# Priority 2 "Breathing Problem" at a SNF



## Handsome Robb (Feb 16, 2013)

This one was probably one of the sickest patient that still had a pulse I've seen in a long time.

I'm on my phone and at work so ill give y'all a brief intro let you go to town and report back with more later when I get to a computer. Still waiting on the ER for a final Dx, just ran this one a bit ago.

Dispatched priority 2 (code 3, possibly life threatening. For all you EMD guys it was a "charlie" response, 33C02T was the official coding) to a familiar SNF/rehab facility for "difficulty breathing". 3 man ILS engine crew already on scene.

62 year old F, supine in bed on her home CPAP for her sleep apnea. Pt at nursing home/rehab facility S/P total left knee replacement 2 weeks prior.

A&Ox4, GCS 14 (3/5/6) 
BP 72/50
Hr 110
RR 20, unlabored, lungs clear to auscultation in all fields, speaks in full sentences.
SpO2 88% on nasal CPAP mask.
CBG 150 mg/dL
Skin ashen/severe mottling, cool, dry

Complaint of 8/10 "sharp" thoracic back pain with no hx of. Also difficulty breathing, nausea and needing to have a BM.

Ready,go!!


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## NomadicMedic (Feb 16, 2013)

PE. 

You guys don't have end tidal, right?

S1, q3, t3?

I love those 33 Charlie calls. You never know what you're going to get.


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## Clare (Feb 16, 2013)

PE, or an AAA.

From what you've said I'm calling her problem time critical / life threatening, put her on the bed, load and treat en-route, oxygen via non-rebreathing mask, put in a drip, give her one litre of fluid as a bolus.

I would take her to ACH as they have cardiovascular surgical, as with sick people, be sure to place an early RT call to the hospital.


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## VFlutter (Feb 16, 2013)

Did she have a murmur? 

Pluse quality? Carotid, radial, and pedal 

EKG? ST changes in the inferior leads?

I agree with possible PE or Aneurysm; Aortic or Thoracic.


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## phideux (Feb 16, 2013)

I agree, either a PE or Aneurism, leaning more towards the Aneurism with the nausea/need for a BM.


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## FLdoc2011 (Feb 16, 2013)

Post ortho surgery now hypoxic and hypotensive, definitely PE is at top of list.  

Bilateral BPs?  
EKG? 
Did spo2 correct at all with supplemental O2?
Were fluids given?
Febrile?

Was she getting some sort of DVT prophylaxis at the rehab facility?  Lovenox, Coumadin or some other anticoagulant.


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## abckidsmom (Feb 16, 2013)

If it is an aneurysm, which I would think is the more likely thing, I wonder if the CPAP is doing anything like splinting the aneurysm by increasing the intrathoracic pressure?


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## Veneficus (Feb 16, 2013)

I am going to put PE at the top of the list too.

While aneurysm is a good second, I hold out hope that prior to operating on a 6 decade patient, somebody did some sort of workup that would have detected an aneurysm large enough to risk rupture.

Do not be fooled by people who talk in full sentences and complain they cannot breath.

The first PE I ever saw in the field was a 7th decade patient that took 5 firemen to hold her down while she scremed she couln't breath at the top of her lungs. 

I walked in the door just in time to see her scream really loud squirm a bit and then code.

She turned blue from about the mid thorax up and there was nothing we could do. The nearest surgery was 45 minute transport and I seriously doubt they would have operated.


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## abckidsmom (Feb 16, 2013)

I have a similar experience Vene. Blocking things up in the lungs makes people crazy.


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## FLdoc2011 (Feb 16, 2013)

Recently had some discussions over the most recent ACCP guidelines with only a 2C recommendation for thrombolytics with acute PE and hypotension. 

So what did they do in the ER?

If she remained hypoxic and "looked sick" this is someone I'd consider securing an airway on earlier rather than later.  We've had some sick PE's come in who continued to deteriorate despite bipap and proceeded to code during intubation attempts.

Would certainly get a bedside ECHO in the ED.


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## EpiEMS (Feb 16, 2013)

What'd the ED find?


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## Veneficus (Feb 16, 2013)

abckidsmom said:


> I have a similar experience Vene. Blocking things up in the lungs makes people crazy.



The best part of that story was since I had never seen it before, I thought the firemen had killed her, by forcinbly restraining her. Since I didn't think they intentionally were doing something wrong I was trying to figure out a way to write the narritive that wouldn't get them in trouble despite my thoughts of why she coded. 

