# Scenario: I can't move my arm.



## JPINFV

Ok, since I don't see very many scenarios here, I'll start one. I'm putting this here since there isn't a scenario forum.

Rules: You are ALS, regardless of level. Points awarded for thought process in figuring out what is going on. At the start, you are on a standard ALS unit. This might change. 

Again, I'm looking for "what's going on and how to treat it" than "high flow O2, IV, monitor, transport." 

This is run by you, the posters. When you ask questions, you will be rewarded with answers. The opening post is vague for a reason. Feel free to assume that you have taken BSI and that the scene is safe because this is not about those.


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## JPINFV

20y/o male complaining of sudden onset paralysis to right arm.

Go.


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## paccookie

JPINFV said:


> 20y/o male complaining of sudden onset paralysis to right arm.
> 
> Go.



What's the pt's LOC?  
How are his ABCs?
Partner to take c-spine control due to potention for trauma.
Baseline vitals?
Onset of paralysis?
What was he doing when the paralysis started?
Any recent trauma/falls/injuries (even if they seem insignificant)?
Medications?
Allergies?
Medical history?


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## MikeRi24

my first thought would be to look for any signs around the scene for a mechanism of injury, and ask anyone around if they saw anything and ask the patient what happened. depending on what i can gather from that, I could go a bunch of different directions in my pt assesment and tratment. 

But, assuming that no one saw anything, and the patient says that thier arm just went numb and they cant move it, and I have NO other information as to how this happened, I would then move on to an exam of the patient to try and narrow it down. 

Again, without knowing much else than what you provided, its kinda hard to pick a direction to go in. Obviously as a trained EMS provider, one would be able to get a better grip on the situation once a patient assesment was started, but, just being given that information, I would maybe consider a stroke a high possibility. I can't really think of much else that would just cause a sudden loss of motion and feeling in a limb like that. Obviously I would look for other signs to support that, and I would also check for a neck or back injury as well. With just the information given and the knowledge that I have (which isn't much since I'm still in EMT classes), I would go with a stroke.


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## Emt /b/

Well, since I do not have the means or training to test for any of the diseases, infections, or toxins that can cause paralysis, my course of action would be to bring them to a hospital. 

If it wasn't trauma related, not really much I could do. And if it was, board 'em. And of course, examine for other signs or symptoms of a stroke.


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## paccookie

MikeRi24 said:


> my first thought would be to look for any signs around the scene for a mechanism of injury, and ask anyone around if they saw anything and ask the patient what happened. depending on what i can gather from that, I could go a bunch of different directions in my pt assesment and tratment.
> 
> But, assuming that no one saw anything, and the patient says that thier arm just went numb and they cant move it, and I have NO other information as to how this happened, I would then move on to an exam of the patient to try and narrow it down.
> 
> Again, without knowing much else than what you provided, its kinda hard to pick a direction to go in. Obviously as a trained EMS provider, one would be able to get a better grip on the situation once a patient assesment was started, but, just being given that information, I would maybe consider a stroke a high possibility. I can't really think of much else that would just cause a sudden loss of motion and feeling in a limb like that. Obviously I would look for other signs to support that, and I would also check for a neck or back injury as well. With just the information given and the knowledge that I have (which isn't much since I'm still in EMT classes), I would go with a stroke.



There are many things other than stroke that can cause sudden paralysis.  Stroke is usually the most obvious, though.  TIA ("mini stroke"), head injury, burst aneurysm/intracranial bleed, arterial blockage, spinal cord injury, psychiatric disorders (think depersonalization disorders), hyperventilation (though this is more numbness than actual paralysis), nerve injuries, vitamin deficiency.  

Given the patient's age as 20, I wouldn't necessarily lean towards stroke unless he had very high blood pressure or a history of a previous stroke or TIA.  My first thought was more towards a head injury, drugs, or some sort of intracranial bleed.


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## JPINFV

Emt /b/ said:


> Well, since I do not have the means or training to test for any of the diseases, infections, or toxins that can cause paralysis, my course of action would be to bring them to a hospital.
> 
> If it wasn't trauma related, not really much I could do. And if it was, board 'em. And of course, examine for other signs or symptoms of a stroke.



Think outside the box. This is more of a critical thinking exercise than a "pack em up, high flow O2, immediate transport" exercise. You can always test the extent of any paralysis.


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## JPINFV

You are escorted to the patient's room by his friend and find him sitting in a chair. Behind the chair is a spot of half dried vomit. You notice that the patient's eyes are slightly sluggish and bloodshot as a slight whiff of alcohol reach your nostrels. 

