# Male Diff breathing



## Angel (Aug 1, 2014)

Here's another one. A call my colleagues ran I'm curious what you all would do differently

About 1030 in the morning, you are dispatched to a residence for a male appx 67 years old who initially had difficulty breathing and an updated page says he is currently unresponsive. You enter the house and hear a hysterical woman screaming and panicked. The voice is coming from upstairs (appx 14 steps)

nearest hospital ~17 mins via highway without traffic, nearest trauma center is ~14 mins on city streets


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## NomadicMedic (Aug 1, 2014)

Initial assessment and vitals please.


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## Angel (Aug 1, 2014)

you walk into the room, the woman grabs you and is screaming in your face, your captain diverts her attention and between the bed and the wall you see an: 
 ~350lb male, unconscious, GCS is E-1 V-2 M-5, difficult to assess RR or quality (due to his weight and position), he does have a palpable carotid you estimate at 64, your brand new EMT partner is also having issues obtaining a BP

the captain alerts you pt has a history of CHF, Asthma, Diabetes, HTN and DVT
takes, Lasix, Coumadin, Albuterol, Coreg, Insulin and K-Dur

nearest hospital ~17 mins via highway without traffic, nearest trauma center is ~14 mins on city streets


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## DrParasite (Aug 1, 2014)

is he breathing?  does he have a pulse?  what history does the wife say he has? what are his vitals?  how heavy is this guy?  what happened when this all started?


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## LACoGurneyjockey (Aug 1, 2014)

Angel said:


> you walk into the room, the woman grabs you and is screaming in your face, your captain diverts her attention and between the bed and the wall you see an:
> ~350lb male, unconscious, GCS is E-1 V-2 M-5, difficult to assess RR or quality (due to his weight and position), he does have a palpable carotid you estimate at 64, your brand new EMT partner is also having issues obtaining a BP
> 
> the captain alerts you pt has a history of CHF, Asthma, Diabetes, HTN and DVT
> ...




Sounds like you can't assess the airway where you found him, so lets make these firefighters work and get him out from between the bed and the wall. Until I get a better idea of what's going on let's try and maintain c-spine while we're moving big boy. 
Now what are his respirations and SPO2? Lung sounds? Pupils? Can we run a 12 lead? If your EMT partner can't get a BP, what did you get when you took it yourself? Facial droop visible? BGL? 
Any signs of trauma particularly to the head? Bruising, lacs? Did he fall out of bed, was he trying to get up, did wifey throw him to the floor in a fit of rage? 
Or did she just come back and find him on the floor? Has he been complaining of anything earlier in the day? Are any of these meds new within the last couple weeks? Has he fallen in the past? Has he ever had a stroke? Has he ever had an MI? 
Did you mean to say 17 min to nearest hospital, 14 min to trauma center? Are trauma centers not hospitals anymore? What are our nearest stroke and STEMI centers?


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## Angel (Aug 1, 2014)

LACoGurneyjockey said:


> Did you mean to say 17 min to nearest hospital, 14 min to trauma center? Are trauma centers not hospitals anymore? What are our nearest stroke and STEMI centers?



 well i was trying to illustrate that although the trauma center is "closest" there's so many lights to clear and possible traffic it may get longer to get to. Both hospitals are a stroke center, the trauma center is the only STEMI center however 

ok so your lovely fire crew helps load the patient on a carry all/tarp (not sure what other places may call them)

once hes situated you get:
R ~4, SpO2 77%, LS none, pupils PERRLA @4, 12-lead afib @67, no noticeable facial droop, BS 308, BP 76/P

wife finally calms down some and says he tried to sit down on the bed and rolled off, no signs of trauma, only complaints was difficulty breathing, albuterol treatments weren't helping. hx TIA but never a stroke


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## LACoGurneyjockey (Aug 1, 2014)

Angel said:


> well i was trying to illustrate that although the trauma center is "closest" there's so many lights to clear and possible traffic it may get longer to get to. Both hospitals are a stroke center, the trauma center is the only STEMI center however
> 
> ok so your lovely fire crew helps load the patient on a carry all/tarp (not sure what other places may call them)
> 
> ...



