88YOF - stroke?

[Melclin]

This is not so much a who dunnit as perhaps an average case presenting several common challenges and I'm interested in some different approaches to dx and management.

At 1342 on a positively beautiful spring afternoon, you are dispatched to a lights and sirens case (Code 3 for Americans right?) for a Stroke - Symptoms <6hrs old, caller stating that her mother has a hx of strokes and is worried the pt is having another stroke. Response time of 45 mins.

On arrival you are met by the pt's middle aged daughter and led to an 88 year old female laying perfectly supine in bed with a neb mask purring away. A single officer from another branch had arrived about 15 mins earlier, has done an "assessment" and you get a very poor handover from him. He found wheezes on auscultation, mild SOB, A-fib of a rate unspecified, BP 110/systolic although I have my doubts due to his technique and neb'd 10mgs albuterol. He has nothing more for you.

Your assessment is as follows:


Hx
A-fib (unclear if paroxysmal or chronic), MI (nSTEMI 2002), Stroke (8/12 ago, apparently very minor with no lasting deficits, daughter states there was disagreement as to whether or not she'd ever actually had a stroke).
TIAs, splenectomy, osteoarthritis, hearing impairment, hypertension (dr says her BP was "fine" last it was checked), hypercholesterolaemia. Orthopnea (unsure if recently worse). Ankle odema (not noted to be worse in past week).

Medications: Warfarin, amoxicillin, irbesartan, escitalopram, esomeprazole, digoxin, Vit-D, carvedilol.

Allergies: Ace inhibitors.

Pt has a 1 week hx of a worsening SOB on exertion with no hx of such, several vomits (food), generalised weakness, productive cough, periodic headaches and nausea.

Currently complaining of: Mild headache, mild nausea & SOB, generalised weakness.

Denies: Chest pain/discomfort, palpitations, dizziness spontaneously or on standing.


O/E:
Neuro/HEENT: GCS 15 but seems mildly confused, some trouble comprehending and answering questions, equal and good strength and sensation bilaterally in arms and legs, PEARL (3mm), normal visual acuity/visual fields bilaterally, nil nystagmus, denies diplopia. Normal gait. White sclear, pink conjunctiva.

CVS: BP 180/110, pulse 140 irregular but strong, slightly pale per daughter, cold extremities. Good skin turgour, moist mucousa, nil tongue furrowing. Orthostatic HR/BP nil change. JVP 2cm.

Resp RR 36, Nil increased work of breathing, nil accessory muscle use, apparent distress etc, SpO2 on RA 86%. ++ quiet breath sounds in all fields, low pitched insp/exp wheezing, coarse midzone crackles bilaterally.

Abdo/GI/GU: Minor abdo distension per pt, nil spontaneous pain but tenderness on palpation of upper quadrants and moderate pain and guarding on palpation on right lower quadrant. Periodic small vomits in past few days although pt is vague, 1x small vomit of food this am. Poor oral intake of both food and fluid for past few days although again pt is frustratingly vague about the specifics. Normal daily bowel movements until this morning's which was "loose". Urinated 4 times yesterday, twice this am, normal frequency, nil urgency, pain/abnormal odour.

ECG: A-fib, narrow QRS complex, nil ST changes, normal T-waves. Rate of between 125 and 150 registering on monitor, pulse matches monitor, nil 12 lead performed due to lack of equipment.

BSL: 5.7
TEMP: 37.0 (98.6)

What do you want to do think is wrong with this pt, how will you manage her and to where will you transport her (if at all).

 

[KellyBracket]

One small point about your description of the ECG - if you just have a rhythm strip, you can't really interpret the ST-segments.

This women sounds more like CHF, given the respiratory complaint, and the cardiac findings, as well as the hypoxia. However, the RR of 36, with no apparent increased work of breathing, may suggest the "quiet tachypnea" of a metabolic acidosis.

And yeah, I am voting for transport to the ED. Despite the high-level H&P you obtained, she needs a good deal of laboratory and radiologic investigation.

I'm not sure how to comment on the "several common challenges," however. What were the elements that seemed to cloud the evaluation? Her mental status, or her GI complaints? Wheezing as opposed to crackles?

