# Endometrial Hyperplasia



## vquintessence (Nov 7, 2009)

You are a dual Paramedic unit.
Approximately at 13:00 you're dispatched to intercept with a FD BLS Rescue already en route to local level 3 facility.  Call comes in as syncope.  En route the Rescue provides no updates, but asks you to continue.

U/A you find a 37 y/o female AOx3 speaking full sentences and semi-fowler.  Woman presents very pale and notably lethargic; pt has to be continually prompted to answer questions and remain alert.  Pt only offers a complaint of abd pain.

BLS relays pt was about to under go a biopsy in a physicians medical office for endometrial hyperplasia.  They state the physician had ordered/given:  diazepam 10 mg PO (this morning self administered by pt) and demerol 50 mg IM.

About twenty minutes after demerol, pt found by staff to be profoundly lethargic, at which point EMS was activated.

BLS relays pts only PMHx is "thickened uterus", takes no medicates, denies allergies.  Their vitals prior your arrival:  120/62, 72 HR, 15 RR.  The EMT teching denies any changes in status while in their care, and the driver offers a nearly inaudible apology for "wasting your time".

How would you proceed based on your initial findings, and the story relayed to you?  Transport time is completely irrelevant...
[After a few treatments and options are followed, I'll go with the crews actual findings and field treatment.]


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## Onceamedic (Nov 7, 2009)

IV, O2, monitor and narcan.  The endometrial hyperplasia is a bit of a red herring, as the pts vitals do not support hypovolemic shock.


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## Griff (Nov 7, 2009)

I would need detailed assessment findings and an ECG to make a more definitive treatment decision. Regardless, I agree with the above poster; IVO2Monitor (one word  ) and transport. I wouldn't give narcan in route unless noted respiratory depression was observed (which it doesn't seem to be), and that is the protocol here (it might be different somewhere else).


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## RyanMidd (Nov 7, 2009)

I would also give the "driver" a smack, because no altered LOC is a "waste of time".

But second the previous Tx - Narcan, O2, position of comfort, and keep an eye on BP change.


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## JPINFV (Nov 7, 2009)

If V/S are good and the patient is A/Ox3 (Guess here, this is a location that favors A/Ox3 over A/Ox4), why Narcan?



RyanMidd said:


> I would also give the "driver" a smack, because no altered LOC is a "waste of time".









Sorry... can't find a Gibbs head slap LOLcat picture.

/I can haz Caterday?


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## RyanMidd (Nov 7, 2009)

JPINFV said:


> If V/S are good and the patient is A/Ox3 (Guess here, this is a location that favors A/Ox3 over A/Ox4), why Narcan?



Because you asked her if she had taken any of her own medications, and she said no. Obviously she's a liar and a thief!


But really, though? In a case of altered LOC with recent physician interaction, perhaps the Dr. made a "whoopsie", and the Narcan will cancel out that mistake.


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## mycrofft (Nov 7, 2009)

*Pallor, lowered LOC but not hallucinating, belly pain and normal VS.*

It's dark in there, get her to a hospital.

No pupillary info, no capillary refill, no belly exam or ausc, no chest ausc. No characterization of pulses (bounding, regular, thready, irregular,) nor resps. Not to fault you, probably fine and discounted mentally, but I'm not there. Back or shoulder pain? Pedal pulses compared and characterized? Gums or mucosae pale or red? Temperature?

C/O plus signs suggests something is interfering with brain perfusion, maybe all over.

If the pt has endometriosis then her menstrual hx would be of interest to the ER staff.

OK...GIVEN transport time no matter, O2 can't hurt,monitor is good idea along with frequent BP's, Naloxone not indicated strictly by this hx and could cause repercussions with demerol, IV not indicated since VS ok and no parenteral route tx indicated so far. If transport time is a factor, get a line started with large bore needle. Fingerstick glucometry not a bad idea if obtunded but VS are good. Ask if pt has been sleeping ok.


