# SOB suddenly crashes after being taken to ER



## Jim37F (Nov 10, 2013)

We're a BLS ambulance dispatched to a private residence for shortness of breath. Arrive on scene to find the local FD Paramedic Rescue squad on scene already, beginning their assessment. 

PT is a 62 yo male found sitting high fowlers in a chair in his living room. PT is conscious, alert and orientated times 4, GCS 15 with a chief complaint of difficulty breathing. PT is a bigger gentleman at 276lbs. 

Medics state his lungs are clear, but the Pt has audible rhonchi. PT does state the problem is in his throat, not chest or lungs. Tidal Volume is normal, with a respiration rate of 26-30. SpO2 96% room air. Skin is pale w/ normal cap refill. BP is 140/palp, pulse 100, eyes PEARRL. 12 lead shows NSR, Blood Sugar 130. 

PT states the breathing problems were progressively getting worse over the last 2-3 days, was planning on seeing his doctor the next day until it got bad enough to call 911. Exertion made the breathing worse. PT described it as a sore throat and fever times 1 day, felt like he had trouble swallowing. No real pain associated w/ the symptoms, rated 0 out of 10. 

Negative chest pain, negative JVD, positive 3 word dyspnea. 

Prior medical history of hypertension, gout, acid reflux, thyroid issues, and kidney stones. No known allergies. Unknown medications. 

PT was ambulatory with assistance, helped into the gurney and placed high fowlers. PT given O2 @15LPM via NRB. On scene time of 12 minutes, 20g lock established in left AC by medic enroute, pt transported Code 3 (lights and sirens) with medic on board to hospital, 4 min transport time. 

PT stated to oxygen helped him breathe, but once we got to the ED asked us to take the mask off because he now felt it was easier to breathe without it. PT ambulated w/ assistance into hospital bed and I start my paperwork. 

NOW here comes the crazy part. While I'm still doing my paperwork, within just a few minutes he just crashes. Is just white and starting to turn blue, ED MDs begin intubating and at that point I'm just in the way and get out of there as it becomes a beehive of activity. 


My question is why did he deteriorate so rapidly? He seemed (relatively) stable with us, even said he was starting to breathe easier by the time we got there, what would've caused such a sudden and drastic change?


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## Rialaigh (Nov 10, 2013)

My guess is he threw a massive clot (PE) and died instantly. Could be several different things but I would think this is the most likely. No amount of CPR and secured airway or drugs will get this guy back.


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## teedubbyaw (Nov 10, 2013)

PE is definitely possible. I'd be interested to see the 12 lead. Other than that, no telling. Will you be able to find out of his outcome?


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## PFDEMT (Nov 10, 2013)

Something I kind of do with a pt that is giving me signs of MI but 12lead shows normal. 
Is take a look at all extremities especially the legs, leg px is very common in a pt throwing a PE.


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## wildrivermedic (Nov 11, 2013)

Jim37F said:


> Medics state his lungs are clear, but the Pt has audible rhonchi. PT does state the problem is in his throat, not chest or lungs. ...
> 
> ... PT described it as a sore throat and fever times 1 day, felt like he had trouble swallowing. No real pain associated w/ the symptoms, rated 0 out of 10.



What was the pt's temp? Any edema or swollen nodes in the neck? Drooling? Epiglottitis is not exactly common in elders, and they are less likely than kids to progress to complete loss of airway, and that progression would have been really fast in this case... but maybe? 

Did he remain sitting up after transfer to the hospital bed? 

Easier to breathe without mask on doesn't necessarily mean easier to breathe in general, could he have been losing his airway and feeling suffocated?

Thanks for a well-worded scenario with a lot of relevant info! I appreciate the opportunity to learn from it


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## mycrofft (Nov 11, 2013)

Pt Hx? Meds? Good presentation.

Sudden loss of consciousness, rapidly followed by pallor then cyanosis, in an overweight male (with classic oveweight male maladies) without classic chest pain and normal EKG (??) suggests PE.  Rhonci...dunno.

Outriders: could mistake chest pain for reflux MAYBE, not too likely. Feeling of dysphagia then later tight throat re respiration...sort of a hint of cardiac here, but the ekg was normal?


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## HandsInTheER (Nov 11, 2013)

First post here, so if it comes in buggered up, I'm sorry about that.

Just reading the scenario my first thoughts are: rule out PE, r/o upper airway constriction, r/o bleeding esophageal verices, r/o epiglottis, and r/o partial foreign body/aspiration.

The patient's need to remove the NRB in the ED was the clincher for me, suggesting that he was just about to crash. As GranolaEMT mentioned, that suffocating feeling if fairly common, and pts with heart failure or impending blockages related to PE get this panic look and smothered feeling right before they go down. The ambulation to the hospital bed may have been just the extra motivation a small hanging clot needed to shift and occlude a major pulmonary vessel, causing real distress.

