I promised a hard scenario, consider it delivered.

[Lifeguards For Life]

one thing still throwing me for a loop is the "constant trickling bloody discharge from the vagina" being a manifestation of an OB emergency vs. the patient having Disseminated Intravascular Coagulation.

And the patient having subcutaneuos emphysema in the mons pubis area.

I believe there are only a few pathologies that can cause this. one being blunt trauma, the other being a bacterial cause.

Clostridium perfringens could of caused the patient to have subcutaneous emphysema near the mons pubis.

but could that cause DIC?

And I still haven't seen how the patient could have gotten Clostridium welchii....

it has been isolated and found to culture near the perineum right?

 

[EMTinNEPA]

Has the patient been gaining or losing weight recently?

Any changes in behavior? Has she been depressed? Apathetic? Socially withdrawn?

Has the mother noticed her daughter's voice becoming hoarse or deeper lately?

The patient is a starter for the volleyball team... does the team practice indoors or outdoors?

 

[Veneficus]

one thing still throwing me for a loop is the "constant trickling bloody discharge from the vagina" being a manifestation of an OB emergency vs. the patient having Disseminated Intravascular Coagulation.

When in doubt choose both.

And the patient having subcutaneuos emphysema in the mons pubis area.

How would you get air in there?

I believe there are only a few pathologies that can cause this. one being blunt trauma, the other being a bacterial cause.

Clostridium perfringens could of caused the patient to have subcutaneous emphysema near the mons pubis.

near the mark with C perfringes.

but could that cause DIC?

It can, DIC can be a complication of sepsis. However, in this particular scenario DIC is one of the earliest pathologies (prior to sepsis and promoting it)

And I still haven't seen how the patient could have gotten Clostridium welchii....

it has been isolated and found to culture near the perineum right?

yes, but it is inconsequential to this case.

 

[Veneficus]

Has the patient been gaining or losing weight recently?

no.

Any changes in behavior? Has she been depressed? Apathetic? Socially withdrawn?

No changes in behavior were noted other than the N/V for days. The mother tells you that the girl has such a busy schedule she is usually only home to eat, sleep and do homework. She spends most of her time on the internet in her room when awake at home.

Has the mother noticed her daughter's voice becoming hoarse or deeper lately?

no

The patient is a starter for the volleyball team... does the team practice indoors or outdoors?

Both, of no importance in this Dx.

 

[Smash]

It's late and I'm tired, but this sounds suspiciously like Toxic Shock Syndrome to me.

Treat for SIRS/Sepsis, to wit: Oxygen, IV x 2 or 3 or something; large. Lots of fluids, then inotropes of whatever flavour is in vogue in your area. If things start looking worse intubate and provide 100% O2.
We don't carry an appropriate antibiotic for early empirical administration in this case, and it is probably too close to hospital to use anyway. Remove (or get removed) the tampon, although there isn't really good evidence that this will help.

Drive to high level hospital with much of the fastness, this girl needs aggressive intervention with EGST and ICU admission and the local community center probably won't be up to caring for her.

 

[EMTinNEPA]

I agree... not much we're going to do pre-hospital except try to combat the shock long enough to get her to the hospital alive. I seriously doubt the local community hospital will be able to appropriately manage her case without transferring her out.

 

[Seaglass]

The vaginal discharge might be a red herring, but I'd start wondering about TSS as well as general gyn history, and would see if there's a tampon to be removed. Sepsis in general seems like a solid guess, though I don't know what from. I'm also wondering about some kind of vasculitis. My zebra guess: Takayasu's?

Regardless, I'm a basic on a basic truck. I might not even be able to get several of the vitals you mentioned. I'd administer oxygen and gasoline. I'd either wait for ALS or get an intercept on the way to the higher-level hospital, depending on where the nearest intercept is. I'd get in touch with the intercept, the receiving hospital, medical control, or some combination of the above, depending on where I'm working.

 

[Melclin]

This girl is sick.

With the pupuric rash and septic shock, I'd be remiss not to pour ceftriaxone into her although I'm not entirely sure what it is off the top of my head. The septic shock and rash point to menningoccocal but the length of time she's been sick seems a little to long (It was a few days wasn't it?) so I'm not sure its that. Without some googling and "hittin' the Harrison's" I couldn't speculate what this might be.

I think as paramedics, we wouldn't wanna sit around getting 15 years of medical history and trying to play noctor she's seriously ill and seriously time critical.

As a basic here:
- PPE.
- rapid infuse normal saline 20mls/kg
- 1g ceftriaxone.
- ~100% oxygen
- Alert receiving hospital - we will be going to the major hospital.

As ALS:
- All of the above
- titrate adrenaline if the blood pressure is refractory to the first..probably 500mls of NS.
- another 20mls/kg as long as the lungs stay clear.
- Consult the clinician for dexamethasone dosage.