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## Griff (Nov 7, 2009)

RyanMidd said:


> Because you asked her if she had taken any of her own medications, and she said no. Obviously she's a liar and a thief!
> 
> 
> But really, though? In a case of altered LOC with recent physician interaction, perhaps the Dr. made a "whoopsie", and the Narcan will cancel out that mistake.



Narcan is used in my region solely to correct respiratory depression secondary to opiate overdose. Perhaps your protocols are different, but I agree with JPINFV that naloxone isn't indicated in this case based on the available information. I would guess that benzodiazapine/opiate administration has caused potentiation of limbic system inhibition, resulting in the AMS without the pronounced respiratory depression noted with opiate overdose. I would certainly monitor vitals and keep the narcan handy, but I would only give it if protocols indicated (which mine do not). Just my $0.02. ^_^


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## mycrofft (Nov 7, 2009)

*Second Griff. Better said than mine.*

Unilateral signs? Speech slurred, or slow but distinct?


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## JPINFV (Nov 7, 2009)

RyanMidd said:


> Because you asked her if she had taken any of her own medications, and she said no. Obviously she's a liar and a thief!
> 
> 
> But really, though? *In a case of altered LOC *with recent physician interaction, perhaps the Dr. made a "whoopsie", and the Narcan will cancel out that mistake.



That's my question, though. Given that some systems use A/Ox3 as being fully alert and oriented, it doesn't sound like she's altered any more based on the scenario as given. Additionally, her respiratory system isn't being depressed. Altogether, this makes me question whether administering Narcan would produce any positive benefits short of being one step closer to being able to bill ALS2. 

Similarly, let's assume for a second that she's A/Ox1 (hence clearly altered) with the same vital signs. Still, what benefit would be had by giving Narcan? Sure, she's more alert and oriented, but you haven't changed her ability to load oxygen and unload carbon dioxide. The only thing you've done would be to bring her more into the world of the living while increasing her pain level by decreasing the effectiveness of her pain control.


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## Shishkabob (Nov 7, 2009)

Need more info. BGL? O2 sat?  Etco2?



It's not only the rr we're looking for, but also how effectual they are.


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## vquintessence (Nov 7, 2009)

*Sorry for delay*

AOx3 is the same as systems using AOx4 (sorry for not clarifying).

Neurological:  Speaking full and coherent sentences; -dysphasia, -dysarthria.  There are no auditory or visual hallucinations.  Pupils PERRL bilat; tracking appropriately on command and conjugate.  As far as sensory and motor there are no deficits, there's nothing atypical to note.  Pt is notably lethargic.

Rapid Assessment:  No trauma whatsoever in present or recent past.  All extremities stable however cap refill is delayed; nailbeds blanched.  Skin condition is pale/cool/dry.  Abd is not distended and palpation reveals guarding all quadrants; pain gets no worse nor better during palpation for all quadrants. (Sorry Mycrofft no gastric sounds checked).

Pulmonary:  No respiratory distress, lungs CTA bilat.  RR is appropriate and has adequate tidal volume.  spO2 99% on O2 at 2 l/min via NC.  There is no Etco2 available for this system.

Vitals:  RBG is 104 mg/dL.  As yall suggested, and based on the young pt presenting like crap, you obtain your own vitals and it's drastically different from what was reported.

BP is 76/P which is obtained c difficulty due to weak radial pulse; it is very difficult to auscultate in the moving ambulance.  Pulse is staying in high 40's, confirmed by palpation and EKG.  a 12 lead reveals Sinus Bradycardia.  There is no aberrancy or ectopy to the rhythm.  No AV blocks.  No axis deviation, -BBB.

Course of action?

P.S.  Transport time being irrelevant was only meant to prevent any cop outs for assessing/treating.