How long was he having difficulty breathing prior? Does wifey know if he has a history of A-Fib? Have someone start bagging him. How's your compliance with the BVM? Does he have a gag reflex? He responds to pain right? Does he move both arms? Does he have symmetrical plantar/babinski reflex?
Let's get as large an IV as you can and run it wide open, and I'll try Narcan for :censored::censored::censored::censored:s and giggles. 
I'd be starting to try and find any risk factors for PE, like umm, DVT, or A-Fib, or TIA. 
I feel like we've ruled out cardiac, stroke, narcotics, diabetic, trauma, airway/lung sounds. 
If his GCS declines any more or there's poor compliance with the BVM he's probably getting intubated. Aaaaaand, a diesel bolus to whichever ER you can get to quicker, with a slight preference towards the trauma center. They just seem more capable if it's a negligible time difference.
At this point I'm strongly leaning towards PE...


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## chaz90 (Aug 1, 2014)

LACoGurneyjockey said:


> Does he have symmetrical plantar/babinski reflex?



I know you're not trying to do a detailed check of these reflexes on an unresponsive patient who's not moving any air, severely hypoxic, and has a BP of 76/P...


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## LACoGurneyjockey (Aug 1, 2014)

chaz90 said:


> I know you're not trying to do a detailed check of these reflexes on an unresponsive patient who's not moving any air, severely hypoxic, and has a BP of 76/P...



He scored a 5 on motor response.
I'm moving air for him by now, and I have my EMT partner and 3 firefighters. This takes less than 10 seconds and will help rule out stroke for me in an unconscious pt with hx of TIA. I'm already bagging him and on the verge of intubation, I've got my IV, and I'm not going to try and treat the hypotension with a fluid challenge until I can say he isn't actively bleeding and his lungs are dry.
Genuine question, how do you want to rule out stroke on an unconscious with a history of TIA, who's on coumadin and beta blockers?


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## chaz90 (Aug 1, 2014)

LACoGurneyjockey said:


> Genuine question, how do you want to rule out stroke on an unconscious with a history of TIA, who's on coumadin and beta blockers?



You can't. We get way too caught up in the "rule out" terminology. A clear 12 lead by paramedic interpretation doesn't rule out an active MI, NEXUS doesn't rule out SCI, and a brief, cursory neuro exam doesn't rule out CVA on an altered patient. We can use these things to help guide us, but getting caught up in intricacies can sometimes get us in trouble on these sorts of patients. 

My bottom line was that there are critical problems to manage on this patient, none of which are changed by Babinski reflex findings. I agree with managing the patient with a BVM initially and moving towards (probably quickly) intubation. For treating the hypotension, I don't really care if he's actively bleeding or not in this case. BP doesn't match the classic stroke signs of increasing ICP we would expect in a patient with this kind of GCS. If he's altered and significantly hypotensive, it needs to be treated. Fair enough to try to get a handle on LS first with the history of CHF and initial complaint of SOB, but the bottom line is that the pressure needs to be dealt with. FWIW, I agree with your most likely differential of a PE.

Back to the OP: Has anything similar ever happened to the patient before? Gross dependent edema anywhere? We're certain our BGL is accurate too?


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## LACoGurneyjockey (Aug 2, 2014)

chaz90 said:


> You can't. We get way too caught up in the "rule out" terminology. A clear 12 lead by paramedic interpretation doesn't rule out an active MI, NEXUS doesn't rule out SCI, and a brief, cursory neuro exam doesn't rule out CVA on an altered patient. We can use these things to help guide us, but getting caught up in intricacies can sometimes get us in trouble on these sorts of patients.
> 
> My bottom line was that there are critical problems to manage on this patient, none of which are changed by Babinski reflex findings. I agree with managing the patient with a BVM initially and moving towards (probably quickly) intubation. For treating the hypotension, I don't really care if he's actively bleeding or not in this case. BP doesn't match the classic stroke signs of increasing ICP we would expect in a patient with this kind of GCS. If he's altered and significantly hypotensive, it needs to be treated. Fair enough to try to get a handle on LS first with the history of CHF and initial complaint of SOB, but the bottom line is that the pressure needs to be dealt with. FWIW, I agree with your most likely differential of a PE.