 

[Aidey]

The first thing I would have done after seeing that rash is put on a mask...it may be from the DIC, but it could also be from meningitis, and I'm not going to risk it.

So we've got sepsis, DIC, and pericarditis so far correct?

Maybe I'm over thinking, but she is technically underweight. She is also a 15 year old high achieving female, chance there is an eating disorder underlying all of this?

 

[Veneficus]

Everyone did very well

Many people here got part of the story. Without knowledge of the progression there are only a few subtle hints that point to the primary cause. It was given in the first reply, but nobody followed up on it.



Here is my walk through of the scenario with the key points and predetermined solution.


Though some treated more than others. I presented this same scenario to my classmates. As of this writing, 9 responded, and only one paid enough attention in class and reading to solve the puzzle. (though he did ask for lab values which I gave him because his primary scope is in hospital and limited only by his preceptor)

 

[Veneficus]

Scenario

Dispatch/scene information:
You are called to an upper middle class residence for a 15 year old female feeling “sick for a couple of days.” Upon Arrival you are greeted at the door by the patient’s mother who claims her daughter has been feeling ill and spent the last few days in bed and is now difficult to arouse. On your way into the residence you notice a stack of bills on a bureau, a lack of furnishings and very limited amount of electronic devices. The dwelling is clean but the occasional damage to the drywall has not been repaired. (This is basic information and demonstrates and potential lack of financial means. In the US a person’s ability to pay for healthcare often directly equates to their priorities and health status. Many former middle class families that never used or discussed social programs are often at a loss for options when they find themselves economically struggling. Additionally, households with 2 working parents often do not have any idea what their teenagers lives are like.)


You make your way up the stairs to a second floor bedroom where you notice a 15 year old female wrapped tightly in blankets despite the 85F temperature outside.(subjective feeling of cold, often seen in shock) You next remove the blanket to start your assessment. The female is wearing sweatpants and a t-shirt, she does not appear to be sweating(could be distracting to heat injury, but also a subtle sign of hypovolemia), though she is pale in the face(pale cool skin indicative of shock) and has multiple purpuric lesions on her arms.(gross capillary permeability) While you expose her and perform a physical exam, your partner (a brand new, 1st call ever, provider of the lowest level allowed in your country. This one is all about you) gathers a history.

Vital signs:
Heart rate: 110 regular, central pulses present and weak. Distal pulses absent. (indicative of shock, tachycardia, weak central pulse, absent peripheral pulse)
BP: 80/60 (narrowing pulse pressure another easily identifiable sign of cardiovascular collapse)
Respiratory rate is 24/min and shallow (respiratory insufficiency)
Temperature is 40C rectal. (builds upon the differential of septic shock. Fever, hypotension, purpura)
Capilary blood glucose: 60 (she hasn’t eaten in days and bacteria often utilize glucose as a metabolite, a bigger problem still is the lack of glucose impairs mental function and causes breakdown of RBCs further complicating the hemodynamic picture )
Weight is 47kg height 5’5” (need weight for drug dosing, height demonstrates body proportion)
Sinus tachycardia with occasional (<6 minute) PVCs that do not generate a palpable pulse wave. (another sign of shock)
Spo2: 89 on room air (respiratory insufficiency caused by some etiology)
ETCO2: 30 (lower than normal CO2 reading, indicating abnormal gas exchange or airway compromise)
GCS: E4 V4 M5 (13, slightly impaired neuro function)

Physical exam:
Hair is oily and matted (recent lack of bathing), skin is pale and cool to the touch,(shock) nothing noted about the ears. Pupils are dilated and sluggish.(impaired neurological reaction, consider forms of insult like both forms of stroke) Sclera has diffuse blood throughout (extravascular bleeding), mucous membranes are dry(dehydration secondary to volume loss), slight bleeding from the gum line(vascular permeability), face and head is otherwise symmetrical with no obvious deformity or masses upon palpation.(eliminates lymphoid findings indicating early onset of sepsis) Trachea is midline without shift, (no pneumo) JVD is noted (physiologic in reclined position but does give a clue about potential insufficiency) and skin is also pale on the face/neck. (shock) Thyroid and lymph nodes are not enlarged (rapid onset sepsis) carotid pulse is present and weak. (shock)

Exposing her chest you observe multiple purpuric regions (>2cm in diameter) (sepsis or other form of capillary permeability like late DIC), breathing is shallow and rapid at a rate of about 24/minute,(acidosis compensation) breasts appear at stage 5 development.(stage of full adult breast development in female, not normally seen until 17 or older, breasts fully develop in pregnancy also) Breath sounds are diminished with crackles in the bases,(in this case from blood/fluid in the alveoli) Heart tones exhibit a gallop and sound distant.(new onset cardiogenic shock) Apex of the heart is at the normal level,(rules out hereditary cardiac malformations) lungs also within normal topographic parameters.(same with lungs) Back has similar purpura legions. Skin is cool to the touch. (by now you should get the sepsis/DIC picture)