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## Griff (Nov 7, 2009)

JPINFV said:


> That's my question, though. Given that some systems use A/Ox3 as being fully alert and oriented, it doesn't sound like she's altered any more based on the scenario as given. Additionally, her respiratory system isn't being depressed. Altogether, this makes me question whether administering Narcan would produce any positive benefits short of being one step closer to being able to bill ALS2.
> 
> Similarly, let's assume for a second that she's A/Ox1 (hence clearly altered) with the same vital signs. Still, what benefit would be had by giving Narcan? Sure, she's more alert and oriented, but you haven't changed her ability to load oxygen and unload carbon dioxide. The only thing you've done would be to bring her more into the world of the living while increasing her pain level by decreasing the effectiveness of her pain control.



This is exactly my point; the (possible) reversal of opiate-induced AMS (assuming the Demerol alone is causing it) seems like a fairly weak benefit compared to the potential cost of reducing analgesia. Her vitals are WNL with opiates on board and reduced analgesia could compromise that stability (i.e. elevated BP, RR, HR secondary to poor pain control). Clinically, we don't stand to gain a whole lot from naloxone administration (maybe a better history from the pt); the cost versus benefit analysis (let alone protocol) simply does not indicate Narcan, in my opinion.

<RANT>
To get off-topic for just a second (sorry, I realize that Narcan has been beaten to death around here  ), I see a lot of medic students (I am a student myself) wanting to push Narcan whenever possible. The most important point my instructors (who, unlike me, are quite experienced paramedics) have instilled in me is this: just because we can doesn't mean we should. Great clinicians operate with the "big picture" in mind and weigh the pros and cons of each intervention. 
</RANT>


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## lightsandsirens5 (Nov 7, 2009)

Griff said:


> Narcan is used in my region solely to correct respiratory depression secondary to opiate overdose. Perhaps your protocols are different, but I agree with JPINFV that naloxone isn't indicated in this case based on the available information. I would guess that benzodiazapine/opiate administration has caused potentiation of limbic system inhibition, resulting in the AMS without the pronounced respiratory depression noted with opiate overdose. I would certainly monitor vitals and keep the narcan handy, but I would only give it if protocols indicated (which mine do not). Just my $0.02. ^_^


 
Same here. Although I have wanted to give it to some CAO pts just to ruin their impending high or whatever!


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## Griff (Nov 7, 2009)

vquintessence said:


> AOx3 is the same as systems using AOx4 (sorry for not clarifying).
> 
> Neurological:  Speaking full and coherent sentences; -dysphasia, -dysarthria.  There are no auditory or visual hallucinations.  Pupils PERRL bilat; tracking appropriately on command and conjugate.  As far as sensory and motor there are no deficits, there's nothing atypical to note.  Pt is notably lethargic.
> 
> ...



LOL now naloxone (and possibly flumazenil) is indicated. Did we get a med hx, especially in regards to how long pt has been prescribed diazepam? Any needle tracks? What is her temperature?
I would consider giving this pt atropine .5mg every five minutes up to .04mg/kg or until hemodynamically stable as per protocol.


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## mycrofft (Nov 7, 2009)

*Support vitals and boogey.*

Blood's in the pelvis or the abd. Thinking a bleed disguised by uteral c/o.
Any women getting into this discussion?

PS: I'm thinking of the change in vitals as diagnostic, not a sign of medical incompetence.


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## Shishkabob (Nov 7, 2009)

Screw atropine, she already has analgesics on board, go right to the pacing


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## Shishkabob (Nov 7, 2009)

My edit button disapeared??


She's obviously near decompensated shock if not in it, so 2 large bore ivs with fluid running in to get bp around 90


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## Griff (Nov 7, 2009)

Linuss said:


> My edit button disapeared??
> 
> 
> She's obviously near decompensated shock if not in it, so 2 large bore ivs with fluid running in to get bp around 90



Good point. ^_^


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## VentMedic (Nov 7, 2009)

RyanMidd said:


> Because you asked her if she had taken any of her own medications, and she said no. Obviously she's a liar and a thief!


