57 yo F - AMS

[Medico]

I had this call today and the outcome was, ok. I feel there could have been more I could do. Lets hear what you would have done.

You're called for a 57 year old female with AMS.

Dispatch gathers some additional and advises you that her "home healthcare nurse" also reports that she has low stats, is hypotensive, and bradycardic.

On your arrival you find a morbidly obese woman sitting in her chair starring off into space. You get her attention by calling her out by name, as this is your frequent flyer. She acknowledges your presence by looking at you. She is aware of her surroundings, responds appropriately to commands, but is not oriented to place/time/event.

Home health nurse states the pt has been like this for approximately 4 hours, and was normal the night before. When questioned if she has been suctioned the nurse responded, "No she said she didn't want to be suctioned".

The pt is assisted to the stretcher and moved outside to the ambulance.

She has a trach with a passy muir valve, and receiving 15lpm humidified o2.
A pic line in the left arm, receiving continuous antibiotics, for an unknown reason.

Your vitals are:

HR: 50 strong and regular
RR: 18, equal with rales bilaterally
BP: 90/54
Spo2: 86%
Temp: 97° oral
BS: 77
Skin warm and dry. PERRL. GCS 14.

I've also included your initial 12-lead.

 

[Rykielz]

What was her return SpO2 saturation when she was put on high flow O2?

What's her history, allergies, and medications?

 

[Medico]

What was her return SpO2 saturation when she was put on high flow O2?

What's her history, allergies, and medications?

That was her initial o2 stat with the high flow o2.

Sorry, I thought I had the additional info. Must of cut out.

PMI: Aneurysm (unknown origin), MI, HTN, COPD, Asthma.

Allergies: Dilaudid

Meds: Cardizem, Coumadin, Aspirin, Diamox, Lasix, Plavix, Prilosec, Lisinopril, Albuterol,Zocor.

 

[Hunter]

That was her initial o2 stat with the high flow o2.

Sorry, I thought I had the additional info. Must of cut out.

PMI: Aneurysm (unknown origin), MI, HTN, COPD, Asthma.

Allergies: Dilaudid

Meds: Cardizem, Coumadin, Aspirin, Diamox, Lasix, Plavix, Prilosec, Lisinopril, Albuterol,Zocor.

Considering AMS due to hypoximea secondary to CHF then pulmonary edema, she's sating low even with high flow O2 which tells me the O2 isn't making it to the her alveoli, they and lung sounds. I'll add more details when I'm home but initially I'd put her on a cpap, ask the nurse when was the last time she took her lasix?

 

[Urbanems]

Do we have a temperature?

 

[Rykielz]

Considering AMS due to hypoximea secondary to CHF then pulmonary edema, she's sating low even with high flow O2 which tells me the O2 isn't making it to the her alveoli, they and lung sounds. I'll add more details when I'm home but initially I'd put her on a cpap, ask the nurse when was the last time she took her lasix?

It's very strange that her skin is warm and dry, yet she's bradycardic and borderline hypotensive with what appears to be a CHF crisis. Normally it's the exact opposite.

I agree with the CPAP that's the next best step after the high flow O2. In most cases the CPAP will fix the problem quickly. Obviously I'd be holding off on NTG, Lasix, etc. because of the BP and a fluid bolus because of the rales. Just to r/o stroke I'd get some grips/pushes if possible as well. From what you've described there's a possibility that this could be an overdose.

 

[truetiger]

Im not sure CPAP would be the best option.....the intrathoracic pressure from the CPAP will not do great things for her pressure. Why not give her some dopamine (preferably dobutamine but I realize thats probably not an option) to get her pressure up and then you can CPAP her. How do you plan on CPAPing this patient with a trach?

 

[Wheel]

Cardizem OD? Low bp, heart rate, and maybe retaining some fluid causing the rales.

 

[hibiti87]

Cardizem OD? Low bp, heart rate, and maybe retaining some fluid causing the rales.

^ this perhaps trial some calcium chloride.

Also of course address the low o2 saturation.

I am leaning towards AMS from infection though.

 

[truetiger]

Trousseau sign present when you took the BP?

 

[Clare]

In the absence of tachydysrhythmia do not think her pulmonary edema is cardiogenic.

Her heart rate is regular and very slow which is unusual for what, at first glance, looks like AF. Perhaps it is artifact? I do not see any ischaemic changes in the ECG but then again, its not the easiest to determine.

I would give her some atropine, 250 ml of fluid and see if she would accept a tight fitting bag mask with a PEEP of 5

If these improve her BP and O2 sat then she can be classified as serious problem but not life threatening but is time sensitive (status 2) but if she doesn't improve or gets worse then she will be status 1 (critical problem that is life threatening or time critical)

 

[cruiseforever]

[. How do you plan on CPAPing this patient with a trach?[/QUOTE]

Wondering the same thing.

 

[Rykielz]

[. How do you plan on CPAPing this patient with a trach?

Wondering the same thing.[/QUOTE]

Haha good point. Selective reading I suppose. In that case I'd say Dopamine may be your only option in the pre-hospital setting. The other option is to simply high tail it to the ED.

 

[Veneficus]

The other option is to simply high tail it to the ED.

This I think is the best response here.

It looks to me like low output failure with renal insufficency if not failure.

Edit: with sepsis maybe.

 

[abckidsmom]

This I think is the best response here.

It looks to me like low output failure with renal insufficency if not failure.

Edit: with sepsis maybe.

Even though it is a boring set of tasks, some of my most interesting patients, all I do is investigate the history well enough to give a good solid get-the-ball-rolling report, establish IV access, monitor and add oxygen as needed.

 

[Veneficus]

Even though it is a boring set of tasks, some of my most interesting patients, all I do is investigate the history well enough to give a good solid get-the-ball-rolling report, establish IV access, monitor and add oxygen as needed.

History is probably themost important part.

It is often said in medicine that a good history often can lead to a Dx even without an exam. I am not sure if there are any studies on it, but it seems to be very true.

 

[Medico]

A lot of great responses and use of critical thinking.

I was wondering the same, CPAP on a trach? I imagine it has been done before, but I would be curious with how much success. lol

Here, I'm not allowed to access a pic line. I was able to get a 22 in her hand, luckily. As you may have gathered, she has bad opportunities for access.

I removed her passy muir (I had a pt having seizures, and it was blamed on the passy muir and ruled to be hypoxic seizures), no rise in sats. I then put 4ml of fluid into her trach and suctioned a large mucus plug. Her o2 sats rose and sat around 92-95%.

I then administered 500ml of NaCl. Her BP systolic rose to 100/50, and fluctuated slightly around there.

With no resolve to her bradycardia, and none to her AMS. I gave her .5 of atropine. Her pulses rose to 110. But remained at a GCS of 14.

I did not think to remove her inner canula to be changed, as she may have be bradycardic due to a vagul response from additional mucus.

Rales is a normal finding for this pt, that is why I was not aggressive with CHF treatment. However, with the discussions I feel I may have went the wrong way with my treatment.

I ignored the monitors diagnosis of A Fib, as she was between 40-60, and it appeared to be artifact.

She received rapid transport to the hospital that knows her best. I plan on following up on this call.

I did place her on ETCo2, and she would not come below 60. She had good box wave form, no indicators of obstruction/constriction.

 

[Veneficus]

Nevermind.

Didn't see part of the first post.

 

[Hunter]

Nevermind.

Didn't see part of the first post.

Seems we all have selective reading.

 

[phideux]

What kind of antibiotics is she getting, and why????
A good persistent UTI????