# Bloody 21 YO Male



## Handsome Robb (Dec 30, 2011)

Nothing complicated

Dispatched out as Priority 1 Hemorrhage. We arrive on scene to find the fire department assessing the patient. 

Pt states he was supposed to wake up early for work then was planning on coming home and going to sleep. The last thing he remembers is going to bed. Grandma found him wandering around the front yard this morning covered in blood. 

C/C of a splitting headache and "feeling like I'm going to die"

We find ~200 ccs of blood in his closet in his room where it appears he went headfirst through the closet door. 3 cm full thickness laceration from right in between his eyes running vertically. Pt was pretty well covered in blood. If I had to estimate I'd say 400-500 ccs total blood loss.

The bullets:
GCS 14 - 4/4/6 (you could argue 13 - 3/4/6) , AA&Ox2 (person and place, keeps thinking it's 12/2012) Pupils reactive but sluggish at 4mm.
HEENT - appears atrauma except for the laceration, no fluid from the ears/nose present no depressions or abnormalities noted. 
Neck - midline pain on palpation, no JVD, trachea midline
Chest - equal bilaterally, no complaints, clear breath sounds bilaterally
ABD- SNT
Pelvis - stable, no complaints, pt ambulatory.
Extremities - good distal CMS, no numbness/tingling, ambulatory, equal push/pull and grip strength. 

Pt and his grandmother both repeatedly deny any ETOH use or drug use. Per grandma "I've never seen him even drink one beer in my life, we have lived together for 4 years." House is clean and well kept, same goes for the Pt's room, nothing that really jumped out at me as unusual minus the broken closet door and all the blood :rofl:

H: ADHD
A: NKA, NKDA
M: Ritalin

Vitals:
132/84
110 sinus tach without ectopy on the monitor, strong, equal, bilateral pulses
RR 32 unlabored and regular
96% on RA
BGL 213

So we are on scene, where do you go from here? I'll answer questions as the are asked


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## exodus (Dec 30, 2011)

It can't be as simple as DKA can it?  Stimulant OD?


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## Handsome Robb (Dec 30, 2011)

exodus said:


> It can't be as simple as DKA can it?  Stimulant OD?



I'd expect to see the BGL much higher for DKA.

No evidence of drug use in the house but it can't be ruled out. According to grandma and a phone conversation with mom he's an outstanding student and a a very hard worker. No abnormal behavior has been noted recently.


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## NomadicMedic (Dec 30, 2011)

DKA? You mean hypoglycemia, right?


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## exodus (Dec 30, 2011)

n7lxi said:


> DKA? You mean hypoglycemia, right?



DKA / Hyperglycemia = Above average BGL.
Hypoglycemia = Below average BGL.

IIRC at least.

And good point NV. I'm unsure at my level what his could be, those are the two that jumped out at me. tachypnea and tachyardia would lead me to the OD, Tachypnea would lead me to DKA. But as you said It's almost certainly not DKA.


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## Handsome Robb (Dec 30, 2011)

n7lxi said:


> DKA? You mean hypoglycemia, right?



at 213?? :unsure:

I see your thought process exodus but I was looking for horses not zebras on this scene. 

I'll give some people more time to respond before I starting giving up more info


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## NomadicMedic (Dec 30, 2011)

That's what I get for looking quickly, I looked at GCS, and saw CBG. CBG is the abbreviation we use here for capillary blood glucose. 

Doh. 

 Forgive me.  I'm not really an idiot, honest.


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## exodus (Dec 30, 2011)

Figured you made a mistake! I'm eager to see what's going on.


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## NomadicMedic (Dec 30, 2011)

It seems like this is one of those "we ain't gonna know til we see bloods and a CT".

I'm curious if he OD'd on his meds, or mixed them with alcohol/other drugs at a holiday party. Seizure? Or, just drunk and clumsy? Maybe he got up to pee and had a syncopal episode? 

People do not just get up and crash through the closet door in the middle of the night for no good reason.  (At least at my house...)

I'm not seeing any zebras here.


