# 49 yo C/C of N/V x3 days



## Handsome Robb (Dec 17, 2011)

Alrighty I'll give it a go. Not a brain twister by any means just wondering what you all would have done. I'll start off slow and add what we did in as responses come.

Toned out priority 2 for shortness of breath. Upon arrival you find a 49 yo female pt in bed. Pt complains of severe N/V x 3-4 days, denies diarrhea. States "I can't keep anything down, not even water"
H: of left arm amputation after a MVA 15 years ago, IDDM, HTN, asthma.
A: Penicillin
M: Methadone, oxycodone, endocet, insulin, albuterol.

Vitals: 200/120, ST @ 140 without ectopy on the monitor, RR ~30, BGL comes back as "Hi" on the glucometer, SpO2 @ 90 on RA. 

What else do you want?


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## STXmedic (Dec 17, 2011)

To start: End-Tidal? Urine output? Skin turgor? Temp? Breath sounds? Compliance with meds? Any complaints of pain?


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## Arovetli (Dec 17, 2011)

Breath sounds/physical exam findings? 12 Lead, Capno, Temp? Med compliance and last oral intake that wasn't vomited.


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## usafmedic45 (Dec 17, 2011)

Blood sugar is the answer to almost the entire presentation.  Nausea and vomiting and a relative dehydration are common findings in hyperglycemia.  Stick an IV in her, start rehydration and get her to the hospital where they can do something about that blood sugar.


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## Arovetli (Dec 17, 2011)

usafmedic45 said:


> Blood sugar is the answer to almost the entire presentation.  Nausea and vomiting and a relative dehydration are common findings in hyperglycemia.  Stick an IV in her, start rehydration and get her to the hospital where they can do something about that blood sugar.



Agree and prudent initial course of action based on what is presently known.


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## usafmedic45 (Dec 17, 2011)

Arovetli said:


> Agree and prudent initial course of action based on what is presently known.


It's about the only course of action we have in the field unless you can do a blood gas and give insulin.  Some anti-nausea meds might be in order as well.


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## Arovetli (Dec 17, 2011)

Assuming the only pertinent data is that which is listed in the OP, a little O2, IV, fluids and tx.


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## usafmedic45 (Dec 17, 2011)

Arovetli said:


> Assuming the only pertinent data is that which is listed in the OP, a little O2, IV, fluids and tx.



Why O2?  Her sat is at or above 90.  It would be of marginal benefit in this case if at all.


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## Arovetli (Dec 17, 2011)

Local protocol specifies <94% automatic O2. I agree with you though, little clinical significance.


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## usafmedic45 (Dec 17, 2011)

Arovetli said:


> Local protocol specifies <94% automatic O2. I agree with you though, little clinical significance.



Ah....our protocols were below 88-90% in adults or below 92-94% in kids depending upon the associated situations.


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## Arovetli (Dec 17, 2011)

OP, would still like to know exam findings, med compliance, urine output etc.


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## Handsome Robb (Dec 17, 2011)

Arovetli said:


> OP, would still like to know exam findings, med compliance, urine output etc.



Slow your roll, turbo! I'm about to leave for work so this might not be exactly what you want. 

Pt states UO is minimal to none and very dark and "stinky", no pain/burning on urination.

No sidestream end-tidal on our ground units, sorry Poetic :/

Skin is pale, dry and hot. No tenting though but the pt just feels very very dry, mucousal membranes dry and lips chapped. 

Clear breath sounds bilaterally.

Usually is compliant with meds however has been unable to keep anything down x4 days so no over the last 4 days, specifically the atenolol. Pt didnt know if she should take her insulin if she hasn't been able to eat so she hasn't taken it in "a couple of days"

No complaints of pain.

We didn't capture a 12-lead, sorry.

So her BS are clear bilat and RR is regular and unlabored, why the low SpO2? Oxygenation problem? or volume problem? or both?

Alright tx wise I got a 24 in her thumb, poor dear  
Started 1000mL bag of cool NS.
2 lpm via NC boost SpO2 to 93ish. 
We get 4 mg zofran on board.

What else would you like to know?


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## truetiger (Dec 17, 2011)

I'd be interested to see a cap waveform. Been compliant with her albuterol?


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## Simusid (Dec 17, 2011)

Hot, tachy, and hypertensive.   Isn't this also a possible triad for sepsis?  I'm probably way off base.   If I'm wrong I want to make sure I purge that from my brain.


