56 y/o, f

[Hunter]

Had a patient the other day, 56 y/o F, cc: fell down not feeling well, I wanna go to the hospital. U/A: found 56 Y/O F on the ground, managed to crawl around and grab her pillow, phone and purse, when she moves around you notice that she's deficated herself. In some distress but she's able to sit up on the ground. She's AAOx3, GCS 15, states "I felt weak and fell down, and then I couldn't get up. Denies LOC, trauma or pain anywhere.

Get her on the stretcher and in the truck vital signs where approx:
BP: 75/40, HR: 150-170, 4Lead ECG shows PSVT, 12 lead: PSVT, SAO2 94%.

How do you treat/assess?

 

[Dwindlin]

I'm sure there is a catch, but from what you've posted here she appears unstable and is very tachycardic. I'd address that first with cardioversion, then reassess.

 

[Hunter]

I'm sure there is a catch, but from what you've posted here she appears unstable and is very tachycardic. I'd address that first with cardioversion, then reassess.

Yeah there's a catch, think of etiology, and instead of treating the symptom, try and find the cause. Would you ask her anything else other than the information I gave you?

 

[Nattens]

Yeah there's a catch, think of etiology, and instead of treating the symptom, try and find the cause. Would you ask her anything else other than the information I gave you?

Looking at the causes of PSVT we've got a few possible causes

-Overexertion (Ask if an abnormal exercise, usual exercise tolerances)
-Stimulants (Alcohol, Tobacco, Coffee, Amphetamines, Cocaine. So ask if any recent ingestion of any of these substances)
-Hyperventilation (Which we would notice, what was her respiratory status?)
-Electrolyte Imbalances and Acid Base Imbalances(Recent substance ingestion, any history of metabolic or respiratory disorders)
-Emotional Stress (Any recent changes, loss of a relative etc)

As far as treatment goes patient is rapidly detriorating so

-Midazolam 2.5mg IV repeating 2.5mg IV until patient only responds to painful stimuli
-Cardiovert 75j biphasic, if no reversion 150j biphasic
-Transport

 

[hibiti87]

medication list, does she take blood thinners, how long has it been going on, has she felt this way before, what does the BM look like, has she been having BMs more frequently. shes gcs 15 granted low bp, im not to concerned though, transport patient trendelenburg, start iv give fluids, reassess.

That being said i would most likely not cardiovert the patient. Afib.

 

[Hunter]

medication list, does she take blood thinners, how long has it been going on, has she felt this way before, what does the BM look like, has she been having BMs more frequently. shes gcs 15 granted low bp, im not to concerned though, transport patient trendelenburg, start iv give fluids, reassess.

That being said i would most likely not cardiovert the patient. Afib.

Only history is of hypertension, for which she no longer takes medications because her BP was becoming too low consistently. Weakness has been going on for a few days but worsened today.

 

[Hunter]

-Overexertion (Ask if an abnormal exercise, usual exercise tolerances)
-Stimulants (Alcohol, Tobacco, Coffee, Amphetamines, Cocaine. So ask if any recent ingestion of any of these substances)
-Hyperventilation (Which we would notice, what was her respiratory status?)
-Electrolyte Imbalances and Acid Base Imbalances(Recent substance ingestion, any history of metabolic or respiratory disorders)
-Emotional Stress (Any recent changes, loss of a relative etc)

As far as treatment goes patient is rapidly detriorating so

-Midazolam 2.5mg IV repeating 2.5mg IV until patient only responds to painful stimuli
-Cardiovert 75j biphasic, if no reversion 150j biphasic
-Transport

Resp where 14, sao2 94%,
negative to all of those except, however she said she hasn't eaten in 5 days, and hasn't had anything to drink in 2-3 days.

 

[mycrofft]

"How do you treat assess?"

(I AM controlling myself, I AM controlling myself!").h34r:

 

[JPINFV]

Resp where 14, sao2 94%,
negative to all of those except, however she said she hasn't eaten in 5 days, and hasn't had anything to drink in 2-3 days.

