, I kid. :rofl:


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## mycrofft

Hahaha!

Seriously, with the trend now to train every layperson to address adult loss of consciousness with (at least) hands-only CPR, we need to start seeing postmortems recording if the CPR we teach causes signifcant cardiac insult to offset benefit. Used to be starting CPR when any pulse was palpable was a "horror of horors".


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## Steveb

firefite said:


> Based on my limited knowledge I would say I agree with a possible PE.
> 
> My mother had a PE and all her symptoms area exactly the same as what has been described except for the stiff mass and luckily the PEA.



What is a PE???


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## SoCal911

Pulmonary embolism


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## Maine iac

Halfway through reading this my idea was PE, then it changed to a witnessed AAA, and now I am some what torn between the two (hahah torn.. :rofl. He was playing racket ball earlier.. might have gotten hit in the chest causing a dislodge of plaque going into his lung causing a chain reaction and death. 

I would be interested to know what the FAST exam showed. If he was still in PEA at the hospital, doubtful, but I would hope that the hospital would be aggressive to try everything for him. 

Did you guys mess around on the scene or was this like a 4 minute scene time? Not that it would have changed anything at all- but just wondering.


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## exodus

Do you have the 12 lead still? I'd like to see it.


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## RanchoEMT

exodus said:


> Do you have the 12 lead still? I'd like to see it.



I'll get it when i go back to work, thursday...


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## RanchoEMT

Maine iac said:


> I would be interested to know what the FAST exam showed. If he was still in PEA at the hospital, doubtful, but I would hope that the hospital would be aggressive to try everything for him.
> 
> Did you guys mess around on the scene or was this like a 4 minute scene time? Not that it would have changed anything at all- but just wondering.



you know what, honestly, they didnt try for very long. Me and my medic where kinda hopefull... We both were kinda bummed afterwards cus it seemed like they didnt try as hard as they could have for a witnesssed arrest like this.

Scene time was prolly 10-15 minutes... 45 seconds getting to patient, patient coded about 5 min after, we worked on him for about 7 minutes, then transported. 10-15ish...


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## mycrofft

Never heard of blunt force dislodging  plaque. Those are in the vessel wall, not like grease in the drain trap like we initially thoght. 
But blunt force could cause cardiac tamponade (see above).


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## Squad51

Aidey said:


> *facepalm* I bet $10 the guy had an umbilical hernia totally unrelated to anything going on. That is the only thing I can think of that would be in that spot and would show up when sitting up and disappear when lying down.
> 
> 
> And when was the last time anyone heard of a patient with an SpO2 of 94% and non-localized cyanosis?



Echo echo echo. I was just thinking the same thing about the hernia but you beat me to it! I agree with everyone else. Most likely a PE. Depending on the location of the clot, could be why he was so tachy and hypotensive with decreased SpO2. The clot probably dislodged and put him in full blown cardiac arrest. Not much you could do different. The "mass" probably had nothing to do with it. He probably had a hernia that he did or did not know about. Certainly fits the description you gave when you sat him up.


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## RanchoEMT

Lets say for a second it was an aneurysm and the patient did go into a PEA full arrest. Is it possible(and/or probable) that the PEA showing on the monitor and verified by a lack of palpaple pulse was in fact Wrong??? Again, Assuming for a second that it was in fact an aneurysm is it possible that the heart was still beating, but due to the aneurysm, the distant pulses were not pulsating?

Obviously, the heart bleeding out wouldn't last for long with the drop in blood volume, (resulting in a true arrest) but Does any one auscultate the heart in a full arrest just to verify this???

***Noticed, when they called him later at the hospital, he was still in "PEA". ***


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## 94H

Im thinking AAA also just because of the mass. Did you notice if it was pulsating at all?


