# 60 yo "Sick Person"



## Lady_EMT (Feb 9, 2011)

It's 03:00 in a rural country town. You and your partner are woken from your sleep by the tones, dispatched to a 60yo male sick person. You and your partner are an ILS crew (both of you are EMT-I/AEMTs). It's dispatched as a code 1 response. You get there to find a 60 yo male, laying in bed. Pt had surgery 9 days prior on his intestine. Pt is AOX3, and able to answer all questions given to him. Pt stated that he was having some minor abdominal pain, was feeling weak, and his stomach was a little unsettled. Pt complaining of minor diff breathing, and to cover your ***, you call the medic. You obtain a set of vitals:

HR- 66
BP- 120/60
RR- 18
Rx- Magnesium Nitrate
Augmentin
Laxatives

Hx-Surgery 9 days ago

Allergies- NKA

You and your partner transfer the pt from the bed to the stretcher. Upon moving the pt, he starts to complain of some nauseousness. As you begin rolling the stretcher out of his room, pt suddenly goes unconscious, and is only responsive to painful stimuli. Pt starts to come back, grabs you by the collar of your shirt, pulls you in close, and goes entirely unresponsive. Your partner goes over the radio and asks the medic to step it up to a Code 3 response. You obtain another set of vitals.

HR- 80
RR- 14
(*All further vitals were obtained by the medic)

The medic arrives on scene as you are loading the pt into the ambulance. Your partner establishes an 18g IV, and you turn around to grab something from the cabinet, and when you turn back to look at the pt, there is pink frothy sputum coming from his mouth. The medic attaches his monitor, and tells us to get him to the hospital ASAP. So your partner jumps up front, and you get in the medic car to follow the ambulance.

You hear the medic patch into the hospital, telling them to prep for a code.

You arrive at the hospital, open the back doors of the ambulance to find the medic bagging the pt. (Patient still has a pulse/is breathing, but is still totally unresponsive.) You transfer care to the ER staff, and your job is done.


Given the information, what is your opinion on what happened to the patient?


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## MrBrown (Feb 9, 2011)

Pulmonary edema


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## bigbaldguy (Feb 9, 2011)

Bear in mind I'm just a basic so don't hammer me too hard but could it be sepsis related to the surgery. Other thing that jumps to mind would be a bowel obstruction of some kind based on the use of laxatives and abdominal discomfort.


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## bigbaldguy (Feb 9, 2011)

Lady_EMT said:


> Pt complaining of minor diff breathing, and to cover your ***, you call the medic.
> 
> and when you turn back to look at the pt, there is pink frothy sputum coming from his mouth.



Your right Pulmonary edema fits these symptoms. Sorry I wish to withdraw my dumb answer.


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## Lady_EMT (Feb 9, 2011)

MrBrown said:


> Pulmonary edema



I'm sure that the cause of this whole thing lead to some pulmonary edema, but it isn't the main issue this guy is dealing with.

And, when the pt began complaining of diff breathing, my partner auscultated his lungs, and they were clear. The medic also checked, and found the same result.

When/If someone guesses, obviously I'll chime in =)



> Bear in mind I'm just a basic so don't hammer me too hard but could it be sepsis related to the surgery. Other thing that jumps to mind would be a bowel obstruction of some kind based on the use of laxatives and abdominal discomfort.



Not a dumb answer. And it does have something to do with the surgery.


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## bigbaldguy (Feb 9, 2011)

Low potassium from an overdose of the laxatives? Again just a shot in the dark. It might explain the LOC and maybe the Nausea. I can't remember anything else about low potassium except that it can be brought on by severe diarrhea and laxative overdose and it causes fainting (I don't want to cheat and use google).

Oh and if I do say something that is way off the mark please let me know so that I can learn from it.


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## medicRob (Feb 9, 2011)

H202 production by the small intestine caused by surgical stress resulting in ever-increasing levels of xanthine oxidase-dependent H202 in the mesenteric lymph which then enters the lungs where it increases the overall permeability of the capillaries directly contributing to pulmonary edema.


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## bigbaldguy (Feb 9, 2011)

medicRob said:


> This is just a shot in the dark, but would this have anything to do with surgical stress  inducing H202 production by the small intestine increasing levels of H202 in the mesenteric lymph resulting in xanthine oxidase-dependent H202 entering the pulmonary circulation where it increases the permeability of the capillaries directly contributing to pulmonary edema?



Oh well now that just makes my answer sound silly. I am so out of my league here. I'm gonna go play with my legos


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## Lady_EMT (Feb 9, 2011)

medicRob said:


> H202 production by the small intestine caused by surgical stress resulting in ever-increasing levels of xanthine oxidase-dependent H202 in the mesenteric lymph which then enters the lungs where it increases the overall permeability of the capillaries directly contributing to pulmonary edema.



Nope, it actually had nothing to do with his lungs. 
Let's focus for on the abdominal cavity.


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## medicRob (Feb 9, 2011)

Lady_EMT said:


> Nope, it actually had nothing to do with his lungs.
> Let's focus for on the abdominal cavity.