I so wanted to post, "fluids" before something like this got posted. That way I could be all smooth.

 

[JPINFV]

How do you treat assess?

[YOUTUBE]http://www.youtube.com/watch?v=kY84MRnxVzo[/YOUTUBE]

 

[Hunter]

"How do you treat assess?"

(I AM controlling myself, I AM controlling myself!").h34r:

fixed -.-

 

[hibiti87]

I so wanted to post, "fluids" before something like this got posted. That way I could be all smooth.

i said fluids before, therefore it makes me smooth?

 

[abckidsmom]

I so wanted to post, "fluids" before something like this got posted. That way I could be all smooth.

I try not to cardiovert someone whose volume status I'm not sure of.

 

[NomadicMedic]

Correct. She's going to get a fluid bolus before I start messing around with rate control.

I'd try adenosine before I lit her up.

You said the HR is variable. Is it really SVT or is it afib with RVR.

 

[Rykielz]

This is a very sick woman and I'd get her going asap. First thing i'd do before I left scene is grab her meds. You said she's been off the HTN RX because her BP was getting too low? That could be part of the problem today. Check her lung sounds (i=Is she SOB? Do I hear rales?). I'd look at the stool too. Is is bright red? Black? Foul or unusual odor? She could be bleeding out internally. If she hasn't eaten in 2-3 days and those are her vitals that is another red flag. I'd be cognizant of dehydration and malnutrition. Has she been vomiting as well? If so, what color is the emesis? Palpate the abd (make sure there's no pulsating masses or abnormal distention). Another great thing to grab would be her grips/pushes and have her smile for the differential diagnosis to r/o stroke. Then check her pedal and brachial (since radial probably won't be felt) to make sure they're present and equal. As far as treatment I'd do this:

1) Place her in shock position
2) Oxygen 15 LPM via NRB
3) Cardiac monitor (Have my partner perform a 12-lead)
4) Bilat. large bore IV (grab a bs as well)
5) NS fluid bolus (That could very well correct her HR and her BP)
6) I'd be careful with adenosine. She's unstable and this appears to be
a hypovolemia and not a conduction issue. Cardioversion (Versed
beforehand for pre-cardioversion)may be the better option although
that probably won't do much either.
7) Perform another 12-lead if I'm able to get the HR to slow down. This
could very well be an MI as well.
8) Get her to the hospital asap. She needs the higher level of care.

***I had a call very similar to this. 30-ish y/o female fell suddenly had been sob for several days. By the time we got there she was lethargic and unable to speak due to her breathing. VS: 230 HR SVT, BP 70/P, RR 60 rapid and shallow. LS were absent in the bases with rales heard in the upper lobes bilat. I ended up popping bilat. large bore IV's in her, bagging, and cardioverting her 3 times which didn't do anything. I wanted to put her on CPAP but she did not meet the criteria according to my protocols. Well when we get her to the hospital the doc put her on their CPAP and she was fixed within 10 minutes; full sentences and everything. Never had an SVT call like it since.***

 

[Hunter]

Just to clarify we gave her 1L Fluid, which brought her BP back to about 110/60, and her pulse to somewhere around 125-130 (Don't remember exact numbers), and transported her to the hospital. We considered adenosine, but after she told us that she hadn't had anything to drink in days we decided to go with the fluid bolus. Also when she said that we checked skin turgor and it was at least 3 seconds.

 

[Handsome Robb]

She's awake, talking moving around and you want to jump to zapping her??

Fluids, watch her for fluid overload, consider adenosine maybe...

Using the 220-age rule she's barely into the SVT range...

 

[Rykielz]

Just to clarify we gave her 1L Fluid, which brought her BP back to about 110/60, and her pulse to somewhere around 125-130 (Don't remember exact numbers), and transported her to the hospital. We considered adenosine, but after she told us that she hadn't had anything to drink in days we decided to go with the fluid bolus. Also when she said that we checked skin turgor and it was at least 3 seconds.

Clearly a fluid issue then, but I'd continue to reassess and look to see if anything else was going on. Definitely a call where I'd be texting the nurse to see the outcome too.