As luck would have it, one of the best ED docs I ever met saw me struggling to write the report and asked why I was so upset this time. (I never get upset over patients and have even been written up for not sounding "panicked" enough in my radio reports or "urgent" enough on scene)

Anyway, the doc started laughing when I told him and explained to me that that is what acute massive PE presents as. 

I have now seen it too many times to recall. 

But I usually jump on instructors who tell people "if the person is talking they are breathing," because as is evident, that oversimplifies the whole ventilation/perfusion/respiration concept a little too much.


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## abckidsmom (Feb 16, 2013)

Veneficus said:


> The best part of that story was since I had never seen it before, I thought the firemen had killed her, by forcinbly restraining her. Since I didn't think they intentionally were doing something wrong I was trying to figure out a way to write the narritive that wouldn't get them in trouble despite my thoughts of why she coded.
> 
> As luck would have it, one of the best ED docs I ever met saw me struggling to write the report and asked why I was so upset this time. (I never get upset over patients and have even been written up for not sounding "panicked" enough in my radio reports or "urgent" enough on scene)
> 
> ...



The lady that taught me this phenomenon was a parking garage attendant in a booth who could not be made to get on the stretcher and BARELY rode safely to the hospital on the bench with me.  I felt like such a failure, and had no idea what was wrong with her, and took her to the wrong hospital in the face of "closest hospital." 

But I learned, and I find that to be something.


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## Handsome Robb (Feb 17, 2013)

ECG, sorry, this was the best one I could get, tried multiple times to get a clean tracing. 







This is what the MRx decided to say about it.


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## Handsome Robb (Feb 17, 2013)

My list of 4 DDxs was, in order, PE, Aneurysm, Sepsis, HyperK.

Hx of COPD, heroine abuse, depression, NIDDM, obstructive sleep apnea and hypertension. Facility denied any Hx of TAA/AAA the patient stated she had heard "something about that" but couldn't tell me more than that. 

NKDA

Ventolin, advair (I believe, can't remember, should've written it down), amlodipine, lisinopril, lasix, potassium chloride, glipizide, some antibotic and methadone.

Attempted 5, yes 5 lines en-route, 1 successful, by my stud of a partner, in the right foot just before we departed. Assessed for EJ placement with nothing showing even with pressure applied to her liver. One failed right tibial plateau IO attempt, unfortunately we don't carry bariatric needles. 

Transported emergent, I hate transporting code 3 by the way. Never really had to do it on night shift, days are a different story though. 

Diverted from the original destination facility on my discretion to the trauma center because of my DDx list and the potential for vascular and/or thoracic surgery resources. 

HR unchanged, SpO2 increased to 93% on NRB, RR unchanged, BP up to 86/50 after 1000cc of NS, no other changes in assessment or pt complaint. 

No obvious line of demarcation. 

14 minute code 3 transport.



n7lxi said:


> PE.
> 
> You guys don't have end tidal, right?
> 
> ...



No sir, no sidestream ETCO2 unfortunately, I really wanted it on this one. Considered trying to jerry rig something with our ETT/King ETCO2 probe but couldn't figure it out. 

I'll admit I'm not the best at reading 12-leads, definitely not nearly the caliber of you guys but I didn't see anything that screamed PE at me in it, it's posted above for y'all.



Chase said:


> Did she have a murmur?
> 
> Pluse quality? Carotid, radial, and pedal
> 
> ...



S1, S2, no gallops or murmurs noted.

Absent radial and pedal pulses, carotid was weak but easily palpable. 



FLdoc2011 said:


> Post ortho surgery now hypoxic and hypotensive, definitely PE is at top of list.
> 
> Bilateral BPs?
> EKG?
> ...



Bilateral BPs equal. 

EKG above, sorry just got a chance to post it. 

1000 CC NS pressure infused through a 20g in her right foot. 

SpO2 increased to 93% on 15 LPM NRB as noted above. 

96.0 F temporally per the ER. 

Didn't notice any antiplatelet/anticoagulant in the paperwork but the way they list them is a total pain in the *** to follow at this particular facility. 



EpiEMS said:


> What'd the ED find?



Not gonna give the Dx up yet. They did CMP, CBC, D-Dimer, cultures, echo, CXR, central line, hung levophed (not sure of their dosage) and last I heard were trying to take her to CT but couldn't get her "stable" enough for the doc to be comfortable to put her into the CT machine per the ER RN. 

