# My Wednesday night..,



## NomadicMedic (Jan 26, 2017)

It's about 7 PM on a Wednesday evening. You, a paramedic, and your EMT-B partner respond to a private residence for a medical alarm activation.

You have all of the usual paramedic goodies with the exception of RSI. It's raining, so there is no helicopter available. You are approximately 15 to 20 minutes away from a level III community Hospital and approximately 50 minutes away from a PCI/stroke center.

As you're making the 10 minute response, the dispatcher tells you that they called back and a family member relates that the patient fell and is unconscious, but breathing. The dispatcher also tells you that the patient has a history of diabetes.

When you arrive on scene you find the residence to be a very unkempt single wide mobile home. There are several random people milling about in the house, and none of them say anything to you when you walk in. You noticed a fire department first responder SUV parked in the yard so you know that someone is inside with the patient.

You're silently pointed towards the back bedroom where you come upon a approximately 60-year-old woman lying supine amidst the slats of a broken bedframe. No mattress in sight. She's lying in between two slats of the bedframe on the floor. There's a first responder kneeling in the wreckage next to her. You know this guy, and you trust what he tells you. He looks up and says, "I'm having a hard time finding a radial, but she has a carotid pulse of about 60 and I got a blood pressure of 84 palp".  He also says, "I know this woman. I was here about four months ago and we ran her as a full arrest." At that point, the woman's elderly husband shambles into the room and says, "she fell and was on her face, we done turned her over." You ask how long ago this happened and when the last time he saw her, he replied, "she was fine 10 minutes ago."

You inquire further about her medical history and he replies vaguely "she's got the sugar, the high blood and something with her heart. They done got all that at the hospital."

You look down, and notice that her eyes are open, pupils are dilated and responded sluggishly to light. She does not respond to any painful stimulus, does not track with her eyes. She is nonverbal. However, if you say to her "hey, squeeze my hand if you can hear me" you are rewarded with a very weak squeeze. Her extremities are cool, and capillary refill is delayed. As you send your partner to the truck to get a tarp to move her out of the extremely tight trailer to the ambulance stretcher, you get a blood sugar and it is 97.

Okay. What else would you like?


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## STXmedic (Jan 26, 2017)

Vitals of course. BP, respiratory rate and regularity, O2, EtCO2, ECG/12 lead. You know, the usual. Also, if we could find her medications to see what she takes, if she takes them, and any history of recreational drug use (meth much?). What the cause of her SCA a couple months ago?

Obviously she's urgent, and would be leaning towards a bleed/cva. So scene time would be limited, and transporting to the stroke center (assuming we're able to control her airway)


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## VentMonkey (Jan 26, 2017)

Assess airway and breathing for adequacy. Does she require assisted ventilations in spite of responding with a faint squeeze of the hand? While determining such direct my tech to place this patient on the SPO2 (RA?), sidestream ETCO2 if available, cardiac monitor, and reconfirm the first responder's blood pressure.

Is she taking any medications, either prescribed or OTC? Does she have any allergies to medicine? Judging by the fact that she responds to verbal stimuli with a hand movements, she appears to be cognizant of what is going on. Is she a smoker? Does she have any history of CVA/ familial CVA? What is her family's history? Does she seem abnormally hot, or cold to the touch? Are we able to R/O trauma since she "done fell out"?

Once my V/S are confirmed I'd like to work on moving her to the ambulance. If there is no change in her mental status, and/ or assuming she does need airway protection (even if it's basic) I may opt for the closest, and then linger around a bit until CT comes back. If the CT in indicative of anything worth transferring, then I can call dispatch and let them know they'll have one going out to a tertiary center, and since it's my patient to begin with, I'll stick around until they're ready to transfer out.

As far as interventions en route, as stated with no changes, protect this patient's airway. The standard lock (or two), and if her MAP can't come above 60 mmHg via my NIBP, then she may get a fluid challenge in 250 cc increments. A 12 lead is warranted as well, and I would be interested to know if there are any indicators for gross electrolyte imbalance.