 

[Frozennoodle]

Why is she on antibiotics?

 

[mycrofft]

Great eval! We Amurricans may need to research the meds' names.

What exactly alerted the daughter to the potential need for medical intervention at ths time?

Did sitting up cause productive cough with clearing of the airway to some extent? (In my little book of potential tattoos, "Supine Sucks" is a prominent candidate. Right next to "Anitbiotics for Seniors are Not Mother's Milk").

I would have questions about albuteral use with atrial fib. Some a-fibs react to caffeine and epinephrine in local anesthetics.

 

[Veneficus]

Before reading KBs comment I also was thinking CHF.

 

[VFlutter]

Why is she on antibiotics?

Probably an UTI

Great eval! We Amurricans may need to research the meds' names.

Coumadin, Lexapro, Coreg, Nexium, Dig, and an ARB. Sounds like a pretty standard cardiac med list to me.


The RLQ tenderness and GI complaints are a little suspicious

 

[Handsome Robb]

Probably an UTI


Coumadin, Lexapro, Coreg, Nexium, Dig, and an ARB. Sounds like a pretty standard cardiac med list to me.


The RLQ tenderness and GI complaints are a little suspicious

Agree with the probable UTI. Every old person has a UTI until proven otherwise. Doesn't seem like urosepsis though.

Worsening exertional(is that a word?) SOB x 1 week, chronic low SpO2% and tachypnea makes me think pneumonia.

12-lead would've been nice

The first responder reported a BP of 110 systolic but with 10mg of albuterol on board I don't doubt it potentially had an effect on HR and BP.

I'm sticking with pneumonia, everything supports it along with possible pneumosepsis sans the BP and temp but that's my very undereducated opinion.

 

[VFlutter]

Agree with the probable UTI. Every old person has a UTI until proven otherwise. Doesn't seem like urosepsis though.

Worsening exertional(is that a word?) SOB x 1 week

Dyspnea on exception, or exertional dyspnea, is what I usually see it charted as.

 

[Handsome Robb]

Dyspnea on exception, or exertional dyspnea, is what I usually see it charted as.

I'm guessing that's supposed to be "dyspnea on exertion" not exception

My laptop didn't like "exertional" but google-fu says otherwise.

As for wether she needs to be transported or not, I say yes, she does. There are too many question marks that can't be answered without labs and potentially radiological assessment of her abdomen. CBC + cultures to start.

As far as treatments en route, vitals q10, monitor, IV, some oxygen and re-assessment. You could continue the nebulized albuterol but it doesn't seem to be helping at all so I'd move towards D/Cing it, especially after 10mg without improvement but that's just me. Why keep using something if it isn't working? Any ipratropium bromide/duoneb onboard or only albuterol?

Random question that I generally ask most if not all patients on coumadin/warfarin, when was the last time she had her PTT/INR checked and what was it?

Is she med compliant?

 

[mycrofft]

Folding Occam's Razor and putting it away for a second.

"Minor abdo distension per pt, nil spontaneous pain but tenderness on palpation of upper quadrants and moderate pain and guarding on palpation on right lower quadrant. Periodic small vomits in past few days although pt is vague, 1x small vomit of food this am. Poor oral intake of both food and fluid for past few days although again pt is frustratingly vague about the specifics. Normal daily bowel movements until this morning's which was "loose". Urinated 4 times yesterday, twice this am, normal frequency, nil urgency, pain/abnormal odour".

Is this a cardiac patient with a bowel obstruction? Possibly a cryptic sepsis (subdued immune response due to age and asplenic condition?)

Either requires the diagnostic resources of at least a clinic and can fulminate.

(A-Fib with strong pulses of 140 and hypertension? Hmmmmm.....)
Also "like" NVROB delving into meds. More meds means higer likelihood of polypharmacy, botched admin of proper meds, and the changing response to meds of the elderly.

 

[KellyBracket]

Folding Occam's Razor and putting it away for a second.
...

Indeed - some would suggest that "patients can have as many diseases as they damn well please!"

 

[Melclin]

But what are you going to do with her?

