# 70 yo Female found face down



## LACoGurneyjockey (Aug 2, 2014)

You get dispatched to a fall. Arrive to find an elderly female in bed, with her husband stating he found her face down in the front yard and brought her back to the bedroom. Conscious, alert, confused. You notice a couple small lacs to the forehead and obvious facial droop. 
Vitals: BP 148/80, 120 sinus tach on the 4 lead, SPO2 92%, RR 24, skins warm/pale/moist. 
Go!


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## Angel (Aug 2, 2014)

Cspine! rapid trauma assessment. 
was the fall witnessed?
is the facial droop something new? do a CPSS, check for any [new] deficits, blood sugar, meds, med compliance, medical hx, allergies


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## LACoGurneyjockey (Aug 2, 2014)

Angel said:


> Cspine! rapid trauma assessment.
> was the fall witnessed?
> is the facial droop something new? do a CPSS, check for any [new] deficits, blood sugar, meds, med compliance, medical hx, allergies



Husband only states she was gardening, he came outside to check on her and found her lying face down. Nothing else in the trauma assessment. Right sided facial droop, non cooperative with arm drift, slurred speech. BGL is 160. Husband is fairly clueless as to the meds, but you find Plavix, aspirin, amoxicillin, NSAIDS, and metoprolol in the medicine cabinet. He says she takes her meds. NKDA. Husband states she had a stroke 3 months ago but that today she's not acting right. Normally GCS of 15 and ambulatory. Today GCS of 14 and cannot get out of bed. Only other Hx is HTN and diabetes.


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## gonefishing (Aug 2, 2014)

How about a canula


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## NomadicMedic (Aug 2, 2014)

Stroke alert and transport.


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## tklingbeil (Aug 2, 2014)

Quick question from a noob. I've heard conflicting things on giving oxygen for possible stroke pts, something to do with oxygenating blood and the leak. Can anyone tell me which it is and why?


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## VFlutter (Aug 2, 2014)

tklingbeil said:


> Quick question from a noob. I've heard conflicting things on giving oxygen for possible stroke pts, something to do with oxygenating blood and the leak. Can anyone tell me which it is and why?



When dealing with Ischemic events (MI/CVA) you want to avoid hyperoxemia. Oxygen, in high concentrations, is a vasoconstrictor and has been shown to increase SVR and decrease Cerebral/Coronary perfusion. It also causes free radial production. 

Realistically, you probably won't cause any harm with a Nasal Cannula but you may with a NRB. High Fi02 for prolonged periods of time is bad. 

If they are not hypoxic then they do not need oxygen. 


http://www.ncbi.nlm.nih.gov/pubmed/3098265


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## tklingbeil (Aug 2, 2014)

Thank you chase definitely makes sense.


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## LACoGurneyjockey (Aug 2, 2014)

DEmedic said:


> Stroke alert and transport.



Nope, come to find out she hasn't had a stroke since her original one 3 months prior.


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## tklingbeil (Aug 2, 2014)

Any allergies to bee stings or ants? Any swelling?


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## Angel (Aug 2, 2014)

is the droop anything new? or from her previous stroke?

i wonder if its an ICP issue...head injury + blood thinners
pupils?


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## LACoGurneyjockey (Aug 2, 2014)

No allergies, no swelling/bites/stings. 
Pupils are PERRL, husband says she's had facial droop since her first stroke.
Only new complaint is AMS and weakness.


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## captaindepth (Aug 2, 2014)

Any changes in her urine/stool? How long has she been taking the amoxicillin and for what reason?


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## LACoGurneyjockey (Aug 2, 2014)

captaindepth said:


> Any changes in her urine/stool? How long has she been taking the amoxicillin and for what reason?



"Oh that stuff, she had a UTI in the hospital but it's all good now". Discharged a week ago after having a foley placed while she was there for a hip fx


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## Angel (Aug 2, 2014)

skin signs? temp if youve got it


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## captaindepth (Aug 2, 2014)

Ambulatory on a recent hip fracture? is she taking any pain meds, OTC medications for pain, or illicit drug use? Do we have an idea of down time? A full 12 lead would helpful for a more complete picture.


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## Rialaigh (Aug 2, 2014)

Urosepsis secondary to pylo which has gotten rapidly worse due to environmental exposure outside...


I would go with head bleed or ischemic stoke but if stroke is off the table I'm going with sepsis.


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## Carlos Danger (Aug 2, 2014)

Elderly + clopidogrel + aspirin + fall + not acting right = IC bleed until proven otherwise.


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## LACoGurneyjockey (Aug 2, 2014)

Skins noticeably warm (sorry no temp) pale, moist. 12 lead shows sinus tach. Sepsis got it.
This was another crew that ran it, ended up calling a trauma activation and stroke alert, both, and flew the patient out. She arrived at the trauma center with severe sepsis, no head bleed, no trauma, no cva.


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## Angel (Aug 2, 2014)

The only thing that threw me off on sepsis was the BP....foley and ALOC (plus the previous uti) were good questions because that's what made me think about temp and skin signs. 

We're repeat BP getting lower?


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## NomadicMedic (Aug 2, 2014)

Remi said:


> Elderly + clopidogrel + aspirin + fall + not acting right = IC bleed until proven otherwise.




Truth.


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## VFlutter (Aug 3, 2014)

Angel said:


> The only thing that threw me off on sepsis was the BP....foley and ALOC (plus the previous uti) were good questions because that's what made me think about temp and skin signs.
> 
> We're repeat BP getting lower?



Not everyone with SIRS/sepsis present with hypotension and/or shock. An uncomplicated infection in the elderly can easily cause AMS and weakness without unstable vitals. Also, she is likely compensated given the HR. So I wouldn't rule out sepsis from a differential just because there is no hypotension.


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