# Alert and Oriented to Unresponsive?



## ItsTheBLS (Feb 2, 2013)

BLS dispatched for a motor vehicle accident. Upon arrival find a 2 car MVA. 

One vehicle on its side, with all passengers out and about walking around talking and crying to PD. Second vehicle ejected passenger with another BLS unit doing CPR. ALS unit on the way.

I find my patient alert and oriented completely (third most severely injured on scene, the other two have been transported) walking around. 20 year old male. I get his information, he says he was in the back seat of the car, self extricated, and has shoulder, neck and back pain. He is collared and boarded. 

In the back of the ambulance his vitals are assessed to be:
Pulse: 84
BP: 140/86

Note: A girl, of unknown relationship to him, was in the back of the ambulance as well. All i know is that she was in the vehicle as well.

He begins complaining of shortness of breath and is placed on a NRB @ 15 LPM. He states no medical history, medications or allergies.

He suddenly begins to stop responding to us and just has this dazed look in his face. No real response to verbal or painful stimuli. This apparent drop in mental status happens over about 1 minute. I didn't try the "Drop hand on face test".

What do you guys think?


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## NomadicMedic (Feb 2, 2013)

Responsive to pain? Changes in HR or BP? What was his sugar? Pupils? Did his airway become an issue?


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## ItsTheBLS (Feb 2, 2013)

Slightly responsive to pain, he moved a bit.
No remarkable changes in HR or BP.
BGl unknown, we don't assess that.
Pupils not assessed.
His respiratory rate remained the same, no obvious breathing issues.


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## EMT B (Feb 2, 2013)

petit mal seizure? did he ever come to? did you call for ALS?


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## ItsTheBLS (Feb 2, 2013)

He never came to. We were about 2 minutes from the hospital when this began so no ALS.


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## medicdan (Feb 2, 2013)

Epidural bleed with lucid interval?


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## EpiEMS (Feb 2, 2013)

emt.dan said:


> Epidural bleed with lucid interval?



That sounds quite plausible. OP, what were the vital signs as time went on (any trend)?  And do you think you could get some follow-up from the ED? I'd be curious to hear what happened (and how they did their workup).


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## VFlutter (Feb 2, 2013)

ItsTheBLS said:


> Slightly responsive to pain, he moved a bit.
> No remarkable changes in HR or BP.
> BGl unknown, we don't assess that.
> Pupils not assessed.
> His respiratory rate remained the same, no obvious breathing issues.



Is there any particular reason why you did not assess pupils? That would be on top of my priority list for any patient who went unresponsive after a trauma. 

And what do you mean by "He moved a bit", did he withdraw or localize to the pain?

There is a lot more assessment that could be done then the "drop hand on face test"


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## Achilles (Feb 2, 2013)

n7lxi said:


> Responsive to pain? Changes in HR or BP? What was his sugar? *Pupils*? Did his airway become an issue?



Ding ding ding we have a winner!
Pupils, the windows of the brain.
Chase got it right on, I would have checked BGL as well, but pupils would have been higher up on the list.


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## Handsome Robb (Feb 3, 2013)

Yea, not going to beat on a dead horse but you need to look at pupils. Live and learn.

If his pressure bottomed out with the respiratory distress I'd say tension pneumo but doesn't sound like it did. 

What was his respiratory rate prior to the change in mentation? Spo2% ? Any carpal pedal spasms?

Everything else was already covered.

He went to a trauma center I'm assuming/hoping...

Any way you can follow up on him?


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## NomadicMedic (Feb 3, 2013)

Either a head bleed or he suddenly realized how much trouble he was gonna be in and had a melt down.  

Either way, monitor and transport, then shove him in a CT scanner and spin his head. I'd like to hear the outcome of this one...


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## patzyboi (Feb 3, 2013)

What is this "drop hand on face" test?
srs


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## Handsome Robb (Feb 4, 2013)

n7lxi said:


> Either a head bleed or he suddenly realized how much trouble he was gonna be in and had a melt down.
> 
> Either way, monitor and transport, then shove him in a CT scanner and spin his head. I'd like to hear the outcome of this one...



Agreed. Or he realized that someone in the accident/one of his friends had died and he just shut down. 



patzyboi said:


> What is this "drop hand on face" test?
> srs



Supposedly if you hold an unresponsive patient's hand above their face and drop it if they're truly unresponsive it will fall and hit them in the face. If they are faking it their hand will miss their face because they subconsciously redirect it. 

Not something I'd go around work bragging about the "cool new assessment tool" you learned. It's not exactly an "accepted" method and lots of people have a problem with it. 

Definitely not something I would use routinely. :glare:


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## Melclin (Feb 4, 2013)

Horses before zebras. 

May have hyperventilated himself into it on account of the generally rubbish situation he found himself in...maybe he's dying... I don't know.

Maybe his brain cells exploded from too much oxygen. I had a provider tell me that once; as the reason why he believed O2 was contraindicated in 'hyperventilation'. 

*Edited*: to be nice.


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## Vahlen (Feb 26, 2013)

Melclin said:


> Horses before zebras.
> 
> May have hyperventilated himself into it on account of the generally rubbish situation he found himself in...maybe he's dying... I don't know.
> 
> ...



........I wouldn't even know how to respond to a statement like that :rofl:


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## NomadicMedic (Feb 26, 2013)

Vahlen said:


> ........I wouldn't even know how to respond to a statement like that :rofl:



Oh, I would. But it would not be something I could ever type on a forum.


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## Carlos Danger (Feb 26, 2013)

I was a pretty new paramedic when I was dispatched to a "man down".

Find this big, healthy looking young guy (early-mid 20's) supine on the living room floor of his girlfriend's house. She says he has no medical problems that he doesn't do any drugs and that she found him like this. No signs of trauma or poisoning. He's breathing fine. Pulse is strong and normal. Pupils are fine. Skin is warm/pink/dry. HR, BP, Sp02, EKG, BGS all perfectly normal. Negative hand-drop test. No response _at all_ to several sternal rubs (my sternal rubs hurt) or to the pinch on the fingernail trick. 

Had a strong feeling the guy was faking, except that he was very convincing in his absolute lack of response to painful stimuli. He had a GCS of 3. All I could think of was some type of bleed or drug OD. NRB, load him up, 2 large-bore IV's on the way to the ED, no flinch then either.

Get him to the ED, they triage him to a regular room and this grisly old guy ED nurse comes in and I tell him the story. 

He says to me "Hey man, hand me the ocular aspiration needle out of that drawer next to you."

Me: "The what?"

Grisly old RN: "The ocular aspiration needle. The eyeball needle."

Me, as I'm starting to catch on: "Oh, the eyeball needle...yeah, what's that for again?"

Grisly old RN: "Well, we have this new lab panel that we can do using eyeball fluid. It's much faster than a blood test. When the needle goes in the eye it's very painful for the patient though, so we only use it on these critical patients who are completely comatose."

Me: "Here's the eyeball needle."

The patient, stirring in the ED bed, acting as though he's drowsy and confused, like he's waking up from a deep sleep: "Dude, where am I? What's going on?".


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