 

[Handsome Robb]

a

This is a very sick woman and I'd get her going asap. First thing i'd do before I left scene is grab her meds. You said she's been off the HTN RX because her BP was getting too low? That could be part of the problem today. Check her lung sounds (i=Is she SOB? Do I hear rales?). I'd look at the stool too. Is is bright red? Black? Foul or unusual odor? She could be bleeding out internally. If she hasn't eaten in 2-3 days and those are her vitals that is another red flag. I'd be cognizant of dehydration and malnutrition. Has she been vomiting as well? If so, what color is the emesis? Palpate the abd (make sure there's no pulsating masses or abnormal distention). Another great thing to grab would be her grips/pushes and have her smile for the differential diagnosis to r/o stroke. Then check her pedal and brachial (since radial probably won't be felt) to make sure they're present and equal. As far as treatment I'd do this:

1) Place her in shock position
2) Oxygen 15 LPM via NRB
3) Cardiac monitor (Have my partner perform a 12-lead)
4) Bilat. large bore IV (grab a bs as well)
5) NS fluid bolus (That could very well correct her HR and her BP)
6) I'd be careful with adenosine. She's unstable and this appears to be
a hypovolemia and not a conduction issue. Cardioversion (Versed
beforehand for pre-cardioversion)may be the better option although
that probably won't do much either.
7) Perform another 12-lead if I'm able to get the HR to slow down. This
could very well be an MI as well.
8) Get her to the hospital asap. She needs the higher level of care.

***I had a call very similar to this. 30-ish y/o female fell suddenly had been sob for several days. By the time we got there she was lethargic and unable to speak due to her breathing. VS: 230 HR SVT, BP 70/P, RR 60 rapid and shallow. LS were absent in the bases with rales heard in the upper lobes bilat. I ended up popping bilat. large bore IV's in her, bagging, and cardioverting her 3 times which didn't do anything. I wanted to put her on CPAP but she did not meet the criteria according to my protocols. Well when we get her to the hospital the doc put her on their CPAP and she was fixed within 10 minutes; full sentences and everything. Never had an SVT call like it since.***

May I ask why?

She needs an ALS workup and transport to definitive care but she doesn't need you running around like a chicken with your head cut off. Despite popular belief, there's very few things where seconds truly count.

The call you referenced is much more severe than the one originally described in this thread.

She's dehydrated. Severely. She doesn't need medications or electricity. She needs fluids and electrolytes. 150-170 isn't that fast for a 56 year old. It's fast and needs to be addressed but she's not going to crump on you. Take the numbers you're getting and combine them with your patient's presentation and decide on the best treatment path.

So you want to give a severely hypotensive patient versed to cardiovert her? Versed isn't as scary as medic school makes it out to be but if she's stable enough for you to mess around with getting a line and drawing narcs she's stable enough for you to start a fluid challenge and consider chemical cardioversion before lighting her up like the morning sky.

You said you'd be wary of adenosine because "she's unstable and hypovolemic, cardioversion is a better option". How is cardioversion even an option in this instance? What is cardioverting a hypovolemic patient going to do for them other than hurt? Replace the volume, see what that does then reconsider your plan of action...

Where the heck did a CVA assessment come into play? I'm all for being thorough but nothing here says stroke to me at all. Maybe I'm missing something but you can do a pretty solid neurological assessment by just interacting with a patient. She complained of generalized weakness, not unilateral weakness....

 

[PaddyWagon]

A basic student's guess: maybe stroke + dehydration. See if she remembers recent headache(s), check facial droop, slurring of words, and the arm drop test.

Stroke would account for the original fall and loss of ability to get back up. Dehydration leads to hypovolema and accounts for the low BP. It's possible for a stroke to build up over days, though I have to read up on how common that might be.

Am I way off base, I'm still a newbie for sure?

Here in LA county we're taught to not do Trendelenburg.

I'm going to read up on the treatments brought up even though they're way out of my scope, never hurts to know =)