# usalsfyre's Train Wrecks #1



## usalsfyre (Aug 24, 2011)

So I thought I'd try something new, I know it's been done before, but we'll go for another round of it. Once a week I'm going to post a scenario. Anyone with case ideas feel free to PM me.

It's 1800 in the middle of the week, your the medic on a Medic/Basic CCT truck in a rural city with a small community hospital. You get bumped out with the local FD for a CO alarm sounding at a residence. On arrival you find a 60 year old man c/o flu like symptoms and a CO detector activated near the furnace. Thoughts? 

More to follow...


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## Handsome Robb (Aug 24, 2011)

Well first thought is CO poisoning, but it's titled a usalsfyre's Train Wrecks and that's way too easy. I hear zebras?

Given the info get the patient and yourself out of the house. Probably shouldn't have entered unless your on a SCBA but I have no fire training so I'm gonna leave my nose outta that part. 

General impression of the pt, skin signs, any respiratory distress noted, how is his mentation, when did his symptoms start?
I'd like a full set of vitals, including a SpO2 reading, even with the presence of CO if the patient has high reading but is having difficulty breathing and/or showing signs of poor perfusion it can help confirm your ddx and possibly transport/destination decisions. Toss him on the monitor, haven't gone through cardiology yet, but I would guess that if he was hypoxic you could have some disrhythmias/ectopy present depending on the severity.

Has fire broken out their detector yet and checked the entire residence? Where was the patient found in the home? 

Alright, be gentle


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## usalsfyre (Aug 24, 2011)

Goo


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## usalsfyre (Aug 24, 2011)

Good points. Couple of thoughts. What time of year is it (and why does this matter)? I probably wouldn't enter the residence, simply knock on the door and coax the patient out.

So...your patient is an ambulatory 62 YOM in a well kept home, you notice gobs of trophy heads on the living room wall as you see past the patient at the door. He says he's been feeling sick for three days. PT describes lethargy and SOB accompanied by occasional chest pain with excursion, pt is currently pain free. Pt had a bout with the flu a couple if weeks ago. He's currently taking metoprolol for HTN and simivastin for  hyperlipidemia, no other history. NKDA. 
Physical exam as follows 
Healthy, well nourished ambulatory male with no gait ataxia but noted to be pale.

HEENT:Intact, pupils are PERLA, no facial droop and clear speech. Some JVD is noted.

Chest:Slightly increased chest excursion, some accessory muscle use with activity. Crackles noted in the bases. S1 and S2 are clear, no S3 noted.

Abdomen: Soft and non-tender

Extremities: Intact, no ataxia and good coordination. +1 edema in the patients feet

Vitals: B/P 102/65; HR 42; RR 22 SpO2 90% on room air. 

Fire just showed up and is inside checking out  the house with a CO monitor. 

You have ALS and CCT equipment available, including an iSTAT. 

EKG tomorrow.


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## Handsome Robb (Aug 24, 2011)

It's hunting season, well almost, also depends on your location. Wild animals are dirty. Has he been hunting in the past few weeks? If he has, how long ago? If he has was he bitten or could the animal's saliva come in contact with an open cut?

Is he febrile? Hows his skin turgor? What is his normal resting HR? 42 is pretty low along with a lowish bp but again what is normal for him?

When he had the chest pain what kind of pain was it? Regional or could he localize it? Did it radiate anywhere? Has he ever had chest pain like this before? 1-10 scale how bad was it? Any tightness in the chest?

Has he ever had trouble breathing before? 1-10 scale on the SOB? Is he getting tired from the accessory muscle use or is it just sleepiness? 

Has he always had the edema or is it new onset? Did he see a doctor for his 'flu' 3 weeks ago? 

What's his BGL? When did he take his meds? Is it possible he took an extra dose of the Metoprolol by accident? The bradycardia and bp with a history of HTN makes me curious as well as signs of right sided heart failure.

I have no CCT experience or knowledge, but know a bit about ABGs so might as well get a set seeing as we have an iStat.

