# Unresponsive



## truetiger (Aug 24, 2011)

I'll throw in a scenario for fun, nothing tricky. You receive a third party 911 call for difficulty breathing. You arrive on the scene and find the fire department (bls) attending to an elderly woman in the front seat of a car. She appears unresponsive. They have started her on  NRB and state her sats are at 90%. 

Patient is responsive to pain only. GCS of 9. You note deep respirations of 20/min. No cyanosis present. Airway is clear. Strong radial pulse. Skin is pink/warm/dry. Pupils dilated bilaterally and sluggish. Husband states they just left a level 1 hospital about an hour and 20 mins ago and just pulled in the drive way. He went inside for a minute and came back to find her unresponsive. Only hx is a TIA a few years ago and lung cancer for which she was recently hospitalized for.

Patient is quickly moved to ambulance and an als assessment reveals:
HR 80's
BP120's/80's
Respirations still 20/deep
Oxygen sats are 94% on 15L
BGL is 206 no hx of diabetes
12 lead is non diagnostic.

Husband denies any pain meds or pain patches today. None found either. She was completely alert for the whole car ride home ( 1hr 20 mins). Patient is on blood thinners. No allergies given.

Your choices of hospitals are the local hospital which is about 20 mins away and or a level one about 35 mins away by helicopter. Time of day would put you in rush hour traffic going to the city.


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## IvanD (Aug 24, 2011)

I'm shooting in the dark here with my limited knowledge but could this be a hyperglycemic episode?

Her BGL suggested hyperglycemia for me, however can a patient without diabetes have a hypo/hyperglycemic episode? Wouldn't their pancreas correct that if they didn't have diabetes? 

I'm not exactly sure what the s/s of hyperglycemia is but I'm guessing since it will affect neurological stats, that might explain her deep breathing and sluggish pupil response?

I'm going to be a bit bold and say that her hyperglycemia caused AGE-production which potentially caused a stroke?

(truetiger, if you don't want to reveal the answer in this thread yet, could you PM me the answer? I'm really intrigued now.)


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## NomadicMedic (Aug 24, 2011)

Based on the CVA/TIA hx and the blood thinners, my first guess is a bleed. 

Is she warm? Maybe septic? 


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- Sent from my iPhone.


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## truetiger (Aug 24, 2011)

Not warm. No reason to suspect sepsis. In the end I called it a cva/bleed and flew her back to the hospital she had just been discharged from.


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## HMartinho (Aug 24, 2011)

truetiger said:


> Not warm. No reason to suspect sepsis. In the end I called it a cva/bleed and flew her back to the hospital she had just been discharged from.




In some cases of sepsis, patients could be hypothermic, not hyperthermic.


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## truetiger (Aug 24, 2011)

Nothing in my exam findings suggested sepsis.


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## usalsfyre (Aug 24, 2011)

Sepsis should ALWAYS be a differential in unconscious/unknown etiology. Maybe not your primary treatment pathway, but a thought. Scepticemia is a tricky little bugger.

Metabolic acidosis is another thought here.


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## STXmedic (Aug 24, 2011)

truetiger said:


> Not warm. No reason to suspect sepsis. In the end I called it a cva/bleed and flew her back to the hospital she had just been discharged from.



Do you have the actual Dx, or are we just stopping at CVA/TIA?


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## truetiger (Aug 24, 2011)

PoeticInjustice said:


> Do you have the actual Dx, or are we just stopping at CVA/TIA?



Haven't heard back yet.


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## Handsome Robb (Aug 24, 2011)

Did you do an EtCO2 by chance? We are just finishing pulmonology and this is a new toy for me :rofl: Rapid, deep respirations could indicate her body trying to compensate by off-gassing CO2. 

I'm leaning towards a bleed as well given the history, however, like usalsfyre said, metabolic acidosis is a possibility as well.


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## NomadicMedic (Aug 24, 2011)

We're doing POC lactate to get a heads up on sepsis in the field. Any time I have an unconscious or altered pt, I always get a lactate when I start a line. 


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- Sent from my iPhone.


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