He doesn't know when the paralysis started, but it's not new and his memory is a little hazy from last night. He doesn't think he fell and you don't notice any swelling, bruising, or deformaties on him. There is some reddness in the right axillary region though. 


He denies having any medical problems or taking any medication, leisure or otherwise. Your partner grabs a set of V/S which comes out with a pulse of 90 beats/min, blood pressure of 130/78 mm/Hg, and 20 breaths a minute. 




> With just the information given and the knowledge that I have (which isn't much since I'm still in EMT classes), I would go with a stroke.



There's always more information when you do an exam and history...



> I would maybe consider a stroke a high possibility.



Would you like a Cincinnati stroke scale or a Los Angeles Prehospital Stroke Scale?


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## MikeRi24

oook, now that we have a little more information.....

based on what I now know, I would go with this:
Patient was presumably out drinking, doesnt remember much of the outting. He could have also fallen, hitting his head and if he was sober, he may not remember the fall anyway. So, I'm going to start thinking that he fell, causing a head and/or neck injury. At this point, im going to immobilize the neck and spine. I'm also going to further evidence my thoery of falling by the redness on the right axillary region, however that could be totally unrelated and maybe he fell asleep against something that caused that, but I would prefer to err on the side of caution and stay away from that idea. 

The vomit, which appears to have been semi-recent, is most likely because he drank a bit much and vomited as a result. But again, that could be caused by something else, and I'm going to take all precautions here. 

At this point, he appears to have a sufficient airway because he is talking to me, however I would like to see more description in the vitals rather than "respirations: 20/min." I will still put him on high flow O2 with a non-rebreather because it's our protocol to give that to every patient. I'm going to have suction ready just in case he vomits again so that I can keep the airway clear.

Now that I have him on a backboard, I am going to do a quick assessment of the rest of his body, when I get to his hands and feet, I will do a quick neurological exam ("push down on my hands...pull up....can you wiggle your toes for me....can you feel me touching your toes? squeeze my hands...wiggle your fingers....which finger am i holding?"). At this point, I would pull out my mini mag light and check the pupils, which  was already stated that they were bloodshot and sluggish. This could be due to the alcohol or a head injury, and again, im going with the head injury. 

At this point I'm probably going to prepare to transport. his friend that is with him probably knows what happened durring his friend's drunken stupor, so I'm going to try and get as much information out of him as possible. once I have the patient in the ambulance, I am going to re-assess everything, and continue my evaluation. At this point, I am really really starting put more of my eggs in the head/neck injury basket. Still have a little bit of concern for a stroke or realted condition, but knowing what I know now, I'm starting to veer off that path, but I am also not going to completely rule it out.


Thats where I'm at now. I'm anxious to see others responses, and I'm going to bring this up in class tomorrow and see what others have to say about it. I like this stuff...makes me think!


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## Jolt

Does he have a palpable radial pulse in the affected arm?  Sometimes I wake up with a dead arm and all I have to do is get the blood back.

Just a thought.


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## MikeRi24

Jolt said:


> Does he have a palpable radial pulse in the affected arm?  Sometimes I wake up with a dead arm and all I have to do is get the blood back.
> 
> Just a thought.



kinda like it fell asleep? Not at all trying to say that it's not possible, but I would think that by the time this guy realizes he cant feel and move his arm, decided to call 911, and you show up, it would come back. Would temporary loss of circulation also cause him to not be able to move it at all? in any case, while I am doing what I referred to as my "quick neurological exam" (can you squeeze my hand? wiggle your fingers?.....) I am also checking both wrists for a radial pulse. 



is anyone actually give a right answer for this or is this just kind of a "no right or wrong answer, just your opinion" kind of thing?


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## JPINFV

The patient is backboarded [alcohol, even if it's just residual from the night before, plus neuro deficit] and on high flow O2. 

He is able to move his feet and toes on command. He has a normal range of movement and grips on his left hand, but he is unable to extend his right wrist. When asked to open his right hand, he is able to open it, but only with considerable effort. In addition, he states that he can't feel anything on the back of his hand and the posterior region of his forearm. Other stroke scale aspects [LAPSS=not applicable [not over 45] and Cincinnati is negitive outside of the right hand.]. He is able to close his hand though. There is a strong and regular pulse in both wrists [to complete the earlier V/S, reps are 20 with normal tidal volume and effort]. Pupils are equal, round, reactive, sluggish, and bloodshot bilaterally. His eyes track movement normally and he has no visual disturbances. He has also states that he has a headache, but nothing out of the normal after a night like last night [must be a Giants fan :angry:]. 




MikeRi24 said:


> is anyone actually give a right answer for this or is this just kind of a "no right or wrong answer, just your opinion" kind of thing?