As for treatment, I'd give him o2 via a cannula and see what that does for his sats. I'd go for a 12/15 lead but I have to wait for tomorrow to get that back haha. I'd get an IV with a saline lock, I'm not keen on giving him fluids with the crackles present and the JVD, but if his pressure drops it might be necessary. At first with the bradycardia I thought of 0.5 mg atropine but he isn't terribly symptomatic and with signs of heart failure I don't think I want to ask more of his heart unless I absolutely have to. 

How far to a hospital with wider capabilities?


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## abckidsmom (Aug 24, 2011)

Travel?  Where's he been hunting lately?

What's he tanning in the basement with a kerosene heater, lol?


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## phideux (Aug 24, 2011)

I think the CO alarm is just there to throw a curve in the scene. What kind of heads on the wall? Is he a deer hunter?? Is it hunting season??? Or pre-season where he might be walking around the woods scouting?? I'm thinking Lyme disease from a deer tick.


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## bigbaldguy (Aug 24, 2011)

Lupus


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## mikie (Aug 25, 2011)

*What happened to scene safety?*



usalsfyre said:


> I probably wouldn't enter the residence, simply knock on the door and coax the patient out.



That was my original thought...if you hear a CO alarm, as purely EMS (w/o SCBA, etc), YOU'RE TOO CLOSE!  You're no good to the patient, your partner, etc, if you succumb to CO poising too.  

I'd have the FD get the pt out.  I'd try to make verbal communication to ascertain if the pt can ambulate himself outside; if FD is far far away, break/open some windows/ventilate and consider removing the pt.  

It's just not worth the risk, IMO.


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## Aidey (Aug 25, 2011)

Is the EKG going to show the 3rd degree block I think he might have?


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## Handsome Robb (Aug 25, 2011)

Aidey said:


> Is the EKG going to show the 3rd degree block I think he might have?



I don't have any cardiology background besides the Colorado EKG course I took and what's taught in the I/85 scope so it's pretty limited but I'm wondering why your thinking this? Why would the heart block cause SOB? I want to see the EKG.

My original thought was CO poisoning but I knew that it was too easy, like I said I hear zebras (with my level of knowledge at least). Second thought was rabies with the flu like symptoms, apparent hobby of hunting, the time of year and the ongoing flu like symptoms but the pt doesn't have any mentation changes or ataxia/paralysis. My third choice was possible accidental OD on the Metoprolol with the bradycardia, low-ish bp with a Hx of HTN and signs of new onset CHF specifically right side  (+1 peripheral edema, SOB, JVD) but the crackles could indicate pulmonary edema secondary to left side heart failure. I was under the impression that it went left to right in heart failure instead of right to left as this seems to be presenting, unless I'm missing something. 

I like these scenarios, they make me think and when I'm unsure I research my thoughts. It's forced studying! I'm glad other people are playing too


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## Handsome Robb (Aug 25, 2011)

bigbaldguy said:


> Lupus



Good call, House


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## STXmedic (Aug 25, 2011)

NVRob said:


> I don't have any cardiology background besides the Colorado EKG course I took and what's taught in the I/85 scope so it's pretty limited but I'm wondering why your thinking this? Why would the heart block cause SOB? I want to see the EKG.



A 3rd degree block would likely cause a bradycardic rhythm. The bradycardia could then lead to lowered BP 2/2 decreased CO, and signs of CHF caused by a back-up in the venous system leading to PE, JVD, and peripheral edema. 

At least I believe that is Aidey's train of thought


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## Aidey (Aug 25, 2011)

usalsfyre said:


> Healthy, well nourished ambulatory male with no gait ataxia but noted to be *pale*.
> 
> HEENT:Intact, pupils are PERLA, no facial droop and clear speech. Some *JVD is noted*.
> 
> ...





PoeticInjustice said:


> A 3rd degree block would likely cause a bradycardic rhythm. The *bradycardia *could then lead to l*owered BP *2/2 decreased CO, and *signs of CHF* caused by a back-up in the venous system leading to *PE*, *JVD*, and *peripheral edema*.
> 
> At least I believe that is Aidey's train of thought



Pretty much.


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## usalsfyre (Aug 25, 2011)

We've got an astute bunch here!