I'm assuming he most likely had significant BLE edema and possible undiagnosed respiratory illness. The sore throat may be unrelated to the ultimate crash, but could be reason enough for someone to decrease daily activity and become sedentary for a few days, leading to clot formation and a worsening disease process. A detailed medical hx and list of medications would help narrow things, but you take what you can get.

Ultimately, I would say your crew did everything that was possible and correct for this pt. I might have given him ASA prophylactically, but this would depend on me being on scene and sizing him up. Ultimately he needed a chest CT and more detailed studies. Good scenario!


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## Anonymous (Nov 11, 2013)

I am enjoying this thread. Jim37F any chance you can get any info out of the receiving facility next time you are there?


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## Carlos Danger (Nov 11, 2013)

Classic massive PE presentation.


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## Jim37F (Nov 12, 2013)

Only real way to follow up would be to ask someone at that ER. If we go back today, I'll try and ask. Didnt get a chance yesterday

While I was doing my paperwork, before he crashed, I overheard a couple of the docs talking, sounded like they suspected a slow onset allergic reaction. They called the RT and were staging advanced airway supplies, but because his symtoms onset over a couple of days they wanted to wait for fiber optics. Of course this was about a minute or two before he crashed.

So it seems like pulmonary embolism is the general concensus here. I must admit, I'm not the most familiar with PEs. What would the physiology have been? Blood clot breaking free somewhere and then occluding a coronary or cerebral artery? Would the PE have been related to his SOB? (He had no complaints about his chest or lungs. Everything seemed to point more to the problem beung in his throat than anywhere else)


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## teedubbyaw (Nov 12, 2013)

PE's often originate in the legs (deep vein thrombosis) that becomes an embolus and occludes a branch off of pulmonary artery. Of course there can be other occlusion areas. What happens when the pulmonary artery is occluded? There's part of your answer to SOB.


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## VFlutter (Nov 12, 2013)

If not a PE then maybe some type of laryngeal edema. Angioedema "should" have been fairly obvious but possible acutely worsening in the ER.


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## FLdoc2011 (Nov 14, 2013)

Do we know his meds?  Any recent new meds?  Was he on a ACEi? 

Did y'all look in his mouth/throat? 

PE is always up there,  though this reported difficulty swallowing makes me think something more like a "mechanical" problem in upper airway or pharynxz.


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## Beaujangles (Dec 7, 2013)

I actually ran a call like this a few weeks ago. Almost identicle except he had pain on his left lower quadrant. He was very weak, pale, diaphoretic and from the time we were on scene, 5 minutes, to when the ambo pulled up, 2 minutes later, his lips started turning blue, despite a pulse ox of 98 on nasal cannula at 3lpm. We had to use a canvas stretcher because of his hallways being tight. When we loaded him into the ambo he started to deteriorate. They started a line and requested a firefighter ride along for additional help. Last thing we heard was he had a PE. So this call had a lot of similarities but some differences. I heard he crashed once but they were able to get him back. Not sure if he lived or not.


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## Akulahawk (Dec 7, 2013)

Chase said:


> If not a PE then maybe some type of laryngeal edema. Angioedema "should" have been fairly obvious but possible acutely worsening in the ER.





FLdoc2011 said:


> Do we know his meds?  Any recent new meds?  Was he on a ACEi?
> 
> Did y'all look in his mouth/throat?
> 
> PE is always up there,  though this reported difficulty swallowing makes me think something more like a "mechanical" problem in upper airway or pharynxz.


Another possibility is that there could be several contributing problems that all coalesced into one big crump at the ED. Assuming the Medics are proficient at listening to lungs, the "audible rhonchi" could very well be laryngeal or pharyngeal edema where the tissues are flapping back and forth causing the rhonchi-like sounds. ACE inhibitors can cause laryngeal edema, but since we don't know if he's on any of those meds, it's hard to say for sure. Another issue could be infection. If the tissues become swollen enough, again, rhonchi-like sounds might be heard. Then there's the fact that he's 276 lbs. I doubt he's all that mobile, or at least hasn't been for a while in the very recent past, so that brings up the possibility of PE. 

A possible (and plausible scenario in my mind) is this: He had some difficulty breathing from some kind of infective process (painful swallowing complaint) so he calls 911. You get there and move him. He's been sitting around for a while because it's not easy to get up, and he's SOB because it's just not easy to breathe. He gets to the ED and a now weakened thrombus (from all the jostling and moving) kicks loose travels to the lungs where, (insert ta-daa sound) it blocks some big pulmonary arteries, causing massive PE... and he crumps.


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## mycrofft (Dec 8, 2013)

Oh, wait.

"Medics state his lungs are clear, but the _Pt has audible rhonch_i. PT does state the problem _is in his throat_, not chest or lungs. Tidal Volume is normal".

Was he hoarse?

Epiglottitis?!

PS: by "rhoncii", did you mean "stridor"? Was the throat auscultated? If it wasn't in the chest it wasn't rhoncii. Noise and greater difficulty on inhalation, especially coupled with hoarseness, suggest lower oropharyngeal or peri-laryngeal blockage. Epiglottitis can be a rapid killer in adults when it reaches a certain stage.


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