As far as differentials for now, I'm going with CNS in nature vs. an autoimmune deficiency and/ or R/O a neuromuscular pathology such as ALS vs. Guillain-Barre syndrome; possibly severe myasthenia gravis.


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## NomadicMedic (Jan 26, 2017)

Because you know ... past arrest, you slap the pads on. This is the first rhythm you see. 

You head out to the truck and obtain a set of vitals. First BP is 114/58. Respiratory rate 16, unlabored. EtCO2 is 38, SpO2 is 100%. HR is 62. 

The meds that you can find are; Seroquel, Lisinopril, Celexa, Coumadin, trazodone, and Folic acid.  Nobody's able to give you any background on her past cardiac arrest. (or if it really was a full arrest. I don't know. I trust that first responder, but… then again.) 

The husband says she ate dinner and went to go do something in the back room.  She hasn't been sick recently, at least as far as he can tell. No complaints. He said she seemed 100% normal. 

You get IV access with bilateral 18s. With one, you hang 1000 bag of normal saline and run it wide open. The other side is a saline lock. 

There is really no response during any of the interventions. Patient doesn't make a sound, will open her eyes if you yell at her. Doesn't track. May occasionaly squeeze as response, but not every time. No flinch during the IV. 

You cycle the BP cuff. 98/64. 

Local hospital 15 minutes away or the level II 50 minutes away?


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## EpiEMS (Jan 26, 2017)

@DEmedic, first of all, thanks for the excellent scenario.

Earlier...[Vitals are the first step here. As @STXmedic said, I'd like BP, O2 sat, ETCo2, ECG (probably a 12), temp, and lung sounds. How's the airway looking? Sounds like we might need some support. Definitely going to want to keep her packaged warmly. I'd likely throw on a C-collar (per protocol/chicken soup), but that's all in the way of immobilization I'm doing.

Do we have a med list? If not, any pill bottles around? What's her baseline mental status?

Sounds like we've ruled out hypoglycemia. Other concerns are the ambient temperature in the house, possible CO exposure, substance (ETOH + others) use.

As far as a transport decision, we could go with the Level III for now, and perform a better neuro assessment en route, given the patient isn't particularly stable.]

Shoot. Sorry guys, I missed @DEmedic's last update!

So, now, I'm thinking let's get to the stroke center...

Do you have a temp, by any chance? How about a second HR/BP?

So far, my DDx includes: CVA, sepsis (or other infection), arrythmia (transient?), and drug toxicity (very speculative). (Semi-related: Could she be experiencing some sort of "failure to thrive" for the elderly?)


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## VentMonkey (Jan 26, 2017)

DEmedic said:


> The meds that you can find are; *Seroquel*, Lisinopril, Celexa, Coumadin, trazodone, and Folic acid.  Nobody's able to give you any background on her past cardiac arrest. (or if it really was a full arrest. I don't know. I trust that first responder, but… then again.)


This med right here coupled with prolonged QT duration, and her presentation may also indicate an overdose, either intentional or not; ask about that as well. I'm sticking with going to the closest, and hanging around to transfer out if it's a stat (emergent) transfer.


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## EpiEMS (Jan 26, 2017)

@VentMonkey, is that rhythm indicative of ventricular hypertrophy? Or am I totally loony?

Also, I'm *so* glad I thought OD earlier!


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## VentMonkey (Jan 26, 2017)

EpiEMS said:


> Shoot. Sorry guys, I missed [USER=4347]@DEmedic's last update! So, now, I'm thinking let's get to the stroke center...[/USER]



Don't second guess yourself, Ep; stick by your guns:). At this point we're all taking shots in the dark, and none of know for sure. Also (whispers), I don't think it's a stroke;).


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## NomadicMedic (Jan 26, 2017)

All of those beats are perfusing. The SpO2 is reading low perfusion because the BP cuff was cycling. (I know, poor form to put the pulse ox and BP cuff on the same arm. So shoot me.)

At about this point, she bradys down to 50, BP is 90/50. You've got 300 of that bag in.


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## VentMonkey (Jan 26, 2017)

VentMonkey said:


> Don't second guess yourself, Ep; stick by your guns:). At this point we're all taking shots in the dark, and none of know for sure. Also (whispers), I don't think it's a stroke;).