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## Remeber343 (Dec 30, 2011)

Well, something isn't adding up.  He either got hammered and fell into the closet, or some sort of DV happened. Guess it could be a head inj from the fall through the closet door, it can take a pretty good hit to break a door...

I had a pt break a the holding tank of the toilet water with her head... that was a good fall lol.  But i'm think granny doesnt know whats going on, or perhaps he took some of her meds?


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## Handsome Robb (Dec 30, 2011)

My first thought was drugs as well, but being on scene it never seemed like a viable option to me. 

My partner and I both came to a similar conclusion as you n7. Seizure -> fall -> bleed. I suggested syncopal as well but he didn't remember ANYTHING from the time he was getting ready for bed. I would think that he would have some recollection of what happened minus the syncope itself. Also I agree, this thread wont get a definitive answer until I work tomorrow and can try to follow up on it.

So he ended up in full spinal motion restriction and an IV. We started transport and he began to complain of nausea, needless to say I'm a little grumpy I didn't drive a bit faster, I lolligagged a little bit to try and smooth the ride out for him. PT projectile vomits all over the back of the unit. Roof, walls, the radio in the box, everywhere. The vomiting breaks the clot in his lead lac which proceeds to squirt with every heave, all over everything he just puked on while I try to get parked and my partner scrambles for an emesis bag and 4x4s all the while attempting to avoid a shower of bodily fluids. 

So it's looking more and more like a bleed to me but the vitals don't exactly point to increased ICP although we could have caught it early enough. Any thoughts on that? 

Also per grandma when she found him wandering around he "wasn't himself, at all". Points to drugs or TBI or both.


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## NomadicMedic (Dec 30, 2011)

Well, the "altered female" in the scenario thread had normal VS too... Absolutely normotensive, normal sinus on the monitor and respirator of 18. So... Who's to say. I'd be curious to see results of his blood and his CT.

And no Zofran on that truck? It can do wonders for nausea.  and keep you from becoming the "covered with puke guy".  Also, did you start a line with fluid running, or just a saline lock?


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## Handsome Robb (Dec 30, 2011)

n7lxi said:


> Well, the "altered female" in the scenario thread had normal VS too... Absolutely normotensive, normal sinus on the monitor and respirator of 18. So... Who's to say. I'd be curious to see results of his blood and his CT.
> 
> And no Zofran on that truck? It can do wonders for nausea.  and keep you from becoming the "covered with puke guy".  Also, did you start a line with fluid running, or just a saline lock?



That's very true about your altered girl. 

This is were mine and my partner's views differed, respectfully though and he explained his reasoning later to me.

He has lost volume and is presumably compensating with his tachy rate, also with the BGL being elevated at 213 I was on the train of a 500mL bolus and see how that did for him. Although I also wasn't sure if it was appropriate with a presumed increase in ICP. My partner, the medic elected to leave it as just a lock seeing as we were about 7 minutes from the Level II.

I also started to get the zofran out when he started complaining of nausea right before we started transporting and was shut down by my partner. "If it is a TBI zofran wont do anything for him". It was my first day riding with him and he's been a medic for about as long as I have been alive so I didn't want to pick an argument at the beginning of a 16 hour shift, especially being the FNG at my agency. Even if he is correct I still felt it was appropriate to trial it. If it works it works, if it doesn't it doesn't. It wasn't contraindicated although there aren't many contraindications to begin with.

The more I work in the field the less I feel I know.


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## exodus (Dec 30, 2011)

A seizure fits the ritalin as well. It's a side effect of regular usage. I know very well of the side effects of that drug having developed tourettes because of it at a very young age.


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## Melclin (Dec 30, 2011)

Do you not routinely give anti-emetics to spinally immobilised pts?


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## Handsome Robb (Dec 30, 2011)

Melclin said:


> Do you not routinely give anti-emetics to spinally immobilised pts?



If it were my patient he would have gotten it. Working ILS in NV anti-emetics are out of my scope and my ALS partner decided against it. 

Now had I been the ALS intern on the truck this PT definitely would have gotten 4mg of Zofran.


