87 yo M Fall, Unresponsive, hypotensive

[LACoGurneyjockey]

Called for a fall, arrive to find 87 yo male on the floor states he fell getting out of bed. Stood up, became dizzy, fell at ground level. No head/neck/back pain, A/Ox4 but slow to answer. Only meds are antihypertensives, history is HTN. Patient's been constipated for 5 days with ABD pain, slightly distended, no bruising/discoloration. Fire helps the patient up to sitting, where he shortly becomes dizzy, tries to vomit, and subsequently becomes unresponsive. No radial pulse, snoring respirations, BP 70/40. After loading the patient and enroute he regains consciousness but is still altered. With fluids the BP is up to 80/50, after another 1000ml in ER BP comes up to 110/70.
I was thinking GI bleed or vasovagal from the constipation and trying to vomit, but it doesn't quite satisfy my curiosity...
So...thoughts anyone?

 

[mycrofft]

Lung sounds? Meds including (!!!!) OTC's? Diet? Hydration? Apical pulse, or only radial? Skin tenting? Living alone?

With constipation, plus if the BP rose and everything got better (nothing worse) after fluid bolus, I'd suspect dehydration as one factor. As we get more frail, one problem, unmasks others; maybe there is a cardiac insufficiency which causes orthostatic hypotension, maybe (probably) the pt's nutrition is down, and more horses and zebras. Stress of vomiting: good catch, think CVA as well as vasovagal.

 

[TheLocalMedic]

Bowel obstruction caused him to vagal, most likely. There's a chance something else could be the cause; too much of his meds, cardiac etc… But with what you described that sounds like a vasovagal from a tummy full of poopies.

 

[LACoGurneyjockey]

Lung sounds? Meds including (!!!!) OTC's? Diet? Hydration? Apical pulse, or only radial? Skin tenting? Living alone?

With constipation, plus if the BP rose and everything got better (nothing worse) after fluid bolus, I'd suspect dehydration as one factor. As we get more frail, one problem, unmasks others; maybe there is a cardiac insufficiency which causes orthostatic hypotension, maybe (probably) the pt's nutrition is down, and more horses and zebras. Stress of vomiting: good catch, think CVA as well as vasovagal.

12 lead showed sinus tach about 100, wife isn't the best historian but denies any other Meds/OTCs but an antihypertensive. Can't remember the exact one, states he took the same dose as usual. BP doesn't come back up when he's supine until the fluid bolus. No facial droop, equal grips, speech is slow but not slurred.
I hadn't thought about dehydration, but now that you mentioned it that sounds pretty good.

Oh, and lungs are clear, RR 20, no complaint of SOB.

 

[mycrofft]

I was thinking of dehydration as the stressor which caused other mechanisms to predominate. We codgers can be dehydrated and not be thirsty, and when it's time to eat, we say "I'm not really hungry" when we ought to be taking our fuel break as needed by our metabolism, not psychological need to eat.

Kids are different animals than adults, and oldsters are too.

 

[VFlutter]

What did the vomit look like? Last bowel movement? GIB is high on my ddx.

 

[unleashedfury]

he's all kinds of backed up from what you say. with constipation x 5 days.

Bowel Obstruction S/S

1. Abdominal Pain
2. Nasuea/vomiting
3. Lack of Bowel Movement

Things I want to know.
BGL
Last Oral Intake. and how well has he been with eating/drinking for the last few days

What kind of Antihypertensives is the patient taking? Theres Beta Blocker, Diuretics, Calcium Channel Blockers. etc.

I am suspecting that the Nausea, vomiting may be caused by the bowel obstruction to be complicated with dehydration if the patient has not been maintaining good nutrition for a few days.

But what about a possible onset of sepsis with the patient being hypotensive.

 

[zzyzx]

Pretty much what everyone else already said. If he does have a bowel obstruction, dehydration, often profound, is very common. That could explain his hypotension and the immediate response with the fluid bolus. His syncope was due to his change in position (orthostatic hypotension), which can be exaggerated in elderly people who don't respond as well to positional changes, not to mention the BP needs he may be on. It is not likely to be vaso -vagal syncope as you would see hypotension and also bradycardia together. Of course there's a whole lot else that could be going on, as others have pointed out

 

[Ewok Jerky]

to echo what everyone was saying...

if he is on a beta blocker for HTN then this will further blunt his ability to compensate for position changes, ie. standing up.

heres how I see it goin down. He takes his BP meds as directed, hes old, so he runs dry and also is constipated. constipation leads to abdominal discomfort whch leads to decreased PO intake > increased dehydration. after a couple days, he stands up, hes volume depleted so BP drops, hes beta-blocked so he cant compensate, his body decides to componsate by going horizontal.

he needs an ekg, IVF, and review of meds just in case.

 

[mycrofft]

(facepalm) His antihypertensives…do they/does it include HCTZ (hydrochlorothiazide)?

 

[bmedic1681]

What was his heart rate?I am thinking more along the lines of dehydration and depending upon how long he has been dehydrated and when his last bowl movement possible impaction which will cause the desire to pouch with no effect other than stimulating the vasovagal response…. was the patients HR tachycardic??? another sign of dehydration especially upon exertion
…

 

[bmedic1681]

lol pouch should have been push…. silly spell check