The abdomen appears similar to the chest, however it is slightly distended,(blood, air, and swollen) locally warm to the touch in the lower quadrants,(localization of inflammation) involuntary muscle guarding is noted on palpation (a very specific sign of a surgical abdominal pathology), you decide not to auscultate bowel sounds,(because that would be useless in the current situation) liver in 2cm beneath normal margin,(liver edema from right heart insufficiency and/or liver malfunction) spleen not palpable.(Rule out pathology of splenomegaly) Diffuse echymosis in the gluteal region(dependant sign of bleeding), constant trickling bloody discharge from the vagina,(active bleeding from the internal genitalia which gives a clue to potential injury to highten index of suspicion but is nonspecific) and subcutaneous emphysema in the mons pubis area . (Trauma is the number 1 cause of air in the subcutaneous tissue if the trauma is not externally visible, this should be a clue of potential occult injuries)

There appears no indication of external trauma with an exhaustive exam. (Should raise index of suspicion on potential urogenital injuries)

Arms and legs are also cool to the touch, difuse purpura throughout. Capillary refill at +4. Femoral pulse is present and weak, distal pulses absent in all extremities. (reinforcing massive bleeding and shock)

 

[Veneficus]

History: Your partner (who is an exceptionally capable historian for a person green as grass) tells you the mother is extremely worried about the cost of all of this as they recently lost their health coverage. But he elicits: (clue about not seeking proper healthcare)

Mother noticed her daughter had been sick the last few weeks with nausea and vomiting (weeks of nausea and vomiting, what could cause that in a female of child bearing age?) and warm to the touch.(nonspecific sign meaning nothing) The girl continued to go to school despite the illness. She came home after hanging out with friends like usual (points to early morning N/V which resolves enough so school officials do not become suspicious) 2 nights ago complaining of abdominal pain and went to her room.(this is the key timeline for the acute pathologies) Next day pt told her mother she was too sick to go to school,(that is an understatement as it is the start of major prblems) was not hungry, but was drinking water and tea,(increase thirst from early shock) vomiting had stopped.(if you were thinking pregnancy and morning sickness, you are probably thinking miscarriage/abortion now) This morning (~48 hours post primary insult, late stages of progression) mom came to check on the girl, who complained of epigastric pain. PT had spit up some gross red blood (peptic ulcer secondary to traumatic injury or neurological dysfunction is a subtle sign, but also indicative of bleeding into the GI, like in DIC) and then mom called 911. (aka: you) (because there is no hiding this now)

The patient has been taking “femrelief” for menstrual cramps as needed for years,(potential to be pregnant, as a guidline all females between the ages of 8 and 55 are pregnant until proven otherwise) the dose of Nyquil on the bottle for the last 3-4 days(the night time sniffling, sneezing, coughing, achy head, fever so you can rest with 10% alcohol available to minors medicine) and has no known allergies medical or otherwise. You notice no drug paraphernalia with a quick cursory search and no street drugs. You also do not notice track marks or venipuncture sites on the pt. (IV drug use is the #1 cause of rheumatic fever, this should help rule out street drugs as well.)

There is no prior medical history.

The girl was born at term, without inducing, from a planned pregnancy with proper preconception and prenatal care. She has had a healthy childhood, meets all developmental benchmarks, has a yearly sports physical, and all vaccinations. (there is no evidence of genetic or chronic illness undiagnosed)

The mother reports the female does not have a boyfriend, is not sexually active, started menstruating at age 10 (average age in the western world is 9) and was not regular, LMP unknown. No history of pregnancy, miscarriage or abortion. (because many parents would like to believe this if they have no overwhelming reason to think otherwise.)

The mother also reports that the patient uses no alcohol and does not smoke. You do not find anything in the environment that contradicts this information. (further ruling out toxins)

The patient has not been eating the last few days but has been drinking a lot of fluids. (early symptom of shock) The mother does not know about urination or defecation habits or frequency.