I was focused on the abdominal cavity. 

Rationale for my train of thought: 

Pink frothy sputum is a classic symptom of pulmonary edema. You said that your patient had intestinal surgery 9 days earlier and that the condition was related to the surgery. There were several studies which indicated that the surgical stress associated with intestinal surgeries (particularly those involving handling of the small intestines) resulted in the production of factors (particularly H202) into the mesenteric lymph where it then entered into the lungs and increased the permeability of the pulmonary capillaries thus resulting pulmonary edema. 

References:

*Hydrogen Peroxide Derived From Intestine Through the Mesenteric Lymph Induces Lung Edema After Surgical Stress*
_Nakamura, Masakatsu; Motoyama, Satoru; Saito, Satoshi; Minamiya, Yoshihiro; Saito, Reijiro; Ogawa, Jun-ichi_

Ogawa M: *Mechanisms of the development of organ failure following surgical insult: the second attack theory.*_ Clin Intensive Care 7:34-38, 1996._

Anup R, Aparna V, Pulimood A, Balasubramanian KA: *Surgical stress and the small intestine: role of oxygen free radicals.* _Surgery 125:560-569, 1999_.

Anyways, back to the scenerio: 


Can you give me some more information about the type of surgery the patient had? What does the wound look like? Do you appreciate any abnormalities (Dehissance, swelling, redness?)


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## Lady_EMT (Feb 9, 2011)

medicRob said:


> I was focused on the abdominal cavity.
> 
> My Rationale for my train of thought:
> 
> ...


_

No abnormalities noted. Upon palpation, only minor tenderness noted. Wound looked fresh (as it was only 9 days old). I believe the surgery was to remove a portion of his small intestine. 

And thanks for the references, I'll look into them. Always open to learn something new!_


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## MediMike (Feb 10, 2011)

Don't got much time but I'm gonna throw a PE into the mix...


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## seekersofthetruth (Feb 10, 2011)

MediMike said:


> Don't got much time but I'm gonna throw a PE into the mix...



I am thinking that as well due to the fact that they dont state that the pt was on any anticoagulants post-op. But that seems like a rather acute filling of Pulmonary Edema for a Pulmonary Embolism? Yes? No?

Was the Cardiac Monitor on the Pt when they had their periods of unresponsiveness? This makes me think of some sort of Cardiac Dysrhythmia with poor Cardiac Output during those intervals?

Skin Color? Fever?

Was he on the Augmentin for post-op recovery to fight infection or pneumonia?

I am just a curious student, dont mind me.


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## Aidey (Feb 11, 2011)

It is possible the blood thinners were left off the med list. The inclusion of magnesium nitrate on the list makes me suspect its accuracy, since that form of magnesium isn't used as a human supplement. That is the form of magnesium found in fertilizer and those little "Do not eat" packets found in packaged goods.


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## seekersofthetruth (Feb 11, 2011)

Oh I thought it may have just been a typo on the pt's medication list for Magnesium Citrate since it is a laxative.


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## Shishkabob (Feb 11, 2011)

Pulse ox?  Etco2?


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## 325Medic (Feb 11, 2011)

Sepsis leading to ARDS, 12-LEAD? P/E?


325.


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## Bosco578 (Feb 11, 2011)

Need more info, further vitals, any other past med hx? Flash PE?, :unsure:


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## Lady_EMT (Feb 11, 2011)

Unfortunately, those are all the vitals I have, due to the transfer of care to the medic. 
And the magnesium I can't explain, I took the med names from the wife/gf. 

That's all the history I obtained before the pt went downhill. I usually get most of my information in the back of the ambulance, and do a second discussion with the pt to make sure all the information was correct. 

Well, I followed up with our Medical Director, and I guess he had torn the internal closure for his intestine. He had torn it open, and was suffering from major internal bleeding. He had finally stopped compensating. The rushed him to the OR after we brought him in. He was in the ICU for a couple of weeks, and ended up being fine and leaving the hospital to go home. The med director told us he was stunned that the man survived, seeing as how severe the bleed was. He didn't say anything about PEs, infections, etc. Just the bleed. 

But now I have a question after reading some of the responses:

Why would he be excreting the frothy blood? Since there was nothing going on in his lungs, where would the froth be coming from?


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## Shishkabob (Feb 11, 2011)

Lady_EMT said:


> Why would he be excreting the frothy blood? Since there was nothing going on in his lungs, where would the froth be coming from?



During a sickness, it isn't just individual systems that are affected.


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## medicRob (Feb 11, 2011)

Lady_EMT said:


> Unfortunately, those are all the vitals I have, due to the transfer of care to the medic.
> And the magnesium I can't explain, I took the med names from the wife/gf.
> 
> That's all the history I obtained before the pt went downhill. I usually get most of my information in the back of the ambulance, and do a second discussion with the pt to make sure all the information was correct.
> ...



See my posts on xanthine-oxidase dependent H202 and second attack theory caused by surgical stress of the small intestine.


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