One small point about your description of the ECG - if you just have a rhythm strip, you can't really interpret the ST-segments.

I can say that there are no ST changes in I, II and III. I realise that this constitutes only a quarter of an ECG but in the absence of posting the actual strips, it seems fair to describe what can be seen. If I was to say several post later, "HAHA! Gotcha there was massive ST elevation in II and III, you all suck", it would hardly be fair. If you would like to donate the money to hasten the expansion of 12 lead beyond the intensive care level, you would be my hero.

....

And yeah, I am voting for transport to the ED. Despite the high-level H&P you obtained, she needs a good deal of laboratory and radiologic investigation.

I should make the point (for everyone) that I wasn't necessarily suggesting not taking her was on the table for me. I just don't like to presuppose anything when presenting scenarios because people can make a lot of assumptions from the information you chose not to include. Care pathways other than ED transport are always options going into just about any job and I like to maintain that mindset as much as possible when presenting scenarios.
....

I'm not sure how to comment on the "several common challenges," however. What were the elements that seemed to cloud the evaluation? Her mental status, or her GI complaints? Wheezing as opposed to crackles?

Common challenges: As I said, I'm not that interested in what people think it turned out to be. I'm more interested in the working diagnosis people might make in the field and the treatments with which they will or won't proceed and why.

This is an absurdly common patient in our system. Old people with pretty non-specific hx and symptoms, but with an awful lot of things wrong with them. They are the pts whose true extent of illness may easily slip under the radar. The EMS evaluation has a role in preventing this. We could take this pt to a community hospital, where a GP might see her later in the afternoon. We could take her to a larger centre, but our assessment may mean the difference between being stuck in the waiting room for 6hrs and going straight to a resus cubicle. Perhaps me move to a community hospital and manage the pt there for 2hrs while we wait for an adult retrieval team to arrive from the city, or maybe they are flown directly to a tertiary centre via HEMS.

I think we can all agree she's not getting flown anywhere in a chopper but you take my point about EMS being the gate keepers to an extent for many arms of the healthcare system.

But to make a decision on transport, and to make treatment decisions, we need to come up with a working diagnosis.

-The first responder has potentially fudged the vitals with his treatment. This is not unusual of either FRs or retrieving pts from smaller hospitals. Is her HR because of the salbutamol or because she's crook.

-Doing a reasonable job of picking the big sick from the little sick in a sea of non-specific presentations in the elderly is an everyday problem for us. They're also almost always very poor historians which obviously isn't communicated here.

-We have opposing diagnoses for which treatments are pretty different. Is she septic? Do we give her fluid? Is this CHF? What of the fluid then? Giving a couple of nitro to a GI bleed or a septic pt probably isnt ideal. Maybe she has a GI bleed, again the approach with fluid may be different. How does the arrhythmia fit into the picture? Will that complicate fluid administration? Should the arrhythmia be treated of will it resolve by itself if when the precipitating cause is corrected? Or do we do nothing?

On the topic of the lung findings, I'm not sure that this makes a difference but crackles were not really the kind that I usually associate with CHF. There were not consistent in any way. Different in nature in different lung fields, not present on every resp, not similar in nature for resp to resp. I'm afraid I don't know how to describe it more formally or if its even a relevant observation, but it was more the snap crackle and pop that I usually associate with an infective process rather than CHF? Am I just talking out my arse?

Why is she on antibiotics?

Her daughter states that she is always on them since her splenectomy. Nothing further.

I would have questions about albuteral use with atrial fib.

So did I.

As far as treatments en route, vitals q10, monitor, IV, some oxygen and re-assessment. You could continue the nebulized albuterol but it doesn't seem to be helping at all so I'd move towards D/Cing it, especially after 10mg without improvement but that's just me. Why keep using something if it isn't working? Any ipratropium bromide/duoneb onboard or only albuterol?

Random question that I generally ask most if not all patients on coumadin/warfarin, when was the last time she had her PTT/INR checked and what was it?

Is she med compliant?

No ipratropium on board yet. It is an option.

I never got an answer on the INR. She was a difficult historian, she trailed off, I got distracted and never came back to it.

She is med compliant but vomited up her meds this morning.