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## jjesusfreak01

Aidey said:


> *facepalm* I bet $10 the guy had an umbilical hernia totally unrelated to anything going on. That is the only thing I can think of that would be in that spot and would show up when sitting up and disappear when lying down.
> 
> 
> And when was the last time anyone heard of a patient with an SpO2 of 94% and non-localized cyanosis?



I don't see how they got a decent SpO2 on this patient to begin with, considering the lack of peripheral pulses, unobtainable pressure, and obvious shunting away from the periphery.


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## TheLocalMedic

Not an AAA, but rather a rupturing thoracic aneurysm.  With a thoracic aneurysm it is not uncommon to get upper limb cyanosis, just like an AAA can cause lower limb cyanosis.  The difficulty breathing sounds like referred pain and an attempt to "self splint" by decreasing chest wall movement.  I had a patient a few years ago that exactly matches the description of this patient and a postmortem revealed an aneurism that began at the aortic arch and descended past the diaphragm.  

And who was it earlier that questioned the use of high flow O2?  Really?  When a patient looks like crap, give them the extra fuel.  The whole issue of using lower amounts of O2 pertains mainly to prolonged use and stable ACS or COPD patients, remember that you should _never_ withhold O2 if they're really sick.  You don't look smart when you do that, it just shows that you haven't truly read the research about what you're preaching.


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## usalsfyre

TheLocalMedic said:


> And who was it earlier that questioned the use of high flow O2?  Really?  When a patient looks like crap, give them the extra fuel.  The whole issue of using lower amounts of O2 pertains mainly to prolonged use and stable ACS or COPD patients, remember that you should _never_ withhold O2 if they're really sick.  You don't look smart when you do that, it just shows that you haven't truly read the research about what you're preaching.


Right, high flow O2 makes all the difference for hypemic issues because the oxygen carrying capacity of plasma is so great ...

If you truly have a ruptured abdominal aneurysm to the point of exangunation you'd likely only have a distended, rigid abdomen due to the amount of peritoneal irritation. A ruptured thoracic aneurysm is more likely but my money is on PE.


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## Handsome Robb

I still want to see the 12-lead 

As far as listening for an apical pulse you could but if you can't find a carotid pulse the guy isn't perusing his brain so I doubt it's going to matter much. Might be viable for organ donation but with the shunting I'm not sure the organs would be viable anyways...


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## RanchoEMT

NVRob said:


> I still want to see the 12-lead .



I looked for it when i came back to work and realized fire used their monitor, its saved on their LP15... In other words its gone, sorry.


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## leoemt

I know this thread is a couple of months old so don't yell at me for reviving it but I am really interested in this scenario. 

While I don't have the experience yet to really offer a guess I have noticed that no one has keyed on the fact that the patient was playing Racket ball prior to onset of symptoms. 

Is it possible that the patient took a hit to the chest by the ball? That would be enough of blunt force trauma to cause a pericardial tamponade (sp?) I would think. 

Having played racket ball myself I know those hard rubber balls can really get moving. I've seen players get broken bones from those balls.


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## TB 3541

leoemt said:


> ...I have noticed that no one has keyed on the fact that the patient was playing Racket ball prior to onset of symptoms.
> 
> Is it possible that the patient took a hit to the chest by the ball? That would be enough of blunt force trauma to cause a pericardial tamponade (sp?) I would think.



Actually, someone did bring that up:



Maine iac said:


> Halfway through reading this my idea was PE,  then it changed to a witnessed AAA, and now I am some what torn between  the two (hahah torn.. :rofl.  He was playing racket ball earlier.. might have gotten hit in the chest  causing a dislodge of plaque going into his lung causing a chain  reaction and death.



I'm really intrigued by this scenario too, but unfortunately, I don't think we will ever know because we don't have access to any records other than the first-hand experience provided. Really, I think only an autopsy could be definitive.


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## blindsideflank

Problems with coarctation of aorta/dissection
Saddle embolus?