NV
He seems normothermic, and he denies fever. He's never had chest pain before, but described what he had as "just a little discomfort, indigestion is all". He also states he's "just a little tired, I can't take a deep breath. You know I'm just a little older and don't get over being sick as fast". Did not see a provider for the flu, only sees him for checkups. He tells you he really is sorry to bother you, but is pretty sure he doesn't need to go to the hospital. really Finally, are you SURE you want a gas? It's painful, and is it going to change your treatment?

Mikie
If your in open air CO is unlikely to be present in sufficient concentrations to harm you. If standing at an open door would put you out, your patient certainly wouldn't have been able to answer the door.

abc and phideux
He says he's been out doing some preseaon scouting, clearing shooting lanes and such. 

12 lead is:






BGL is 142. FD comes out and reports the CO level is 4ppm. PT is still refusing treatment. What now?


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## usalsfyre (Aug 25, 2011)

Attempting to get a better image of the 12 lead


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## RocketMedic (Aug 25, 2011)

I'm thinking its a myocadial infarct. The St depression in I,II, and III with reciprocal elevation in the AVFs and the elevation in the ventricular leads makes me think there's prior cardiac damage with ongoing aggrivation. Crackles could be explained by pump failure. Lets start him on oxygen if we can, prep him for transport, get a line, and run a 250 MP bolus at tko. I don't see a huge reason to mess with dopamine or atropine since we have decent perfusion, but lets keep it ready.

Reckon that there's a lot of potential causes for this, but Lyme disease is a good differential Dx. I'm still thinking an mi though, especially with the new onset of pain and symptoms with exercise (ie clearing shooting lanes)


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## RocketMedic (Aug 25, 2011)

Lets use that istat for a tryponin test too.


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## Aidey (Aug 25, 2011)

Ha! It is a 3rd degree block isn't it? Do I get a cookie?  It was probably caused by the inferio-lateral MI he had a couple days ago. I would hold off on the iStat for a blood gas. You're already having a hard time convincing him he is sick, it is probably going to be pretty hard to convince him you need to stick a big needle in his wrist. Running a venous cardiac enzyme test might be helpful, but I really suspect he had the MI a couple days ago, when the symptoms first started, and the enzyme tests may not be conclusive this late in the game. 

I don't see any depression, but I do see inverted T-waves in the appropriate leads for an inferio-lateral MI. Inversion usually develops 24+ hours after the MI.


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## firecoins (Aug 25, 2011)

for once, can someone woth flu like symptoms have the flu? I am just sayin!


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## silver (Aug 25, 2011)

firecoins said:


> for once, can someone woth flu like symptoms have the flu? I am just sayin!



or the patient could have a viral/bacterial infection that caused a carditis (peri, endo, myo), where the flu like symptoms preceded any cardiac issues. Something like endocarditis can cause AV block, ST elevations and inversions. Though I am not feeling any of those...

On the other hand an AMI seems too simple...


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## usalsfyre (Aug 25, 2011)

Anybody still thinking CO toxicity?


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## CANMAN (Aug 25, 2011)

Being a fireguy as well with a reading of 4ppm thats not super concerning BUT as a company officer I would have done a 360 of the home upon arrival. Could he have possibly opened the windows today, but they have been closed recently? In my jurisdiction we also have access to RAD57 so I would call for a unit with that and utilize that as well to rule in or out CO toxicity


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## Shishkabob (Aug 25, 2011)

usalsfyre said:


> Anybody still thinking CO toxicity?



You said iStat... do you also have an LP15 with CO monitoring?


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## usalsfyre (Aug 25, 2011)

Linuss said:


> You said iStat... do you also have an LP15 with CO monitoring?



Sure...it's zero. See Roguemedic's writings on the RAD57 to see how useful this is


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## Shishkabob (Aug 25, 2011)

usalsfyre said:


> Sure...it's zero. See Roguemedic's writings on the RAD57 to see how useful this is



You also sad he was satting 90%, so I wasn't even leaning towards CO


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## usalsfyre (Aug 25, 2011)

You convince him to let you transport him and the iStat results are...