The Mother also reports the girl is a straight A student and is a starter on the high school volleyball and track teams, plays in the band and sings in the choir. (since 3rd grade.) (is in very good mental and physical shape, which probably explains why she is still compensating. It also demonstrates the child is not at home very much compared to other activities)

You are working in the US,(because there is no free universal healthcare that would preclude people from going to the doctor if they thought they were pregnant) but operate under your normal protocols or standard of care. So what are your thoughts and orders Captain? Your nearest hospital is a community hospital 10 minutes away.(which is not up for this challenge) A major academic medical center is 30 minutes away.(which is where you need to go) Anyone of 10 airmed providers are at your beck and call and frequently hand out pens and other marketing items but it will take them 40 minutes to respond at best. (in otherwords its faster to drive) You have anything you normally have on your responding unit. You can ask for any clarifications, repeat findings, more detailed findings, or the effect of your interventions. The only ambiguity in the scenario is what you do but I will do my best to respond accordingly and consistently.

Hints to make your head hurt: (these were hints, not a call to imply dx pathology, but your working dx should affect your treatments just like with any patient you see… I hope)

In this scenario there are 5 life threatening pathologies, some secondary to others.

All of the pathologies are readily identifiable by the information given except for the common primary pathology which is alluded to and can be reverse engineered from finding the others. (you have to know your disease progression in order to get to root causes if you ever want to help with more than symptomatic treatments and make good transport decisions)

PS. This is also my original work and not to be distributed without permission, which you have as long as you make no money from it and proper credit is given. 04/25/2010 (because if you get paid for my work, I get paid)

This scenario is hypothetical and bears no relationship to any person known or unknown by the author.(I never saw this patient so they cannot complain I violated their privacy)

 

[Veneficus]

The answer :

This scenario is an acute surgical emergency. (because this uterus problem is going to have to be fixed and the surgical intensivist will probably manage this patient to the end.)

The pathology is textbook complications of an improperly performed abortion ( I took the progression right from published text) when the placental layers are separated and not entirely removed.

In this case rest of the placenta was separated from the myometrial layer and the female was in a supine position during and after the procedure. ( a very reasonable conclusion from incomplete removal/delivery of a placenta)

1.Amniotic fluid sets off the coagulation cascade from protein interaction when it enters maternal blood causing acute DIC and causing systemic microinfarctions. Particularly manifest in the brain, heart, kidneys, and liver. (multiple organ dysfunction secondary to ischemia)

2. With the clotting factors depleted and liver impairment in the first 24 hours, uncontrolled hemorrhage results, both externally and in serous membranes.

3. When in the supine position this separation also allows clinically significant (greater than 100cc) air embolus to enter the maternal vascular system, most commonly resulting in massive PE. This manifests in the right sided heart insufficiency and respiratory findings.

4. With an opening and bleeding via the partially removed placenta, increased growth of normal bacterial flora (particularly S. Aureus or S.Pyogenes) multiply and their metabolites create a toxic shock syndrome resulting in gangrenous necrosis of the entire reproductive tract.

5. Finally acute sepsis from bacteremia .

(the storyline that ties it all together)The patient got pregnant. Scared and ashamed she feared her family would throw her out ( a fear of many teenage pregnancies in the US) and without medical coverage in her desperation (something we will see more of) she opted to look up abortion on the internet and ask her boyfriend for help. (to which he agreed because he saw it on House)

Prognosis: Death (most likely) or major lifelong disability including infertility. (after a lot of luck, herculean efforts, at a cost even Warren Buffet would probably regret losing)

 

[Aidey]

So basically 5 seconds looking at her computer search history would have probably given us the answer?

 

[Veneficus]

So basically 5 seconds looking at her computer search history would have probably given us the answer?

Most probably. Do you do that regularly when you see a patient?

 

[mycrofft]

Way above and beyond. Good mind exercise.

Hot abd with late signs of sepsis. Giddyup, do NOT blow the veins with failed IV's or start little ones, oxygenate, document for rapid pass-off at closest ER.

Unless you can resuscitate a crashing pt better in your rig?

Subcutaneous emphysema is not necessarily air, it can be products of baterial decomp.

What is your best IV solution for this?

 

[Veneficus]

What is your best IV solution for this?
[/FONT]

blood...

Giving this patient a chrystalloid infusion in my opinion would be like flushing the toilet to get what blood was left out of the bowl.

 

[8jimi8]

well i'll take a little confidence boost out of my delirious field impression!

Although I did miss the PE... however, when originally presented the sepsis/dic and s/q emphysema seemed way more emergent than 89%on r/a and resprs at 24...

great scenario.

 

[Lifeguards For Life]

well i'll take a little confidence boost out of my delirious field impression!

Although I did miss the PE... however, when originally presented the sepsis/dic and s/q emphysema seemed way more emergent than 89%on r/a and resprs at 24...

great scenario.

agreed. great scenario

 

[medic417]

Most probably. Do you do that regularly when you see a patient?

No because like House I send my people on wild goose chases to do that for me.

To add things not done, how many that responded or even read but did not respond would have truly exposed this or any patients. It amazes me how many will not remove patients clothes and actually look at the patient to truly evaluate them.