Murder and a fake story


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## VFlutter

Was he in chronic A fib or was this new onset? Any current medications, particularly any Anticoags? Not with this situation but with symptoms after physical activities it always keep spontaneous pnuemo --> tension pneumo in the back if my mind.  


Blue from the clavicles up....Line of demarcation?


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## leoemt

TB 3541 said:


> Actually, someone did bring that up:
> 
> 
> 
> I'm really intrigued by this scenario too, but unfortunately, I don't think we will ever know because we don't have access to any records other than the first-hand experience provided. Really, I think only an autopsy could be definitive.



Sorry my bad, I read Maine Iac's post but apparently I missed that. So much for my observation skills.


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## shiroun

IF I haven't posted this already, has anyone considered triple A? Stiff mass would fit, it could have been a posterior tear when he was lieing down, and when he positioned himself he could have severely torn it, causing that stiff mass to appear, and disappate when he laid down (it would receed a bit), but would still be present.


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## Lfd128

Sounds like a high abdominal aneurysm. Cyanosis onset due to restricted blood flow and mass of aneurysm could have been exasperated by a clot dislodged during the physical activity. Short of administering thrombolytics, there's not much that could be done.


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## Aidey

The description given in the OP and one of the follow up posts fits an abdominal hernia EXACTLY. This is a horses vs zebras one.


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## Swimfinn

i would have thought pneumothorax


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## soon2Bmedic

maine iac, i agree with the AAA!! i am still a medic student but, its the only thing that would make the superior cyanosis make any sense to me. if the guy had a AAA and he was sitting up any at all, then he would lose afterload and therefore lose perfusion to everything above the heart... right?


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## soon2Bmedic

Lfd128 said:


> Sounds like a high abdominal aneurysm. Cyanosis onset due to restricted blood flow and mass of aneurysm could have been exasperated by a clot dislodged during the physical activity. Short of administering thrombolytics, there's not much that could be done.


you really wouldn't want to give thrombolytics to someone your suspecting to have an internal bleed!! they will just make them bleed out faster.


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## OzAmbo

Cyanosis of the type described is associated with forms of obstructive shock, with the main culprits being pericardial tamponade and either saddle massive PE. The mechanism of this cyanosis is poorly understood. When i was doing my bachelors degree i tried to do a literature review on the mechanism of this particular cyanosis and came up with the "poorly understood" line, but my google fu is weak and im sure there is more out there then i was able to locate as an undergrad.

Someone threw coarction of the aorta out there, but i doubt this guy got this far into life without already showing symptoms of that previously.

Thoracic aneurysm fits if they are bleeding into their mediastinum / pericadial sac and the blood loss is limited

Massive PE / saddle PE has been know to cause this type of cyanosis, which im leaning towards as the patient does not appear to have a gas exchange problem (sats 94, RR30 with a clear chest) obvious tissue hypoxia but with good gas exchange (assuming he has normal blood volume and Hb levels) which tells me its more likely an 02 delivery issue. (i bet 5 dollars his ETC02 would show hypercapnia).

so im with obstructive shock - either saddle PE or pericardial tamponade

I think the transient rigid epigastric mass is a red herring ias it doesn't really fit the rest of the presentation, at least in my opinion


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## karaya

No capnometry?


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## Doczilla

Lfd128 said:


> Sounds like a high abdominal aneurysm. Cyanosis onset due to restricted blood flow and mass of aneurysm could have been exasperated by a clot dislodged during the physical activity. Short of administering thrombolytics, there's not much that could be done.



Huh?


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## STXmedic

Either a poor understanding of aneurysms, or of blood flow.... Or poor at putting thoughts into words... :unsure:
Had to read it several times, each making my head hurt worse...


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## SDog

karaya said:


> No capnometry?



I too am curious about the capnometry. It could help rule out PE (or indicate). Some research shows that wave lengths that show "crude oscillatory ripples" indicate PE. Very cool stuff . To me capnography is exciting just because it's a diagnostic tool we get to use!


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