 
Why is the patient a liar?  These meds were orderd by a physician at a facility.  




RyanMidd said:


> But really, though? In a case of altered LOC with recent physician interaction, perhaps the Dr. made a "whoopsie", and the Narcan will cancel out that mistake.


 
Why would you say it is a "whoopsie" or an error by the physician?  The meds and dosages ordered are not abnormal.   Some patients just react differently to other medications.  As well, if you only focus on one area you could miss something else in the assessment.


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## daedalus (Nov 7, 2009)

VentMedic said:


> Why is the patient a liar?  These meds were orderd by a physician at a facility.
> 
> 
> 
> ...



Vent, dont you know???


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## vquintessence (Nov 7, 2009)

The diazepam was ordered by the physician to be taken starting this morning and to continue after biopsy.  Temperature unavailable, only have skin condition to go by.  Socially, this pt is ostensibly an upstanding citizen.  Appears well nourished, well kept and is very articulate.  No physical indicators of drug abuse are observed.

As Mycrofft mentioned, the menstrual cycle is pertinent to the procedure that was going to be performed.  For simplicity the pt has had troubles with her cycle for years and years.

So far yall have given three possible working dx's and treatments:  OD, bradycardia secondary to ?, and internal hemorrhaging being masked by circumstances.  I apologize for offering the information in pieces;  I just didn't want to inadvertently point the discussion towards to final diagnosis or crews actual treatment.

Just picking your brain Griff, how much Narcan would you administer until you get the pt to your comfort level?  Flumazenil for diazepam 10 mg PO?

Linuss, how aggressively will you treat the hypotension/bradycardia?  I got confused by the sarcastic pacing then fluid loading.  ^_^


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## Onceamedic (Nov 7, 2009)

I didn't give details for my reasoning because I wanted everybody to have a chance to rant...  I mean educate ^_^

Endometrial hyperplasia is most often caused by unopposed estrogen.  Typical patients are usually obese (fat cells produce estrogen) and/or perimenopausal - patient stated age of 37.  While distressing, the condition is no more painful than a very heavy period.  The bleeding is caused by constant shedding of an endometrial lining that does not have a chance to breakdown.  It is very rarely a sign of serious metastasis,  thus hypovolemia due to uncontrolled bleeding is not likely.
That left me with one option - which was an OD.


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## Griff (Nov 7, 2009)

vquintessence said:


> The diazepam was ordered by the physician to be taken starting this morning and to continue after biopsy.  Temperature unavailable, only have skin condition to go by.  Socially, this pt is ostensibly an upstanding citizen.  Appears well nourished, well kept and is very articulate.  No physical indicators of drug abuse are observed.
> 
> As Mycrofft mentioned, the menstrual cycle is pertinent to the procedure that was going to be performed.  For simplicity the pt has had troubles with her cycle for years and years.
> 
> ...



To be on the safe side (and the pt isn't going to enjoy this, but it's better than being dead I suppose)-

-Two LB IVs and start fluid replacement.
-Atropine .5mg IV titrated to HR of >60/min.
-Naloxone 2mg and monitor for effect, then another 2mg and monitor for effect. I'm looking for a change in mental status (is it caused by the demerol or not) and possibly a change in HR. I'm iffy on this one but going on the safe side because it's relatively safe and quick to do.
-Start pacing if HR doesn't improve with above Tx.
-Call for flumazenil orders if BP doesn't improve with fluids/atropine/opiate reversal/pacing; I'm thinking possible drug mix-up and the wrong benzo was given (unlikely but possible). Unlike the narcan, I'm worried about acute withdrawal effects with this drug and it is a last-resort option as far as I'm concerned.
-Diesel fuel


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## mycrofft (Nov 7, 2009)

*Did she die yet?*

I know.....
"Paraneoplastric syndrome", House MD"s answer to "subspace anomalies".


