30 Y/0 M Sick Person

[frdude1000]

Dispatched for a sick person on side of highway. Arrive on scene to find male laying in box of a moving truck, moaning in pain. He vomited a large amount before our arrival. Paramedic Engine arrives before us. Pt. states he has LLQ abd. pain 10/10 sharp. Vitals were pulse 30, BP 170/110, O2 sat 96. Pt. stated no prior medical problems, not taking any meds. Transported priority 2, upgraded by ALS engine medic. Enroute, medic started the patient on a bag of normal saline and placed pt. on lifepak. While transferring to hospital staff, he begun to vomit again.

What do you guys think this might be? We are thinking it was either a aortic aneurysm or bad kidney stones.

 

[Anjel]

Dispatched for a sick person on side of highway. Arrive on scene to find male laying in box of a moving truck, moaning in pain. He vomited a large amount before our arrival. Paramedic Engine arrives before us. Pt. states he has LLQ abd. pain 10/10 sharp. Vitals were pulse 30, BP 170/110, O2 sat 96. Pt. stated no prior medical problems, not taking any meds. Transported priority 2, upgraded by ALS engine medic. Enroute, medic started the patient on a bag of normal saline and placed pt. on lifepak. While transferring to hospital staff, he begun to vomit again.

What do you guys think this might be? We are thinking it was either a aortic aneurysm or bad kidney stones.

I don't think it was an aneurysm.

Probably stones of some sort. Maybe colitis, or some bad food poisoning.

Pulse of 30 though? That is very odd. I would suspect 130?

 

[fast65]

Could be colitis or diverticulitis. However, I would like to see a 12 lead on him.

 

[Handsome Robb]

How was his abdomen? Distended? Discoloration? Pulsating masses? Tender to palpation? Referred pain anywhere? Rebound tenderness? Blood in the vomit? "Coffee grounds" in vomit? Did it smell like feces or just regular puke (weird question I know but it's not something you have to really go out of your way to assess)? A&O? Skin signs? Onset? Last BM? Diarrhea? Changes in diet or abnormal foods recently? Hx of kidney stones? Did he feel the pain descend? Any pain in his back? Dizziness? Chest pain? SOB? Hx or family Hx of diverticulitis/diverticulosis? 12-lead done?

HR of 30 a typo or actual rate? AAA would usually be hypotensive and tachycardic not the other way around. Kidney stones would usually present with descending flank pain rather than LLQ abd pain. Wondering your thought process on these two differentials? Not saying you're wrong just wondering how you came to this conclusion.

No zofran/phenergan or pain management? Pain management is presuming he isn't altered.

Could be a perforated bowel causing peritonitis but I'd think it would be more diffuse pain rather than LLQ. Could be a severe bowel blockage (hence the poopy smelling vomit question). HR could also be secondary to a vasovagal response but I'd think his pressure would be dumped out too, "bearing down" or similar pressure secondary to a bowel blockage. Could be diverticulitis or colitis.

edit: dammit, fast beat me to the colitis/diverticulitis.

 

[fast65]

edit: dammit, fast beat me to the colitis/diverticulitis.

It's what I'm here for, you said everything I was too lazy to say, so it's the least I can do.

 

[Veneficus]

How was his abdomen? Distended? Discoloration? Pulsating masses? Tender to palpation? Referred pain anywhere? Rebound tenderness? Blood in the vomit? "Coffee grounds" in vomit? Did it smell like feces or just regular puke (weird question I know but it's not something you have to really go out of your way to assess)? A&O? Skin signs? Onset? Last BM? Diarrhea? Changes in diet or abnormal foods recently? Hx of kidney stones? Did he feel the pain descend? Any pain in his back? Dizziness? Chest pain? SOB? Hx or family Hx of diverticulitis/diverticulosis? 12-lead done?

HR of 30 a typo or actual rate? AAA would usually be hypotensive and tachycardic not the other way around. Kidney stones would usually present with descending flank pain rather than LLQ abd pain. Wondering your thought process on these two differentials? Not saying you're wrong just wondering how you came to this conclusion.

No zofran/phenergan or pain management? Pain management is presuming he isn't altered.

Could be a perforated bowel causing peritonitis but I'd think it would be more diffuse pain rather than LLQ. Could be a severe bowel blockage (hence the poopy smelling vomit question). HR could also be secondary to a vasovagal response but I'd think his pressure would be dumped out too, "bearing down" or similar pressure secondary to a bowel blockage. Could be diverticulitis or colitis.

edit: dammit, fast beat me to the colitis/diverticulitis.