I'll work on getting exact labs for you tomorrow from my girls at the ER. Any specific numbers anyone would like to know? I know I few of the numbers but not all of them. The ones I know made me go "EEEEEEEEEEEEEK"

Anything else you'd all like to know? I kinda gave up all the standard questions in the original post.


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## Clare (Feb 17, 2013)

I am seriously leaning towards an AAA 

This lady sounds sick, I hope she is all right because I have had three patients today who have been critically unwell and its just like enough already!


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## Aprz (Feb 17, 2013)

I feel like I am getting worse at 12-lead interpretations the more I look at them, lol. Would definitely like to hear input from our local ECG experts (Christopher, TomB, Chase).

Things that would point towards PE in the 12-lead is tachycardia, retrograde T-wave in V1 and V2, looks like a pseudo RBBB pattern in V1, V2, and V6, lead I has an S wave, slight right axis deviation per the monitor (otherwise pretty much vertical, usually horizontal in fatties), and atrial enlargement (p-pulmonale in II).

Honestly though, I wouldn't be thinking PE looking at this 12-lead. The T-waves in II, III, aVF, aVR, V4-V6 would make me think hyperkalemia. Additionally, the patient also takes Lisinopril and Potassium Chloride. Hyperkalemia was a theme on all the EMS blogs and podcast recently. You'd think I'd figured it out by now.

From what I've read and the sounds of it, hyperkalemia and PE don't usually show up on ECGs anyhow. The patient could have a really high potassium level with no ECG changes. The patient could have a pulmonary embolism with no ECG changes.

Always possible the patient could be having both, lol.

Sounds like the ER already got labs and you would've known already if it was hyperkalemia though.


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## Aidey (Feb 17, 2013)

The reason hyper K doesn't always show up in the EKG is because of the difference in the body's response to chronic hyper k and acute hyper K. In chronic hyper K the body has a chance to respond, and does by leeching calcium from the bones. Thus, few EKG changes. In acute hyper K the body hasn't had a chance to respond yet, so the EKG shows a hyper K pattern. 

What was the d dimer, potassium and H/H?


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## FLdoc2011 (Feb 17, 2013)

How was her lung exam, any crackles/rales?

What her knee?  Any erythema/edema or other signs of injection?

EKG really doesn't change my view on a PE either way, not really helpful.

But am concerned for hyperK as others have said.  Some basic labs and a quick bedside ECHO will tell a lot.


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## Handsome Robb (Feb 17, 2013)

Welp, since I ended up leaving work early because of the flu I'll give you guys some more, unfortunately not exact numbers just "WNL" or "above/below xxx". Some are exact most are not.

Aidey, d-dimer was 230s, potassium was 6.4, H&H was "within normal limits". Her WBC was elevated, don't remember the number sorry.

FLdoc, Her lungs were pretty clear for a COPDer. She was tough to listen though because she wouldn't stop moaning when I'd try to auscultate. 

Knee was a bit swollen, nothing that jumped out a ton at me. Same temperature as surrounding tissue, no reddening or signs of infection that I noted but it was bandaged and the bandage appeared to have some sort of yellow discharge started to seep through. Probably should have peeled it off and looked but I had bigger fish to fry. 

The doc said the ECHO was "fine".


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## DrParasite (Feb 17, 2013)

i'm thinking AAA.

how is the patient c/o of diff breathing and but her resp are clean and not labour, but you need to BVM and cpap her?


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## Aidey (Feb 17, 2013)

If there is a V/Q mismatch the patient my experience the sensation of difficulty breathing while having minimal easily assessed signs, like wheezing or retractions. The patient was on home CPAP when they arrived, and they switched her to a NRB not a BVM. Which she needed due to a low SpO2.


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## Handsome Robb (Feb 17, 2013)

DrParasite said:


> i'm thinking AAA.
> 
> how is the patient c/o of diff breathing and but her resp are clean and not labour, but you need to BVM and cpap her?



Not sure where you got BVM and CPAP. Aidey beat me to explaining it. 

When I asked her about her breathing she said it was difficult because it hurt to take a deep breath. 

Look at it this way, some cardiac patients complain of difficulty breathing or shortness of breath with no increase in their WOB and clear lung sounds.

More labs for you all. 

Lactate was 14, BUN and creatinine both were marked high high (HH) don't remember the number but it was way up there, GFR was 17 or 18. Per the ER her glucose was 354 mg/dL, needless to say my glucometer got swapped out after I found that out, I suspected it had been giving me some funny numbers over the last week or so.