Troponin is 0.8, CK-MB is 0.7, and I'll give you an extra, BNP is 325.

No open windows.

2L by NC bumped your sats to 95% and gives you a new number, ETCO2 is 32.

Hospital choices are a small community center 5 minutes away, a mid-sized center with a small ICU and a "diagnostic" cath lab 30 minutes away and an academic Level 1 with everything under the sun 90 minutes away. Your the only unit available for the area, back-up truck must respond from the next town over and will add about 15 minutes to the response. Where are you going and why? What do you want to do enroute? So far we've got a saline lock and 2lpm by NC

Before anyone ask, no HEMS, it's cloudy/foggy/down for maintenance/the football game is on.


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## JPINFV (Aug 25, 2011)

For some strange reason I want to throw Lyme disease out there as well as hypothyroid.


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## lawndartcatcher (Aug 26, 2011)

I vote for the cath lab. Continue assessment, full head-to-toe. Any weird / obvious bites / rashes / purpurae anywhere?

I'm not really familiar with Troponin, but I know that .08 is high (normal level ~.1, right?). I also know higher levels can be caused by CO poisoning, MI, sepsis, snake bites, etc. - all the stuff that's been proposed.

To this day I don't trust SPO2 meters. The guy from Masimo told us that any reading up to 5 is within standard deviation, more if your patient is a smoker. A zero reading says (to me) that this isn't a CO case. 

I vote MI, too.



usalsfyre said:


> You convince him to let you transport him and the iStat results are...
> 
> Troponin is 0.8, CK-MB is 0.7, and I'll give you an extra, BNP is 325.
> 
> ...


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## usalsfyre (Aug 26, 2011)

lawndartcatcher said:


> I vote for the cath lab.


Quick word on diagnostic cath labs. These are facilities that can't actually perform baloon angioplasty or place a stent. They can simply diagnose coronary occlusion. Back in the early 2000's they were all the rage, however their popularity has faded for obvious reasons. So if this guy gets in that cath lab and they discover a blockage, they will then have to transfer him out. 



lawndartcatcher said:


> Continue assessment, full head-to-toe. Any weird / obvious bites / rashes / purpurae anywhere?


You notice a "bullsye" rash on the posterior aspect of his left shoulder. When asked about it, the patient says it's been there for a about a week. 



lawndartcatcher said:


> I'm not really familiar with Troponin, but I know that .08 is high (normal level ~.1, right?). I also know higher levels can be caused by CO poisoning, MI, sepsis, snake bites, etc. - all the stuff that's been proposed.


Troponin can elevate for a myriad of things. Anyone know how long it generally satys elevated post MI? 



lawndartcatcher said:


> To this day I don't trust SPO2 meters. The guy from Masimo told us that any reading up to 5 is within standard deviation, more if your patient is a smoker. A zero reading says (to me) that this isn't a CO case.


The "Rainbow" CO2oximeters have a number of doccumented problems. 



lawndartcatcher said:


> I vote MI, too.


This case is drawing to a close, conclusion will be posted tommorow. 

Sorry for the delay today, I'm on shift and we've been all over hell's half acre.


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## Shishkabob (Aug 26, 2011)

usalsfyre said:


> You notice a "bullsye" rash on the posterior aspect of his left shoulder. When asked about it, the patient says it's been there for a about a week.



Lyme disease.

But jpin already said it, so he gets the credit


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## phideux (Aug 27, 2011)

Linuss said:


> Lyme disease.
> 
> But jpin already said it, so he gets the credit



I beat him to it, I went the Lyme disease route the first day.-_-


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## usalsfyre (Aug 27, 2011)

Lyme carditis it is folks. I'd stay away from the small facility but this patient doesn't need a cath lab, just IV antibiotics. 

Scenario 2 goes up Monday, will involve trauma.


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## usalsfyre (Aug 27, 2011)

phideux said:


> I beat him to it, I went the Lyme disease route the first day.-_-



Yep phiduex picked up on it early. It's defintely a zebra, but something to be alert for, especially this time of year for our rural folks.


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## systemet (Aug 31, 2011)

Awesome scenario.


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