EpiEMS said:


> @VentMonkey, is that rhythm indicative of ventricular hypertrophy? Or am I totally loony? Also, I'm *so* glad I thought OD earlier!


It's a known side effect of Seroquel. The Q wave and T wave are pretty far apart, hence the term prolonged QT interval. So, my shot in the dark is leaning towards including an acute drug OD (possibly even a polypharm), amongst the others that I have already stated.


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## STXmedic (Jan 26, 2017)

I'd also like to get a repeat BGL, with our glucometer, making sure her hands are clean. Temp? Is there a 12-lead available?

I like the seroquel OD theory, too. I'm not sold on the prolonged QTc though- especially on the two views we've had so far. Still leaning towards neuro at the moment.


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## NomadicMedic (Jan 26, 2017)

Mike Smith, the guy the wrote for JEMS and EMS1, was my paramedic instructor.  He was an unbelievable source of knowledge. He had tons of little nuggets of wisdom that he would just pour out onto the class. And one thing that he said always stuck with me, "there's three things that'll put you on the floor. Your head, your heart and your sugar."

 Kind of a poor man's AEIOU – TIPS.

 But it's true. And I went through all of those scenarios in my head as I was working down the differential list. I was still leaning towards CVA or some sort of cranial insult. Whether it was a space occupying lesion or some sort of sudden catastrophic process.  I was also going down the list of meds. The Seroquel bottle was mostly full, by the way. Only 2 pills gone.

I didn't know much else about her history. I didn't know anything else that was going on.  Was it another type of overdose? A UTI? Did her husband try to poison her?  There were no signs of trauma, unless you count that busted up bed frame. Most of this other stuff would really just be an unknown without labs.

So, Let me skip ahead a little bit in the scenario, just to kind a get you ahead in this. I did decide to go to the level to STEMI/stroke center.  The community hospital doesn't have any type of capability to manage this. And, as far as unconscious patients go, she was relatively stable.  She needed to be at a place where they could spin her head and run the labs stat.

 So, this transport takes close to 50 minutes.  About 15 minutes away from the destination, she became bradycardic down to 52. I gave her a trial of 0.5 of atropine. Her heart rate increased to 77, pressure came up to 118/68. Her eyes opened and she made some moaning noises.

The 12 lead was unremarkable. I didn't grab a copy to photograph. Sorry about that.  I did take a repeat blood glucose. 99.  And I didn't have a thermometer handy.


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## EpiEMS (Jan 26, 2017)

This is a great thread, @DEmedic. Did you get any follow-up from the receiving facility?

Next time I have a good call, it'll be up here.



DEmedic said:


> . And one thing that he said always stuck with me, "there's three things that'll put you on the floor. Your head, your heart and your sugar."


Quoted for awesome


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## NomadicMedic (Jan 26, 2017)

Yeah. So here's the rest of this. 

 Got her to the emergency department and the doc was nonplussed. He couldn't figure out what was going on. She went for a stat head CT, came back clean, the labs weren't back by the time I left. 

Anyway. I came back a few hours later with chest pain and asked the doc what was going on. He said, "would you believe seizures?"  I said, no… But OK. He said she was actively seizing, they gave her Ativan and Keppra. And she was able to start talking and answer questions.

Wha dafaq?

Strange. Very strange.  

Turns out she also has a history of symptomatic bradycardia, which, in the past, had caused her to lose consciousness due to poor perfusion. 

 Also a history of substance-abuse, alcohol abuse and a bazillion other comorbidities that didn't play into this. She was admitted to the ICU last night. I'm not sure of the final outcome


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## BobBarker (Jan 26, 2017)

VentMonkey said:


> This med right here coupled with prolonged QT duration, and her presentation may also indicate an overdose, either intentional or not; ask about that as well. I'm sticking with going to the closest, and hanging around to transfer out if it's a stat (emergent) transfer.


I agree with going to the closest, if they have CT capability. Around here, even though though a hospital is considered a "Stroke Center", most of those don't have the capability for bleeds, which is what I initially thought. Seeing as her diagnosis was seizures, if we did end up transporting to the closest level III, they should have been able to handle her anyways.