There is a right answer to this...


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## certguy

JPINFV said:


> You are escorted to the patient's room by his friend and find him sitting in a chair. Behind the chair is a spot of half dried vomit. You notice that the patient's eyes are slightly sluggish and bloodshot as a slight whiff of alcohol reach your nostrels.
> 
> He doesn't know when the paralysis started, but it's not new and his memory is a little hazy from last night. He doesn't think he fell and you don't notice any swelling, bruising, or deformaties on him. There is some reddness in the right axillary region though.
> 
> 
> He denies having any medical problems or taking any medication, leisure or otherwise. Your partner grabs a set of V/S which comes out with a pulse of 90 beats/min, blood pressure of 130/78 mm/Hg, and 20 breaths a minute.
> 
> 
> 
> 
> There's always more information when you do an exam and history...
> 
> 
> 
> Would you like a Cincinnati stroke scale or a Los Angeles Prehospital Stroke Scale?




I'm curious , how " not new " is this paralysis ? Sounds like he had it before last night . Other than hangover symptoms , nothing remarkable noted . V/S within normal limits . No other complaints noted . Sounds like he's still somewhat drunk and just telling you he can't move his arm . If it was pre - existing , does he even have a chief complaint or is this a bogus call ?


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## certguy

By the way , what type of chair is he in and was he leaning to the right on your arrival ? This could explain the redness .


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## JPINFV

Sorry, that's a typo... The paralysis had an onset sometime between him starting drinking and when he woke up.



certguy said:


> By the way , what type of chair is he in and was he leaning to the right on your arrival ? This could explain the redness .



You're getting close.


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## certguy

RATS ! I was starting to think you were seeing how many would read too far into it . Okay , he's in a computer chair and the puke's behind him . Sounds like he was sitting at his computer , turned around to avoid puking on it , passed out in an awkward position against his computer desk , and possibly pinched a nerve in the axillary region accounting for the dead arm . 


HOW AM I DOING ??????


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## JPINFV

certguy said:


> RATS ! I was starting to think you were seeing how many would read too far into it . Okay , he's in a computer chair and the puke's behind him . Sounds like he was sitting at his computer , turned around to avoid puking on it , passed out in an awkward position against his computer desk , and possibly pinched a nerve in the axillary region accounting for the dead arm .
> 
> 
> HOW AM I DOING ??????



Winner!

Saturday Night Drunk Syndrome [aka Saturday Night Palsy, Honeymooner's Palsy or official as Radial Nerve Palsy] occurs when pressure is applied over several hours to the radial nerve causing necrosis. An example of such an event could happen if you pass out with your arm hung over a chair. This is because the radial nerve spirals around the medial part of the humerus after giving off its branches for the upper arm. 







Therefore, damage to the nerve, which can be permanent, will affect the muscles of the top/dorsal part of the hand that engage in extending the fingers and the wrist. One of the tell-tale signs of radial nerve damage is called "wrist drop" (hold your arm out straight with your palm down and relax your wrist). Other muscles in the hand can weakly extend the fingers, though, and are innervated by a different nerve.

http://www.emedicine.com/neuro/topic587.htm


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## certguy

Well , what do you know ? I guess watching all those episodes of Monk paid off ! Sometimes you have to do some detective work to figure out what's really going on . 


                                 Good scenerio , 

                                        Craig


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## certguy

Is there a field treatment or transport POC and let the hospital handle ? It's not traumatic , so no splinting is appropriate , right ?


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## JPINFV

POC?


Unless you suspect a fracture (there are other causes, including fractures, that can cause this), there really isn't any pre-hospital treatment that I can think of, since by the very nature of this call and by transporting, the source of compression is going to be removed. Maybe lightly splint the wrist for comfort sake. 

Saturday Night Drunk Syndrome is one of the clinical correlates in my anatomy class and with a name like that, I can't keep from sharing. It's also a good way to think about where the nerves run and what they innervate.


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## JPINFV

POC?


Unless you suspect a fracture (there are other causes, including fractures, that can cause this), there really isn't any pre-hospital treatment that I can think of, since by the very nature of this call and by transporting, the source of compression is going to be removed. Maybe lightly splint the wrist for comfort sake. As I responded to Mike, while there wasn't a fall, I won't fault someone for going down the fall path and splinting the spine [hazy memory+EtOH+neurodeficit], but I was trying to paint a picture that wouldn't have been possible from a fall. 

Saturday Night Drunk Syndrome is one of the clinical correlates in my anatomy class and with a name like that, I can't keep from sharing. It's also a good way to think about where the nerves run and what they innervate.


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## certguy

Position

             Of

                Comfort


                POC


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