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## Nervegas (Dec 31, 2011)

NVRob said:


> So it's looking more and more like a bleed to me but the vitals don't exactly point to increased ICP although we could have caught it early enough. Any thoughts on that?



I would honestly say that you are correct, the vitals do not in any form point to an increase in ICP. I would be interested to see the results of a tox screen, but with the blood loss, it could be masking the expected change in vitals for ICP due to the volume lost. To be honest, I would have given him the zofran and expedited transport, maybe titrate a fluid bolus to bring his rate down a little and keep his volume up. Not really a whole heck of a lot else we can do for this patient.


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## mycrofft (Dec 31, 2011)

*Tripped getting out of pants, fell into the closet door, TBI and deep bloody lac.*

And DKA will not have a normal respiration.


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## Handsome Robb (Dec 31, 2011)

Nervegas said:


> I would honestly say that you are correct, the vitals do not in any form point to an increase in ICP. I would be interested to see the results of a tox screen, * but with the blood loss, it could be masking the expected change in vitals for ICP due to the volume lost.* To be honest, I would have given him the zofran and expedited transport, maybe titrate a fluid bolus to bring his rate down a little and keep his volume up. Not really a whole heck of a lot else we can do for this patient.



The bolded section was my thought process as well. Your treatment plan was where I was headed as well if it had been my patient. 

I will try to poke my nose around tomorrow and find out what I can about him. It was tough to talk to his gma and mom, I could hear the fear and sadness in mom's voice on the phone. I think that's one thing they need to add to EMT and Medic curriculum is family care and communications.


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## Handsome Robb (Dec 31, 2011)

mycrofft said:


> And DKA will not have a normal respiration.



You never cease to amaze me with your down to earth, logical explanations of events. That never even crossed my mind but it makes perfect sense. 

As for DKA and respirations. In the few "good" DKA cases I have seen they all had deep, normal, rapid respirations ie Kussmal's


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## Aidey (Dec 31, 2011)

Since when were resps of 32 "normal"? I agree DKA doesn't fit overall, but it doesn't sound like you could rule it out only based on respirations.


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## Handsome Robb (Dec 31, 2011)

Aidey said:


> Since when were resps of 32 "normal"? I agree DKA doesn't fit overall, but it doesn't sound like you could rule it out only based on respirations.



Sorry, normal was a poor descriptive word. Regular, rapid and deep would have been better.

I'm not attempting to rule out DKA on respirations alone, this patient didn't present as DKA to me or my partner but that may be my inexperience talking.


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## RocketMedic (Dec 31, 2011)

Three questions: 

1. What sort of door? Some of those things can be pretty thick, and the chances of TBI go way up if it's a stout object.

2. Although I think I would have tried the Zofram, from personal experience, your partner is right. Concussions (TBI) _suck_, and Zofram doesn't touch them. 

3. Does mom/gma/pt know of any seizure history at all?


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## Handsome Robb (Dec 31, 2011)

Rocketmedic40 said:


> Three questions:
> 
> 1. What sort of door? Some of those things can be pretty thick, and the chances of TBI go way up if it's a stout object.
> 
> ...



1. It was a hinged door, not flimsy by any means but I think stout would be a stretch.

2. Gotcha

3. None was mentioned and we did ask as well. All said he was healthy with only the ADHD Hx.


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## RocketMedic (Dec 31, 2011)

Perhaps an emotional disorder or psychomotor disorder? I had a soldier with Tourette's whose twitch was to stomp the ground repeatedly with his right foot...perhaps this guys was to headbang?


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## Aidey (Dec 31, 2011)

NVRob said:


> Sorry, normal was a poor descriptive word. Regular, rapid and deep would have been better.
> 
> I'm not attempting to rule out DKA on respirations alone, this patient didn't present as DKA to me or my partner but that may be my inexperience talking.



My reply was actually aimed more towards mycroff, who pointed out DKA pts don't have normal resps. This pts resps weren't normal, so his wisdom doesn't quite apply.


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## exodus (Dec 31, 2011)

Aidey said:


> My reply was actually aimed more towards mycroff, who pointed out DKA pts don't have normal resps. This pts resps weren't normal, so his wisdom doesn't quite apply.