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## Aidey (Nov 7, 2009)

2mg Narcan at once? Wouldn't it be more prudent to maybe give .4mg at a time and titrate it to affect? If this is opiate induced giving 2mg of narcan at once has a good chance of making the pt sick. If it isn't opiate reduced you've just completely knocked out the pain management. Titrating it to affect will allow you to improve her vitals without making her miserable.

I should mention my MD sponsor is vehemently opposed to giving multiple mgs of narcan at once unless the pt is unconscious or not breathing. If you bring in a patient and you didn't try .4 or .8 before giving 2mg or more you better have a damn good explanation for him. 

I would probably do .8mg of narcan first, then a fluid bolus, then atropine....maybe. Hypotension is only one symptom of symptomatic bradycardia. Chest pain, SOB and decreased LOC are all symptoms also and if she doesn't have any of them I would be reluctant to treat with atropine. Yes the pt is lethargic, but that is very likely from the medications and not from the low BP, especially since she is lacking any of the other symptoms of symptomatic bradycardia. 

Also, has anyone found out if the Abd pain is chronic or new?


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## Griff (Nov 8, 2009)

Aidey said:


> 2mg Narcan at once? Wouldn't it be more prudent to maybe give .4mg at a time and titrate it to affect? If this is opiate induced giving 2mg of narcan at once has a good chance of making the pt sick. If it isn't opiate reduced you've just completely knocked out the pain management. Titrating it to affect will allow you to improve her vitals without making her miserable.
> 
> I should mention my MD sponsor is vehemently opposed to giving multiple mgs of narcan at once unless the pt is unconscious or not breathing. If you bring in a patient and you didn't try .4 or .8 before giving 2mg or more you better have a damn good explanation for him.
> 
> ...



Meh. 

That dosage is verbatim from my protocols (your protocols may be different). I am a student, which means I only have protocols to rest on (not experienced enough to be deviating without fully understanding the clinical implications of that deviation); I'm sure that opinions abound as to the pros and cons of narcan administration, but this is what my protocols advise me to do. In the same token, my protocols indicate atropine for hemodynamically significant bradycardia. Specifically, "hemodynamically significant" is not an "all or none" phenomenon.

TL;DR - Your service/med director/state may do things differently from mine.

http://www.adph.org/ems/assets/5thEdParamedicProtocols110209.pdf


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## JPINFV (Nov 8, 2009)

> These protocols are intended to guide the Emergency Medical Technician - Paramedic, in the treatments of patients.



First sentence of the protocol book. It's a guide, not a cookbook. I know your a student, but the sooner you start looking at it as a guide and not as a cookbook, the better. To be honest, if your best reasoning for an intervention is "because of protocol," then you should feel just a tad dirty afterward. Judgment? Sure, even if it's  a little off. Doing something because of a protocol? This should evoke an icky feeling. 

Now, to be clear, I'm not advocating a complete disregard for the protocol book. In the vast majority of patients, the treatment plan you develop for your patient should essentially mirror what the protocol book says. This is because the protocol book is the ideal treatment for the ideal patient. Most patients are ideal and there are plenty of patients that don't read the textbook. It's a psychological difference between you administering a treatment because you know it's the right treatment on it's own and administering the treatment because of a few characters in a printout, even if the treatments are the exact same.


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## Griff (Nov 8, 2009)

JPINFV said:


> First sentence of the protocol book. It's a guide, not a cookbook. I know your a student, but the sooner you start looking at it as a guide and not as a cookbook, the better. To be honest, if your best reasoning for an intervention is "because of protocol," then you should feel just a tad dirty afterward. Judgment? Sure, even if it's  a little off. Doing something because of a protocol? This should evoke an icky feeling.
> 
> Now, to be clear, I'm not advocating a complete disregard for the protocol book. In the vast majority of patients, the treatment plan you develop for your patient should essentially mirror what the protocol book says. This is because the protocol book is the ideal treatment for the ideal patient. Most patients are ideal and there are plenty of patients that don't read the textbook. It's a psychological difference between you administering a treatment because you know it's the right treatment on it's own and administering the treatment because of a few characters in a printout, even if the treatments are the exact same.