Many good questions...

Could I just suggest starting with: "Is the patient able to localize the pain or is it diffuse"

edit: also with the description and vitals here, I would not focus on his abdomen alone and would especially look at his head.

 

[NYMedic828]

Is the heartrate correct?

To have a HR of 30, not be AMS and have a Hypertensive BP is very strange.

Not sure adding more fluid at that point was a necessary move but we weren't there.

A more detailed history would help greatly in this scenario.

 

[abckidsmom]

Many good questions...

Could I just suggest starting with: "Is the patient able to localize the pain or is it diffuse"

edit: also with the description and vitals here, I would not focus on his abdomen alone and would especially look at his head.

That's what I was thinking.

Also, if he's a young healthy guy in a lot of pain, he could vagal his heart rate down that low, and all that pressure would falsely raise his BP.

I don't know about everyone else, but I find that almost everyone is initially hypertensive, and after they settle down a bit, the pressure is more normal. Maybe not almost everyone, but many, many people.

 

[SliceOfLife]

First thing that popped in my head when I heard back of truck was CO poisoning. Symptoms seem to fit too.

 

[LifelongEMT]

First thing that popped in my head when I heard back of truck was CO poisoning. Symptoms seem to fit too.

How long was he in the back of the truck? Was it running? was it hot? Was his skin flushed? Had he been drinking alot of fluids? if so what kind? I know from experience some soft drinks are notorious for kidney stones.

 

[SliceOfLife]

How long was he in the back of the truck? Was it running? was it hot? Was his skin flushed? Had he been drinking alot of fluids? if so what kind? I know from experience some soft drinks are notorious for kidney stones.

Yup. All things to consider for your differential.

 

[LifelongEMT]

LOL how many exhaust leaks did the truck have???? Thats a good one too.

 

[frdude1000]

Yes, heart rate is correct at 30 BPM. I do not have a 12 lead unfortunately to show. We never got a complete history because he was moaning in 10/10 pain the whole time, but for a second he told us he had no medical problems or allergies, or meds. His vomitus was of normal color and consistency. He stated he didn't eat since earlier in the day and he wasn't drinking very much. I believe he was only in the back of the truck so he could vomit in the shade in privacy (since we were on the side of the major highway in DC)--he was never riding back there. This guy was a hard stick and we were 3 min away from ED so he only had a chance to start the IV and hang a bag.

 

[LifelongEMT]

. He stated he didn't eat since earlier in the day and he wasn't drinking very much. This guy was a hard stick and we were 3 min away from ED so he only had a chance to start the IV and hang a bag.

Was it hot out? with him being a hard stick probably dehydrated and maybe heat exahaustion? Just an idea.

 

[Veneficus]

Was it hot out? with him being a hard stick probably dehydrated and maybe heat exahaustion? Just an idea.

Usually the heat related patients get better after they vomit.

 

[LifelongEMT]

Usually the heat related patients get better after they vomit.

I had a heat stroke during a late july football game in high school and the more i vommited the more dehydrated and the worse i got until i finally blacked out and woke up,in the ER, but everybodys different. I have seen improvement in heat related pts after they vommit but not all the time. Just another point of view.

 

[frdude1000]

I was busy putting the pt. on O2, spiking the bag, and getting the patient on the monitor while the medic was doing most of the pt. assessment and getting the line in place during this very short transport. I believe he was dehydrated though because he was diaphoretic and he stated he hadn't been drinking at all during the day.

 

[Melclin]

How many spare hands did you have? How long does it take to draw up your anagesic and antiemetic of choice?

Its not even an matter of being humane. You just won't be able to learn much untill he can speak to you. Nobody will. Head is an option. I think abdo problem is most likely (I think those vitals can be explained by vomiting/vagal), but who knows until you actually examine them properly.

If I were receiving that pt, I would much prefer him delivered to me about 90 seconds later pain free and and not vomiting with a little hx rather than 90 seconds earlier with none of that.

 

[frdude1000]

I agree with you. I was not in charge of the pt, the medic was.

 

[Melclin]

I agree with you. I was not in charge of the pt, the medic was.

Yeah I understand that. I've been in that position plenty of times so I sympathise. My tone was probably a bit harsh. It wasn't directed at you, so much as the idea.