38 year-old male altered mental status

[EMTinNEPA]

You are working on a non-transport capable paramedic intercept vehicle and are dispatched along with the local volunteer BLS service for a 38 year-old male in seizures. You arrive on scene to find the patient awake and alert, but lacking orientation to time and place. Repetitive statements and questioning suggest short-term memory loss. The patient's family states that they found the patient semi-responsive with "drainage" from the mouth and nose and that they did not witness any seizure activity. The patient denies complaints of chest pain, shortness of breath, weakness, dizziness, nausea, vomiting, or flu-like symptoms. The patient complaints of thirst.

Past medical history of anxiety and chronic back pain.

Medications are Percocet and Xanax.

Allergy to walnuts.

VITALS
BP - 80/60
HR - 120
RR - 16
O2 Sat - 86% on room air, 94% on 4lpm via nasal cannula
EKG - Sinus tachycardia without ectopy

Physical exam
HEENT: Normocephalic. No drainage or bleeding from ears, nose, or mouth, Pupils PEARL at 2mm. Negative JVD. Trachea midline.
CHEST: Normal and symmetrical movement on inspiration and expiration. Lungs clear and equal to auscultation.
ABDOMEN: Soft, non-tender, non-distended.
BACK/SPINE: Unremarkable.
PELVIS: Unremarkable.
EXTREMITIES: Unremarkable.

BLS arrives on scene at the same time you do. Your closest hospital is approximately 20 minutes away.

What are your differentials and how would you proceed in treating this patient?

 

[abckidsmom]

Can we check his blood glucose before we dig in here?

 

[MasterIntubator]

He probably took too many of his drugs

 

[fast65]

BG? Anything that suggests he may have OD'd? Any chance he hit his head during the seizure activity, seems like he might have a concussion.

 

[abckidsmom]

My thoughts:

Sugar issues, further assessment required (either hyper- or hypoglycemia.)
CVA
Sz (any trauma?)
Any fever?
Drug OD
Psych issues

Need more info.

 

[fast65]

My thoughts:

Sugar issues, further assessment required (either hyper- or hypoglycemia.)
CVA
Sz (any trauma?)
Any fever?
Drug OD
Psych issues

Need more info.

The complaint of thirst makes start thinking of hyperglycemia, but that's just my initial thought right now.

 

[46Young]

Drug abuse is a possiblilty. I'd like a BGL and a 12 lead. you didn't mention any indication for spinal motion restriction. Besides the hypotension, there's nothing that needs to be addressed onscene that can't be done enroute to the hospital. You've got a 20 minute txp. Do everything enroute. O2's already on, I'd get IV access, hang a bag at KVO to start, then do a BGL and a 12. You should have the driver pull over when you record the 12 to avoid artifact. I'd like to know why he's hypotensive before I just go and give a bolus.

 

[MasterIntubator]

You should have the driver pull over when you record the 12 to avoid artifact.

Do you really do this?

 

[46Young]

Do you really do this?

We did this on IFT cath lab jobs when I worked at NS-LIJ. We had a goal of less than ten minutes from arrival at the ED to transporting. I'd typically attatch the 12 in the bus, since so much of our time was spent getting report, changing over the pumps, getting to and from the ED, etc. It takes less than a minute to pull over to the side of the road, hit the button, and then resume transport when the monitor advisies analyzing.

As far as 911, I like to get a 12 onscene in the house within the first five minutes if indicated. I usually have plenty of help, all of which can properly position a 12. Our txp times run from 5-20 minutes in most cases. I run a repeat 12 at the ED, after turning off the vehicle, before taking the pt out of the bus. For the OP, it's unknown if that crew can place a 12. He's 20 minutes from the closest hospital. He didn't say if it was a stroke center, trauma center, or STEMI center. Twenty minutes is plenty of time to get things done. Although a cardiac event is low on my list of differentials, the 12 can show other things. That's why I said I would do one on the way to the hospital, rather than add on to that 20 min txp time. I've had many 12's ruined by artifact from bumps in the road, rig vibrations, the pt adjusting themselves after said bumps, etc. Stopping on the side of the road only takes a minute, if that. If it's unsafe to do so at the moment, I'll have the driver keep going, run a 12 in motion, and pull over if needed due to the quality of the previous 12.

 

[Mobey]

Temp?