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## 18G (Dec 17, 2011)

Sepsis presents as HYPOtension due to increased vascular permeability from the toxins present. Third spacing occurs with fluid leaving the vascular space. Also, septic patients can very well have decreased body temperature. 

Hypertension in this case is coming from the pt. having a history of HTN, pt. has not taken her atenolol, and the fact her heart rate is tachycardic in 140's... an increase in HR will yield increase in B/P (case depending). 

Sounds like DKA with profound dehydration. Treatment as already specified... fluid bolus's and Zofran. I would have done a 12-lead just to see if it showed any indication of hypokalemia. Granted, we won't fix that it the field but is worth noting.

I am noticing that the N&V started prior to the pt. not taking her insulin. So obviously something was causing her N&V which wasn't blood sugar related initially. Sounds like an infection or some sort which led to N&V and the patient becoming non-compliant with meds resulting in the HTN and DKA. I would obtain temp and get tylenol onboard also if time permitted.


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## STXmedic (Dec 17, 2011)

18G said:


> I am noticing that the N&V started prior to the pt. not taking her insulin. So obviously something was causing her N&V which wasn't blood sugar related initially. Sounds like an infection or some sort which led to N&V and the patient becoming non-compliant with meds resulting in the HTN and DKA. I would obtain temp and get tylenol onboard also if time permitted.


Agreed. DKA, dehydration, and concurrent UTI (considering presentation of UO) possibly. Several electrolyte abnormalities would be expected as well. All we'd really do in the field is IV, NaCl, Zofran and transport. BP is probably elevated 2/2 recent noncompliance with meds. Tachy from possible Infxn and dehydration. Just my .02. Without more info, there isn't too much more to pull (though I doubt there's too much more to pull anyway)


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## Fish (Dec 17, 2011)

Hyperglycemic, treat with NS and Zofran for Nausea. Make sure she brings her toothbrush cause she will be in the Hosp a few days.

Keep monitor on patient the entire time as it is important to continually evaluate a rythm on a hyperglycemic


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## Handsome Robb (Dec 17, 2011)

I agree with everyone on the DKA and profound dehydration. Not a whole lot we are going to do for her. 

simusid - like 18g said sepis would present with hypotension not hypertension, now with a hx of HTN she may not be as hypo as you would expect to see but seeing as she was 200 systolic I highly doubt she was septic. 

Like I said this wasn't supposed to be a brain twister, I was just wondering opinions.

Poetic why UTI? I agree with an infection but I feel like the UO or lack thereof would be secondary to the little to no intake of fluids. My partner thought she might have been on the border of renal failure as well.


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## mycrofft (Dec 17, 2011)

*Parse.*

Urinary hx, glucometry and dryness say start IV, transport. I do not know off hand if Zofran interferes with diabetic situations. Do not get into trying to balance insulin in the field, the fluids will keep her going until a nice endocrine lady or guy can get her started where they can teeter-totter her fingersticks versus her insulin.

Now, absent the obvious IDDM and dehydration (which can lead to renal failure), the narcotics could be doing it. I would also ask about dizziness, maybe have her stand under immediate protection and see if she can even stand up; vestibulitis or labrynthitis could be doing it too. Folks with then "dizzybarfs" would not tend to be eating much; if she did have a vertigo AND did her insulin, then it shouldn't be "HI".

Also, other causes have not been ruled out, but the field EMS answer is hydrate, comfort, and drive humanely to the hospital.


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## STXmedic (Dec 17, 2011)

NVRob said:


> Poetic why UTI? I agree with an infection but I feel like the UO or lack thereof would be secondary to the little to no intake of fluids. My partner thought she might have been on the border of renal failure as well.



LoL because I'm sleep deprived  I associated the dark and foul smelling urine with UTI instead of DKA. So yeah, still will probably get checked, but not as likely as I was thinking when I posted


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## mycrofft (Dec 17, 2011)

*Still could be both.*

But cutting to the chase, still you address the dehydration and comfort issues and transport promptly, code 1.

But then, I wonder if ketones in urine would act bateriocidally?


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## Handsome Robb (Dec 17, 2011)

mycrofft said:


> Urinary hx, glucometry and dryness say start IV, transport. I do not know off hand if Zofran interferes with diabetic situations. Do not get into trying to balance insulin in the field, the fluids will keep her going until a nice endocrine lady or guy can get her started where they can teeter-totter her fingersticks versus her insulin.
> 
> Now, absent the obvious IDDM and dehydration (which can lead to renal failure), the narcotics could be doing it. I would also ask about dizziness, maybe have her stand under immediate protection and see if she can even stand up; vestibulitis or labrynthitis could be doing it too. Folks with then "dizzybarfs" would not tend to be eating much; if she did have a vertigo AND did her insulin, then it shouldn't be "HI".
> 
> Also, other causes have not been ruled out, but the field EMS answer is hydrate, comfort, and drive humanely to the hospital.