Mycroftt was speaking on the



> RR 32 *unlabored and regular*



part and not the rate. Rates abnormal but the mechanics are normal.


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## Remeber343 (Dec 31, 2011)

Aidey said:


> so his wisdom doesn't quite apply.



Aidey, have you even seen dka in a patient?  There's more to dka then just rapid resps.


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## mycrofft (Dec 31, 2011)

*Resps*

DKA cases I saw did not have accelerated rests, but deep and steady, almost labored, sort of like head injury ones I'd seen. They were "found down" cases so I suspect if they were incapable of that deep ventilation they'd have been coroner's cases..but we picked up for them, too. (Long time ago). Smelled like canned pears.

Doing basic sick call over twenty years I often saw patients with resps over twenty per minute because they did not breath deeply. I took resps while taking temp and pulse so the pt didn't see me counting their resps to avoid purple elephant syndrome.* 



As in "Clear your mind, don't think about a purple elephant"...
(or the StayPuff Marshmallow Man..."thanks, Ray!".)


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## Aidey (Dec 31, 2011)

Remeber343 said:


> Aidey, have you even seen dka in a patient?  There's more to dka then just rapid resps.



No never, the ink is still wet on my cert. 

/sarcasm

No kidding there is more to DKA then rapid respirations which is why I agreed that this case did not fit. My issue was the use of the word normal to describe the pts respirations when they were not. The pts breathing was non laborered and regular. Kussmaul's are regular too, so the regularity of the pts breathing really doesn't have much sway in whether the breathing is Kussmaul's or not. 

In metabolic acidosis breathing can be fast and shallow. As the acidosis progresses respirations become deeper to further help compensate. So if the pt had mild DKA their respirations could be shallow or normal in depth. 

So again, while I agree that it is highly unlikely that you will ever have a DKA pt of any severity with normal respirations, this pts respirations are not normal. In this case DKA(or another metabolic acidosis) can not be ruled out simply based on respirations.


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## Handsome Robb (Dec 31, 2011)

Remeber343 said:


> Aidey, have you even seen dka in a patient?  There's more to dka then just rapid resps.



Oh you just stirred the pot.... h34r:

Found out today pt had an epidural hematoma, underwent emergent surgery and has a good prognosis per the scary, scary neurologist.

Also tox screen was clean. 

Still no word on what caused the fall, my vote is still with a seizure. Neurologist liked my reasoning  I'll try to keep after the case and see what they uncover.


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## mycrofft (Dec 31, 2011)

I still think he was taking his pants off and tripped.

The DKA's I found were not fresh, they may have already "blown past" the short and fast stage. Neither last more than a week afterwards nor ever went home.


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## bigbaldguy (Dec 31, 2011)

mycrofft said:


> And DKA will not have a normal respiration.



I was thinking along same lines. Guy is completely exhausted does a bit of sleep walking trips puts his head through a door. dazed he stumbles around in the front yard while losing a bit of blood and getting a nice good panic on. When I was 12 I fell out of a bunk bed onto a glass of water which broke and cut me pretty badly on my forehead. I climbed back into the top bunk without ever really waking up. Dad found me a few hours later and took me in for 18 stitches.


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## Aidey (Dec 31, 2011)

A seizure is so much less embarrassing than tripping over your own pants though, lol. 

I think both scenarios are equally plausible at this point. If he has seizures in the future it will probably be assumed that is what happened.


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## Handsome Robb (Dec 31, 2011)

Aidey said:


> A seizure is so much less embarrassing than tripping over your own pants though, lol.
> 
> I think both scenarios are equally plausible at this point. If he has seizures in the future it will probably be assumed that is what happened.



I vote we lock him in a room and bombard him with multicolored strobe lights and annoying sounds and see what happens h34r:

Yea...he might not like that. 

I bet if he did trip over his pants and he knows it, that's one he will take to the grave with him. Hell he almost did anyways! Grandma saves the day!


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## mycrofft (Jan 1, 2012)

bigbaldguy attempts highdive in his sleep, film at eleven.
Yeah, we'll buy that story for a dollar.


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