I'm not disagreeing with you; I use protocols as a starting point because that is what they are there for.


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## Aidey (Nov 8, 2009)

No, it's not an all or none, but when you only have one symptom of hemodynamicaly unstable bradycardia, and it may be caused by other things going on (as in this case, both the valium and demerol) you don't want to be too aggressive and over treat the pt. 

"Indicated" doesn't necessarily mean "mandatory to give". 

For example, say this was your patient and you only have a 5 minute transport. You don't want to push both narcan and atropine at once because then you will never know which drug it was that helped. So you decide to push narcan first. 

So you draw up the narcan, give it, call the hospital while waiting for it to have an affect, assess the affect, and then take vitals and by that time you are likely at the hospital. Giving atropine somewhere in there wouldn't give the narcan time to work and for you to properly assess its effects before the atropine took affect and you wouldn't have time to properly assess the atropine's effects either. So yeah, atropine is "indicated" but that doesn't mean that you have to give it no matter what.


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## Aidey (Nov 8, 2009)

On the same note of what JPINFV is saying using the protocols as a starting point doesn't necessarily mean that you have to start at the specified dose every single time*

Aside from narcan, another medication that may be better to give under the protocol's starting dose is dextrose. Our hypothetical protocol states "For CBG lower than 60, or in a symptomatic patient administer 25mls of 50% dextrose IVP".

Now say you have someone who is a known diabetic. They are conscious, but altered with a CBG of 55 and you don't feel they can swallow safely. Giving them a whole amp may shoot their sugar up too much, so instead you give 1/2 an amp and see what affect that has first. 

Sure it's not exactly what the protocol says, but it may be better for your patient and starting with a lower dose of dextrose is not going to harm the patient.  

Disclaimer: Only with some specific medications is it safe to give a lower dose and depending on how your medical director feels.


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## mycrofft (Nov 8, 2009)

*And how is the pt this morning?*

5=4...........


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## Griff (Nov 8, 2009)

mycrofft said:


> 5=4...........








It was me ^_^


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## vquintessence (Nov 10, 2009)

*Whoops*



mycrofft said:


> 5=4...........



Sorry to leave you guys hanging; I got distracted by a nasty shift and then just forgot.  :sad:

_I got the simplified version from the facility, but ultimately the labwork (specifically TSH) showed that the pt had quite the untreated hypothyroid disorder.  This disorder, in conjunction with pts lifestyle, and recieving a hefty dose of narcs and a benzo that morning seem to be the culprit._

Sorry, nothing amazing or spectacular.  No House episode to rise from this.  I just found it intriguing because when this case was brought to rounds, there was nearly a 50:50 split in treatments and possiblities brought up by coworkers.


The crew treating the pt initially elected to start with a 500cc bolus of 0.9% NS and trendelenberg position.  The perfusion showed little improvement and bradycardia persisted.  Atropine 0.5mg IVP was administered once, which brought the pt to NSR in 70's and normotensive.  Afterwards, the transport was largely uneventful.

In the hospital, the ED essentially monitored the pt in conjunction with labs and a cardiac work up.  Levothyroxine was ultimately started and pt was released several days in.


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## mycrofft (Nov 11, 2009)

*Good one!*

Thyroid is often overlooked but it can cause many types of apparent syndromes and stray symptoms we rationalizing beings string together. In fact, many people have been put on Xanax who would have profited from a trial of propylthyrouracil (PTU)...which is 'way past tech stuff. 
A thyroid thread would be good as pt hx and meds would be good info to bring in with him/her.
I would have had them pumping her with dye and preparing an OR in case.


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