# Unresponsive 72F@SNF, "difficulty breathing"



## SCMed (May 27, 2013)

Fairly new EMT at the time, curious to see comments/thoughts.

BLS unit called to SNF for "difficulty breathing".

UA 72 y/o F sitting fowlers in bed unresponsive to verbal/painful stimuli.

(To the best of my recollection) Vitals:
PR 130 strong/irr
BP 202/(90?)
RR 30s shallow chunky
Flush/warm/normal
Pupils equal/constricted
Lungs L wheeze IIRC

Hx HTN, DM, arrhythmia, pacemaker
NKA

Pt. daughter claims rapid onset ~20 minutes ago pt. was AO.

Maintained fowlers, applied 6LPM NC, got ALS involved promptly (why SNF staff called in BLS, we still don't know - little scary). Fire shows up and says we handled everything well, waits for ambulance medic - medic walks in and a sternal rub induces a flexion response <_< he thanks and dismisses us. We were posted back in the area, went down to ED, got there a while before the medic unit did so they were on scene for a bit. 

I'll let a couple guesses fly before I say what fire and the medic seemed to immediately peg.


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## Handsome Robb (May 27, 2013)

Sounds like a stroke. 

A bleed would be my first guess with the rapid onset and vitals. 

Or a TIA if your hinting at the patient started responding to painful stimuli.

Or a seizure but no one said anything about seizure-like activity or a history of.


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## rmabrey (May 27, 2013)

Im leaning towards stroke as well.


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## Akulahawk (May 27, 2013)

What kind of pacer and when did the patient last eat/get insulin?


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## DesertMedic66 (May 27, 2013)

I would also lean towards a stroke with this patient. She has some of the main risk factors for a stroke.

Meds the patient is on? Has the SNF been keeping up with giving the patient meds? (I'd like to not even ask that question but it would not surprise me if the answer is no).


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## CritterNurse (May 27, 2013)

Something about this makes me wonder about pulmonary embolism or stroke, but I'm still a Basic.


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## Handsome Robb (May 27, 2013)

Akulahawk said:


> What kind of pacer and when did the patient last eat/get insulin?



Good point. 

I thought about it then said nahhh can't be that simple.


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## chaz90 (May 27, 2013)

Haha, fire and the medic immediately peg? Look what we all just did. I bet you anything somebody is just a wee bit hypoglycemic. The OP also mentions ALS was on scene for a while. Now that I saw that this scenario screams diabetic wake up.


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## rmabrey (May 27, 2013)

I didn't even consider it would be that easy.  I also forget there are still places where techs cant check a BGL, like here


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## SCMed (May 27, 2013)

Great responses  My partner and I did discuss that.

Unknown on the pacer. She had eaten within an hour of arrival on scene. Both services immediately said "she's overmedicated".

Whether or not that's a good call, we unfortunately were not able to follow up, but she was given Ativan due to a little anxiety spell (also forgot to mention that in hx).

Also - can anyone shed some light on the fact that her pulse was irregular and had a pacemaker? It was mentioned that this was a concerning issue.

Note also, to any pertinence, she had fairly bad edema upper extremity (L or R evades me - think it was R).


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## chaz90 (May 27, 2013)

SCMed said:


> Also - can anyone shed some light on the fact that her pulse was irregular and had a pacemaker? It was mentioned that this was a concerning issue.



Could be a demand pacemaker that only activates when the intrinsic heart rate drops below a pre-set number.


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## Handsome Robb (May 27, 2013)

SCMed said:


> Great responses  My partner and I did discuss that.
> 
> Unknown on the pacer. She had eaten within an hour of arrival on scene. Both services immediately said "she's overmedicated".
> 
> ...



I wouldn't be so quick to jump to over medicated unless you're talking about insulin or some other oral diabetic medication. I'd doubt they'd be breathing 30times a minute with enough benzos on board to render her unconscious.

Without having any further information and not. Knowing a CBG I'd treat it as a stroke until proven otherwise but the first thing on my list is check her blood glucose.

She's hypertensive with a wide pulse pressure, had a reasonable rapid onset of unresponsiveness, irregular (my interpretation of "chunky") respirations as well as has other big risk factors for CVA.

She's not bradycardic but that's generally a late sign and secondary to the hypertension.

To answer your questions about pacemakers. There are lots of different types. Sme work constantly while demand pacers only activate in the presence of a bradycardic heart rate. 

Saying the patient had a rapid, irregular pulse makes me think A-fib, which is another massive risk factor for CVA whether it be from a clot finding its way out of the atria or a massive, rapid bleed because they're on Coumadin or something of the sort.


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## FLdoc2011 (May 27, 2013)

Robb said:


> Saying the patient had a rapid, irregular pulse makes me think _Arab_, which is another massive risk factor for CVA.....



That's racist....


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## 46Young (May 27, 2013)

FLdoc2011 said:


> That's racist....



Robb might have been typing from his phone, and "A-Fib" might have been corrected to "Arab" by the software, without his noticing.

Funny response, though.


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## FLdoc2011 (May 27, 2013)

46Young said:


> Robb might have been typing from his phone, and "A-Fib" might have been corrected to "Arab" by the software, without his noticing.
> 
> Funny response, though.



I kind of figured that.


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## VFlutter (May 28, 2013)

SCMed said:


> Also - can anyone shed some light on the fact that her pulse was irregular and had a pacemaker? It was mentioned that this was a concerning issue.
> 
> Note also, to any pertinence, she had fairly bad edema upper extremity (L or R evades me - think it was R).



You have much to learn about pacemakers. http://icufaqs.org/ Click the "pacemaker" tab. 

Long story short: Not everyone with a pacemaker is pacer dependent and 100% pacing. If the patient's intrinsic rhythm is faster then the set rate the pacemaker will not fire. For instance if the PPMs bottom rate is set at 70 and the patient is in A fib RVR then there will be no pacing and you will feel a rapid irregular pulse. ~ that is overly simplified. But that is the proper function of a pacemaker not a malfunction. 


Was the edema on the same side as the pacemaker?


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## Handsome Robb (May 28, 2013)

FLdoc2011 said:


> That's racist....



:lol: fixed. 

That's pretty funny though


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