Gotcha.
So then for a hypothetical now that you've got me thinking. Let's say he has rales throughout and the pressure is still in the 70s, are you still going to dump fluids?
It probably contributes to my desire to rule out stroke/MI/trauma in that where I'm at we have a community hospital with no capabilities, and all our specialty centers are 70-100 minutes by ground. 
Really though these scenarios just make me more and more impatient for medic school to start...


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## DesertMedic66 (Aug 2, 2014)

LACoGurneyjockey said:


> Gotcha.
> So then for a hypothetical now that you've got me thinking. Let's say he has rales throughout and the pressure is still in the 70s, are you still going to dump fluids?
> It probably contributes to my desire to rule out stroke/MI/trauma in that where I'm at we have a community hospital with no capabilities, and all our specialty centers are 70-100 minutes by ground.
> Really though these scenarios just make me more and more impatient for medic school to start...



Pressure in the 70s and wet lungs? At least for me I would be considering starting a drip (if I was in my county it would be just drive since we don't have drips in our protocols aside from mag and amio)


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## chaz90 (Aug 2, 2014)

LACoGurneyjockey said:


> Gotcha.
> So then for a hypothetical now that you've got me thinking. Let's say he has rales throughout and the pressure is still in the 70s, are you still going to dump fluids?



Fortunately, I don't seem to see a ton of patients with hypotension and pulmonary edema. It's an ominous combo, and more closely associated with acute heart failure, IE post/during MI. PPV by ETT will help somewhat with the rales (or at least oxygenating through them). In short, yes I would still be forced to use some fluids on this patient. Even in-hospital, I imagine they'll attempt crystalloids prior to ionotropes. If I were with this patient for an unholy amount of time and he didn't respond to fluid I would be thinking about dopamine.


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## Angel (Aug 2, 2014)

LACoGurneyjockey said:


> How long was he having difficulty breathing prior? Does wifey know if he has a history of A-Fib? Have someone start bagging him. How's your compliance with the BVM? Does he have a gag reflex? He responds to pain right? Does he move both arms? Does he have symmetrical plantar/babinski reflex?
> Let's get as large an IV as you can and run it wide open, and I'll try Narcan for :censored::censored::censored::censored:s and giggles.
> I'd be starting to try and find any risk factors for PE, like umm, DVT, or A-Fib, or TIA.
> I feel like we've ruled out cardiac, stroke, narcotics, diabetic, trauma, airway/lung sounds.
> ...



sorry guys my internet went out, ok
so no all the wife knows is he has an "irregular heart beat" she is otherwise uneducated to most of his medical issues. 

youre bagging with some difficulty, minimal chest rise, he feels "tight", no gag reflex

IV is good, no change with Narcan

and youre en route code 3 to the ER

no change in patient GCS.

Also, i know it was hypothetical but, he currently has NO lung sounds, not wet/rales.


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## LACoGurneyjockey (Aug 2, 2014)

Meh, I'm indifferent on the intubation at this point. If I had a decent RSI protocol I might be more inclined but where I'm at we get versed. And that's it. Not a joke. 
I'll just sit here and keep saying PE til we get to the ER.
No lung sounds, even while bagging? Spontaneous pneumo? That might be the last little bit of encouragement I needed to go ahead and tube this guy. How's ETCO2 after intubation?


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## Akulahawk (Aug 2, 2014)

Angel said:


> sorry guys my internet went out, ok
> so no all the wife knows is he has an "irregular heart beat" she is otherwise uneducated to most of his medical issues.
> 
> youre bagging with some difficulty, minimal chest rise, he feels "tight", no gag reflex
> ...