 

[MrBrown]

Um bloody hell .... Brown is thinking this dude is hyperglycaemic coz he doesnt know he is diabetic yet.

 

[46Young]

Um bloody hell .... Brown is thinking this dude is hyperglycaemic coz he doesnt know he is diabetic yet.

True. He could be in now decompensated shock presumeably from osmotic diuresis per his mental status, BP, and pulse rate.

 

[abckidsmom]

Um bloody hell .... Brown is thinking this dude is hyperglycaemic coz he doesnt know he is diabetic yet.

I'm with you, Brown, dear. But at 38? I don't know.

Seems like we'll just never know. Maybe we should imagine up some details so that we can think more clearly.

 

[46Young]

I'm with you, Brown, dear. But at 38? I don't know.

Seems like we'll just never know. Maybe we should imagine up some details so that we can think more clearly.

Yeah, the OP left us hanging.

 

[MrBrown]

I'm with you, Brown, dear. But at 38? I don't know.

Diabetes doesnt discriminate

Irs nice you think so affectionatly of Brown, but Brown is taken. sorry love, Mrs Brown is not the life-insurance sharing kind

 

[Rykielz]

You are working on a non-transport capable paramedic intercept vehicle and are dispatched along with the local volunteer BLS service for a 38 year-old male in seizures. You arrive on scene to find the patient awake and alert, but lacking orientation to time and place. Repetitive statements and questioning suggest short-term memory loss. The patient's family states that they found the patient semi-responsive with "drainage" from the mouth and nose and that they did not witness any seizure activity. The patient denies complaints of chest pain, shortness of breath, weakness, dizziness, nausea, vomiting, or flu-like symptoms. The patient complaints of thirst.

Past medical history of anxiety and chronic back pain.

Medications are Percocet and Xanax.

Allergy to walnuts.

VITALS
BP - 80/60
HR - 120
RR - 16
O2 Sat - 86% on room air, 94% on 4lpm via nasal cannula
EKG - Sinus tachycardia without ectopy

Physical exam
HEENT: Normocephalic. No drainage or bleeding from ears, nose, or mouth, Pupils PEARL at 2mm. Negative JVD. Trachea midline.
CHEST: Normal and symmetrical movement on inspiration and expiration. Lungs clear and equal to auscultation.
ABDOMEN: Soft, non-tender, non-distended.
BACK/SPINE: Unremarkable.
PELVIS: Unremarkable.
EXTREMITIES: Unremarkable.

BLS arrives on scene at the same time you do. Your closest hospital is approximately 20 minutes away.

What are your differentials and how would you proceed in treating this patient?

The two key points that I've seen from the information you've given thus far, is that he is complaining of thirst (which as pointed out by several people, could be an indicator for hyperglycemia) as well as a low SPO2 indicating hypoxia. Your gonna want to find out what his BS is as well as look at his skin signs. From there I'd want to know if he has a headache or any blurred vision. Also it'd be nice to know what color the "drainage" from his mouth or nose is. It's hard to identify a diagnosis without that information.

 

[abckidsmom]

Diabetes doesnt discriminate

Irs nice you think so affectionatly of Brown, but Brown is taken. sorry love, Mrs Brown is not the life-insurance sharing kind

abckidsdad feels the same way, don't worry. fraternal affection.

I would have been completely on the diabetes team if he'd been having a respiratory rate north of 20. The slow, even breathing convinces me not. But then again, maybe his respiratory rate was more along the lines of WNL. (we never looked)

 

[46Young]

abckidsdad feels the same way, don't worry. fraternal affection.

I would have been completely on the diabetes team if he'd been having a respiratory rate north of 20. The slow, even breathing convinces me not. But then again, maybe his respiratory rate was more along the lines of WNL. (we never looked)

I thought about the resp rate as well. I'll add another diagnostic on my wish list: ETCO2 capnography/capnometry.

 

[abckidsmom]

I thought about the resp rate as well. I'll add another diagnostic on my wish list: ETCO2 capnography/capnometry.

Keep dreaming, we're not getting any more details. We are a needy bunch here, only a few are up to presenting a scenario. (You'll note I never have.) I learn more about what I potentially miss here than what others are catching, lol.

It's all educational, though.

 

[Veneficus]

We are a needy bunch here, only a few are up to presenting a scenario.

Like any other skill, you can't get better without practice.