Is this a cardiac patient with a bowel obstruction? Possibly a cryptic sepsis (subdued immune response due to age and asplenic condition?)

Either requires the diagnostic resources of at least a clinic and can fulminate.

(A-Fib with strong pulses of 140 and hypertension? Hmmmmm.....)
Also "like" NVROB delving into meds. More meds means higer likelihood of polypharmacy, botched admin of proper meds, and the changing response to meds of the elderly.

The possibility of some pretty serious occult sepsis weighed heavily on my mind.

 

[Veneficus]

But to make a decision on transport, and to make treatment decisions, we need to come up with a working diagnosis..

SWI-GOK

diagnosis achieved...

-Doing a reasonable job of picking the big sick from the little sick in a sea of non-specific presentations in the elderly is an everyday problem for us. They're also almost always very poor historians which obviously isn't communicated here..

This is a challenge for everybody in this population.

Most of these people present with nonspecific signs and symptoms regardless of whether the pathology is new onset of something rather common, exacerbation of a chronic condition, or something very sinister.

(thyroid disorders I find particularly difficult to find in the geriatric population without TSH, t3, and t4 levels. Their symptoms in my experience do not usually fit the textbook presentations and often appear "flu-like." Even more problematic when you have to rule out a potential subacute thyroiditis, which I have seen twice in the last few weeks without gross enlargement of the thyroid.)

It may not even be possible to reliably and accurately determine the need for hospitalization of this population in the EMS setting. Even with the most highly capable EMS providers.

 

[Melclin]

AHHH bugger. Please read the second of my two posts. They're not identical.


SWI-GOK?

I wasn't talking about trying to determine the need for admission amongst pts presenting like this and like I said, I don't think anyone would suggest this pt didn't need to go to ED.

Maybe we've run into another cultural difference here, but we generally consider it a pretty important part of the job to at least try to ascertain how sick out pts are, and have a rough idea of the investigations required such that we can take them/direct them to the right place with the right urgency and communicate the point to triage nurses/receiving doctors in the case of ED transport.

A working diagnosis is pretty key to this. For example if a pt has chest pain, I'm not looking to say this pt has had a large nSTEMI and will want flying down to the city, I'm wanting to settle on Acute coronary syndrome or something else, eg pneumonia.

I'm confused as to why this has been a sticking point in this thread. Is it not part of American EMS to settle on some rough idea of whats wrong with a pt before treatment and transport decisions are made?

 

[KellyBracket]

...
I'm confused as to why this has been a sticking point in this thread. Is it not part of American EMS to settle on some rough idea of whats wrong with a pt before treatment and transport decisions are made?

No, perhaps we're just not responding in the spirit you aimed for! Sorry about that - I'll get back on track here.

Indeed, the American system encourages EMS providers to focus on a primary, provisional diagnosis. However, some (many?) critics would suggest that this aspect is overemphasized, to the degree that paramedics are occasionally accused of trying to "fit patients into a protocol."

And this speaks to your point. Some US paramedics may feel "forced" to pick a particular protocol (say, CHF), and then follow that pathway all the way down (nitrites, diuretics), despite equivocal or conflicting elements of the presentation.

I would prefer that we emphasize how to go about initially treating a patient like this with short-acting, reversible therapies (e.g. nitrites, beta-agonists**, NIPPV, perhaps adenosine, or IV fluids as the situation dictates) and defer more committing therapies (e.g. diuretics, calcium-channel blockers) until more thorough evaluations can be completed. Teaching this, and developing guidelines that encourage a more thoughtful approach, is difficult.

**(Yeah, I consider beta-agonists to be basically benign in almost everyone, including rapid AF.)

 

[Melclin]

Indeed, the American system encourages EMS providers to focus on a primary, provisional diagnosis. However, some (many?) critics would suggest that this aspect is overemphasized, to the degree that paramedics are occasionally accused of trying to "fit patients into a protocol."

And this speaks to your point. Some US paramedics may feel "forced" to pick a particular protocol (say, CHF), and then follow that pathway all the way down (nitrites, diuretics), despite equivocal or conflicting elements of the presentation.