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## VentMonkey (Jan 26, 2017)

Billy D said:


> I agree with going to the closest, if they have CT capability. Around here, even though though a hospital is considered a* "Stroke Center", most of those don't have the capability for bleeds*, which is what I initially thought. Seeing as her diagnosis was seizures, if we did end up transporting to the closest level III, they should have been able to handle her anyways.


Unless they have a neurosurgeon on call, and/ or in the building (i.e., epi- and subdural vs. SAH) that does the patient no good.

We have a handful of critical access hospitals in our county. They can perform CT's, and don't hesitate to transfer out, stat or not. This was my reasoning behind my transport decision; not incredibly acute, but not exactly stable either. 

Also, there's nothing in my rule book saying I don't have 15 minutes (transport to the closest) to up and change my mind should I experience a gut-check.


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## NomadicMedic (Jan 26, 2017)

She never displayed any seizure like activity. At all. None. And an hour long postictal period is outside of anything if ever seen before. The hospital I took her to has 24 hour neuro and is THE stroke center for the metro. That's where (I believed) she needed to be. Not a stop at the local band aid station.


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## VentMonkey (Jan 26, 2017)

DEmedic said:


> The hospital I took her to has 24 hour neuro and is THE stroke center for the metro. That's where (I believed) she needed to be. Not a stop at the local band aid station.


Worth a kudos for the effort being in the best interest of the patient.


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## NomadicMedic (Jan 26, 2017)

Still one of the more interesting cases I'd seen. Most odd.


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## VFlutter (Jan 26, 2017)

DEmedic said:


> She never displayed any seizure like activity. At all. None. And an hour long postictal period is outside of anything if ever seen before. The hospital I took her to has 24 hour neuro and is THE stroke center for the metro. That's where (I believed) she needed to be. Not a stop at the local band aid station.



Absence seizure?


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## VentMonkey (Jan 26, 2017)

Chase said:


> Absence seizure?


Of the stat ep variety.


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## NomadicMedic (Jan 26, 2017)

Maybe. Zero history. 

Honestly, seizure was the last thing on my list.


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## EpiEMS (Jan 27, 2017)

DEmedic said:


> Maybe. Zero history.
> 
> Honestly, seizure was the last thing on my list.



Paradoxical withdrawal symptoms? Totally speculative, obviously.


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## Kevinf (Jan 27, 2017)

DEmedic said:


> She never displayed any seizure like activity. At all. None. And an hour long postictal period is outside of anything if ever seen before. The hospital I took her to has 24 hour neuro and is THE stroke center for the metro. That's where (I believed) she needed to be. Not a stop at the local band aid station.



I've seen exactly one patient of mine present similar to yours, and I recorded a nearly 50 minute postictal state for her. Naturally, she became fully conscious and combative just after we transferred her to the ED bed. However I had the benefit of getting a history of poorly controlled seizures secondary to a traumatic brain injury in advance.


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## CWATT (Jan 28, 2017)

@DEmedic - what was your thought process behind that bolus?  Did you suspect high-spacing because of the low diastolic number?  Or was it b/c the First Responder reported a BP of 84/Palp (even though your initial vitals was 114/58)?


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## Akulahawk (Jan 29, 2017)

Given the presentation, I would have opted for the tertiary care center 50 minutes away. Why? The local hospital may be able to do a CT scan but once the patient becomes "theirs" they then have EMTALA to deal with and have to arrange for an appropriate destination, transportation, and the like. Sometimes this can take significant amounts of time especially if you have to wait for labs or you don't have an in-house Radiologist available. It sounds like you deduced that the closest, most appropriate destination was the Neuro/Stroke center that's 50 minutes away and by doing so you probably prevented an hour or two delay in getting the patient where she likely would have ended up anyway.

Good call!


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## StCEMT (Jan 29, 2017)

Too late for me to throw out a guess, but I would go to the further location for the reasons akulahawk listed.