She was able to ambulate with assistance to our gurney. We D/C'd the NIBP prior to the move so no orthostatics...partial fail on our part but even then it wouldn't have changed the treatment pattern. I don't remember offhand if the ambulation provoked dizziness or not.

edit: as for the zofran interfering with diabetic situations either. The aggravation of the FDA claimed prolonged QT from zofran along with presumed electrolyte imbalances crossed my mind but no abnormalities were noted on the printed 4-lead strips although it is non-diagnostic.


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## usafmedic45 (Dec 17, 2011)

> I associated the dark and foul smelling urine with UTI instead of DKA.





> Pt states UO is minimal to none and very dark and "stinky",



Myoglobinuria most likely due to rhabdomyolysis.....how long has she been in bed?




> DKA, dehydration, and concurrent UTI (considering presentation of UO) possibly.



I'm with you on the first two but I'm not so sure about the third one until I see an UA.


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## Handsome Robb (Dec 17, 2011)

usafmedic45 said:


> Myoglobinuria.....how long has she been in bed?



Pt stated 4 days but she had been up and about, albeit very minimally. 

That's a good thought too, didn't think of that. Rhabdo + DKA could end very badly. She was definitely one of the more sickly patients I have seen in my short career h34r:


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## mycrofft (Dec 17, 2011)

*Oh, yeah. With renal shutdown rounding the clubhouse turn.*

If they could dip the urine it would test positive for haemoglobin, if the orange tint didn't confound the reading. (Serial dilution in the kitchen sink...nekulturny). But, field treatment the same.

How about hepatic failure? Stink like ammonia, or like foetid urine, or like canned pears? Never mind, the ER will get a suprapubic or a cath catch and have the whole deal on a cracker in no time.


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## usafmedic45 (Dec 17, 2011)

NVRob said:


> Pt stated 4 days but she had been up and about, albeit very minimally.
> 
> That's a good thought too, didn't think of that. Rhabdo + DKA could end very badly. She was definitely one of the more sickly patients I have seen in my short career h34r:



Rhabdo even in a patient with normal kidney function and no risk factors for kidney failure is a bad situation.


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## Handsome Robb (Dec 17, 2011)

mycrofft said:


> If they could dip the urine it would test positive for haemoglobin, if the orange tint didn't confound the reading. (Serial dilution in the kitchen sink...nekulturny). But, field treatment the same.
> 
> How about hepatic failure? Stink like ammonia, or like foetid urine, or like canned pears? Never mind, the ER will get a suprapubic or a cath catch and have the whole deal on a cracker in no time.



With the chronic pain medication use hepatic failure is a viable option. Pt stated she did not abuse them and with a quick gander at the containers her statement was confirmed. Not to say that she didn't abuse them in the past. Also her husband was *hammered* and this was at around 1300. Without passing judgement this could indicate alcohol abuse with the environment she lived in. They had been married for 20 yrs IIRC. 



usafmedic45 said:


> Rhabdo even in a patient with normal kidney function and no risk factors for kidney failure is a bad situation.



Haha point, set and match. With hyperK I would expect to see a widened QRS and it was not, but again this was a 4-lead.

edit: correct me if I'm wrong about the ECG changes associated with HyperK.


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## Smash (Dec 17, 2011)

It's worth remembering that sepsis does not require hypotension to diagnose (hypotension being a sign of severe sepsis), and that the initial stages of sepsis are typically hyperdynamic, with bounding pulses and good or even high systolic blood pressures.

Sepsis and DKA also like to hang out together causing mischief.

However even if the precipitant was a UTI, (and it is an if, I'm not arguing that UTI is here, merely that one shouldn't write it off automatically) the treatment, particularly from an out of hospital perspective is the largely the same anyway.


Hyperkalemia induced ECG changes depend in part on how high the K is, but yes, wide, slow rhythms occur (amongst other nastiness).


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## 18G (Dec 18, 2011)

Hyperkalemia on ECG will vary based on level of K+. Tall, peaked T-waves are one of the earlier signs along with flattened P-waves. As the K+ increases the QRS widens and can turn into what is commonly described as a "sine wave" pattern.


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