The fact that he's got no lung sounds, he's being bagged with difficulty (feels "tight"), he's got no response to Narcan, has a HX of irregular heart beat, and he's got no gag reflex at this point tells me he's going to be getting intubated right now. Even though his Motor score is a 5, he's unable to protect his own airway. Did the SpO2 %-age come up with bagging?

I'm thinking PE or spontaneous pneumo, and right now, tension pneumo is high on my list of what may be wrong.

Any noticeable tracheal deviation? Yes, it's a late sign, but... 

In any event, he's in a very bad place...


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## Angel (Aug 2, 2014)

no deviation or jvd, spo2 increased to ~86 with bagging. 

here's was the crew did, not saying it was right or wrong. in fact this is what i was told i should try in the case of "no" lung sounds, especially in a patient with asthma. 

they bagged in albuterol and code 3 to the hospital with a slight increase in SpO2 ~89.


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## Akulahawk (Aug 2, 2014)

Given his Hx of asthma, bagging in albuterol isn't a bad idea, on the chance that he's just extremely bronchoconstricted. I've heard of that myself, never had to try it. Given that the crew was able to bring the SpO2 up to 89% from the 70's, that's doing well. Not an easy patient (or family) to have, I suspect. 

Hopefully the patient survived... and I wonder if the guy had ever been intubated before because of his asthma?


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## Rialaigh (Aug 2, 2014)

chaz90 said:


> You can't. We get way too caught up in the "rule out" terminology. A clear 12 lead by paramedic interpretation doesn't rule out an active MI, NEXUS doesn't rule out SCI, and a brief, cursory neuro exam doesn't rule out CVA on an altered patient. We can use these things to help guide us, but getting caught up in intricacies can sometimes get us in trouble on these sorts of patients.
> 
> My bottom line was that there are critical problems to manage on this patient, none of which are changed by Babinski reflex findings. I agree with managing the patient with a BVM initially and moving towards (probably quickly) intubation. For treating the hypotension, I don't really care if he's actively bleeding or not in this case. BP doesn't match the classic stroke signs of increasing ICP we would expect in a patient with this kind of GCS. If he's altered and significantly hypotensive, it needs to be treated. Fair enough to try to get a handle on LS first with the history of CHF and initial complaint of SOB, but the bottom line is that the pressure needs to be dealt with. FWIW, I agree with your most likely differential of a PE.
> 
> Back to the OP: Has anything similar ever happened to the patient before? Gross dependent edema anywhere? We're certain our BGL is accurate too?



I'm with chaz here. The only emergencies we currently have are hypoperfusion and respiratory. And I am going to dump some fluid on this guy even with wet lungs, but this guy is also getting tubed prior to me moving him too. 

I don't care about stroke symptoms, or ruling out or in at least in this scenario, we have a stroke and PCI center less than 20 minutes away. Frankly I don't care about getting a solid 12 lead on him either, my concern is moving him however many hundreds of feet including down stairs without killing him. Respiratory and fluids, if no response to the first couple hundred of fluids I have no problem starting a drip (possibly dopamine, maybe epi...)



If his BgL is not causing it, and Narcan does not work, then your options are extremely limited on what your going to do in the field for this guy...you have fluids, pacing, a drip, and intubation. Anything "diagnostic" outside of that like a 12 lead, spending time getting a history, or anything else will not help you stabilize the patient or make a transport decision in this scenario. All that information will be very useful for the wife to tell the doc ....after you get him to the ER. 




TLDR - My biggest concern (especially if there were wet lungs) on this patient is if we move him prior to stabilizing his respiratory and/or BP then you might kill him in the few minutes it takes to move a patient this size down stairs to an ambulance...Fix the ABC's, worry about the rest when hes comfortably intubated with a systolic of 100/whatever and a HR over 60.


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