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## BobBarker (Jan 29, 2017)

Akulahawk said:


> Given the presentation, I would have opted for the tertiary care center 50 minutes away. Why? The local hospital may be able to do a CT scan but once the patient becomes "theirs" they then have EMTALA to deal with and have to arrange for an appropriate destination, transportation, and the like. Sometimes this can take significant amounts of time especially if you have to wait for labs or you don't have an in-house Radiologist available. It sounds like you deduced that the closest, most appropriate destination was the Neuro/Stroke center that's 50 minutes away and by doing so you probably prevented an hour or two delay in getting the patient where she likely would have ended up anyway.
> 
> Good call!


I absolutely understand your method for the tertiary center. However, given the diagnosis, I don't think she "would have ended up there anyways". If the Level III can CT there, if there is no signs of a bleed/stroke and she has a seizure, they treat and workup accordingly. Once she woke up/found out about the seizure and her CT came back negative, they probably just would have admitted her there.


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## Akulahawk (Jan 29, 2017)

Billy D said:


> I absolutely understand your method for the tertiary center. However, given the diagnosis, I don't think she "would have ended up there anyways". If the Level III can CT there, if there is no signs of a bleed/stroke and she has a seizure, they treat and workup accordingly. Once she woke up/found out about the seizure *and her CT came back negative*, they probably just would have admitted her there.


Here's the rub: if her CT came back positive for a bleed... now  you've committed the patient to at least a 1-2 hour DELAY in getting the patient to definitive care and if the sending facility has instituted therapies that aren't in your scope of practice, the delay could be even longer. I see this stuff happen all the time. I work in a critical access hospital.


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## NomadicMedic (Jan 29, 2017)

CWATT said:


> @DEmedic - what was your thought process behind that bolus?  Did you suspect high-spacing because of the low diastolic number?  Or was it b/c the First Responder reported a BP of 84/Palp (even though your initial vitals was 114/58)?



I'm not quite following what you're asking and I'm not familiar with the term high spacing. 

Are you asking why I gave the patient a fluid bolus?


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## NomadicMedic (Jan 29, 2017)

Billy D said:


> I absolutely understand your method for the tertiary center. However, given the diagnosis, I don't think she "would have ended up there anyways". If the Level III can CT there, if there is no signs of a bleed/stroke and she has a seizure, they treat and workup accordingly. Once she woke up/found out about the seizure and her CT came back negative, they probably just would have admitted her there.



Nope. This patient would have been transferred to the Tertiary.


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## Carlos Danger (Jan 29, 2017)

Akulahawk said:


> Given the presentation, I would have opted for the tertiary care center 50 minutes away. Why? *The local hospital may be able to do a CT scan but once the patient becomes "theirs" they then have EMTALA to deal with and have to arrange for an appropriate destination, transportation, and the like. Sometimes this can take significant amounts of time especially if you have to wait for labs or you don't have an in-house Radiologist available.* It sounds like you deduced that the closest, most appropriate destination was the Neuro/Stroke center that's 50 minutes away and by doing so you probably prevented an hour or two delay in getting the patient where she likely would have ended up anyway.



It shouldn't ever be like that for critical patients, and fortunately, many places it isn't. All it takes is a transfer agreement between the community hospital and tertiary one stating that the tertiary facility will automatically accept a patient once the time-critical diagnosis is made. It streamlines the logistics dramatically.


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## Akulahawk (Jan 29, 2017)

Remi said:


> It shouldn't ever be like that for critical patients, and fortunately, many places it isn't. All it takes is a transfer agreement between the community hospital and tertiary one stating that the tertiary facility will automatically accept a patient once the time-critical diagnosis is made. It streamlines the logistics dramatically.


You're right, it shouldn't be like this. Unfortunately sometimes even with a transfer agreement in place things don't go smoothly, such as those times when you're out of ground transport options because the EMS system won't allow you to use a 911 unit for these time-critical patients and when your IFT units are all unavailable... it's bad. Happens too often.


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## CWATT (Jan 29, 2017)

DEmedic said:


> Are you asking why I gave the patient a fluid bolus?



Yes.


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## NomadicMedic (Jan 29, 2017)

Because she was hypotensive, had signs of poor perfusion and was altered.


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