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## Aidey (Feb 17, 2013)

So sepsis with acute renal failure. From the knee or something else?


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## DrParasite (Feb 18, 2013)

Robb said:


> Not sure where you got BVM and CPAP. Aidey beat me to explaining it.
> 
> When I asked her about her breathing she said it was difficult because it hurt to take a deep breath.


chalk one up to misreading the original post.  I saw "needing to have a BM." and thought that said "needing to have BVM."  

and oddly enough ProQA would consider "hurts to take a deep breath" to not be cardiac related, and not difficulty breathing.


Robb said:


> Look at it this way, some cardiac patients complain of difficulty breathing or shortness of breath with no increase in their WOB and clear lung sounds.


yeah, I completely misread that original part.  my bad :glare:


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## Handsome Robb (Feb 18, 2013)

DrParasite said:


> chalk one up to misreading the original post.  I saw "needing to have a BM." and thought that said "needing to have BVM."



I'll forgive you this time. 



> and oddly enough ProQA would consider "hurts to take a deep breath" to not be cardiac related, and not difficulty breathing.
> yeah, I completely misread that original part.  my bad :glare:



True, it's not cardiac related, neither was this call. That was just an example I was using to make my point that you can complain of difficulty breathing with no objective signs of respiratory distress. 

When I ask her what's bothering her the most and she says "my back hurts and I can't breathe" that's her chief complaint...QA can :censored::censored::censored::censored::censored: and moan all they want but there's nothing they can do about it, that's what she was complaining of. I don't really see how they could have an issue with it though. 

Just because the pain is reproducible, despite what EMS classes say, doesn't mean that it can't be cardiac related. My last STEMI was complaining of right sided, sharp, pinpoint chest pain that reproducible on palpation and deep inspiration.



			
				Aidey said:
			
		

> So sepsis with acute renal failure. From the knee or something else?



I would assume the knee. That was the doc's opinion. I think the renal failure is secondary to the sepsis and she agreed with that as well.


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## VFlutter (Feb 18, 2013)

Aidey said:


> So sepsis with acute renal failure. From the knee or something else?



If it is not the knee my bet would be UTI.


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## Handsome Robb (Feb 18, 2013)

Chase said:


> If it is not the knee my bet would be UTI.



Definitely possible. She didn't have a foley but it's not like you have to have one to get a UTI either.


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## Aprz (Feb 18, 2013)

Doesn't the lab confirm she was hyperkalemic? Normal limit is 3.5-5.0.


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## Handsome Robb (Feb 18, 2013)

Aprz said:


> Doesn't the lab confirm she was hyperkalemic? Normal limit is 3.5-5.0.



Yessir. 

She was hyperkalemic, on the brink of acute renal failure and severely septic. 

HyperK and ARF generally go to the party together.


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## VFlutter (Feb 18, 2013)

Robb said:


> She was hyperkalemic, on the brink of acute renal failure and severely septic.
> 
> HyperK and ARF generally go to the party together.



Throw in an ACE inhibitor and Potassium supplements and you have a real party. All things considered I am a little surprised her K wasn't higher.


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## Aprz (Feb 18, 2013)

Yey, I got something right on the Internet. Now I just gotta be right in real life.


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## EMT B (Feb 18, 2013)

How would hyper k play a role in the back pain?


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## VFlutter (Feb 18, 2013)

EMT B said:


> How would hyper k play a role in the back pain?



It doesn't. The back pain is most likely due to the AKI which explains the hyper K


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## mycrofft (Feb 19, 2013)

chase said:


> did she have a murmur?
> 
> Pluse quality? Carotid, radial, and pedal
> 
> ...



+1...........


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## VFlutter (Feb 19, 2013)

mycrofft said:


> +1...........



Fun fact that some of you may or may not know: Some patients will develop a diasytolic murmur due to acute Aortic regurgitation from a dissecting aneurysm (Or Pseudo-aneurysm to keep Vene happy).

A proximal type A dissection can also directly compress the RCA and produce inferior ischemia/infarct mimicking a MI. I think that is fairly rare.


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## Veneficus (Feb 19, 2013)

Chase said:


> (Or Pseudo-aneurysm to keep Vene happy).



You can be taught... There is hope.

Moving right along, repeat after me:

"There is no such thing as a fibroid, it is really a leomyoma. There is no fibrous tissue in it, it is all smooth muscle."


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