I would prefer that we emphasize how to go about initially treating a patient like this with short-acting, reversible therapies (e.g. nitrites, beta-agonists**, NIPPV, perhaps adenosine, or IV fluids as the situation dictates) and defer more committing therapies (e.g. diuretics, calcium-channel blockers) until more thorough evaluations can be completed. Teaching this, and developing guidelines that encourage a more thoughtful approach, is difficult.

**(Yeah, I consider beta-agonists to be basically benign in almost everyone, including rapid AF.)

And now I'm going to derail a little, but hey, its my thread and I'll digress if I want too

Is it that they feel they have to, or do they really have to? I suppose this is hard to answer as there is considerable variation between systems but surely at the very least US medics can chose whether or not to initiate the protocol, even if they can't vary it. When I say picking a working diagnosis, I'm certainly not talking about picking a subject heading from the "protocol book" and blindly following what ever dot points exist bellow. In fact I would say I mean the opposite. Coming up with an actual idea of what may be wrong with the pt and what the pt needs to be done in order to improve that particular problem as opposed to picking a protocol because because they have symptom X and sign Y.

The short acting idea is not the worst idea, although longer acting therapies initiated early may be beneficial to extent that it isn't really acceptable not to have them. We carry ipratropium, aspirin and dexamethasone not because they make patients better in the short term but they improve longer term outcomes, duration of admission, death etc. It would be a shame to move away from that idea when I think we should really be moving more towards it where possible (TXA, PRBCs, thrombolysis for MI, ketorolac etc).

If you want to achieve more thoughtful processes in the minds of paramedics, the guidelines they work under are not the first thing that needs to change. It is their education. Good baseline education in the form of a degree. Structured in-field clinical education in the form of what we would call a graduate year, and ongoing QA/QI and CPE (both of which should be carrots and not whips).

That said, once you've achieved this, you need guidelines that are flexible in order to support decision making in the grey world.

Take for example my service's anaphylaxis guideline. It asks that in the setting of some combination of a potential exposure to an antigen, angio-oedema, urticaria or GI disturbance in addition to some combination of suggestion of less than adequate perfusion, and/or alteration of conscious state and/or respiratory distress. Honestly, I think I see at least two pt's a week who could be made to fit that guideline. It relies on an understanding of anaphylaxis beyond the guidelines to prevent every second pt getting adrenaline, but it gives you a certain flexibility to apply it when you see fit (Not that anaphylaxis is high on my list of super difficult to diagnose problems, but you take my point). Add to that a culture with no online medical control available, and in which bending or directly contravening guidelines if you have some reason, is not only allowed but encouraged, then I think you're heading in the right direction.

 

[mycrofft]

Indeed - some would suggest that "patients can have as many diseases as they damn well please!"

Ah, Hickam's Dictum!

 

[mycrofft]

further down the sidetrack

Melclin, citing your latest reply and avoiding a huge quotation, the phenomenon of protocols needs to be looked at.

The writers are strapped to do the most good and address the largest likely number of situations with the least protocols. Trying to systematize clinical reality, which always is like peeling onions*.

Managers/legislators/administrators tend to use them as an absolute standard or benchmark of performance. Sort of "Protocol Fundamentalists" if you will.

Utilizers/customers (say, paramedics? Etc Etc) initially see them as answers to how they can address certain situations, and later as limits to their responses. Some (latent or failed administrators, or hierarchial bullies)come to use them to beat their peer/co-workers about the head with.
I will quote you here:
" It relies on an understanding of anaphylaxis beyond the guidelines to prevent every second pt getting adrenaline, but it gives you a certain flexibility to apply it when you see fit (Not that anaphylaxis is high on my list of super difficult to diagnose problems, but you take my point). Add to that a culture with no online medical control available, and in which bending or directly contravening guidelines if you have some reason, is not only allowed but encouraged, then I think you're heading in the right direction. "

Right on!!



* Peel it far enough and it's all gone.

 

[mycrofft]

But what of our damsel in distress?:huh:

 

[Veneficus]

SWI-GOK?

Something Wrong Inside-God Only Knows.

I wasn't talking about trying to determine the need for admission amongst pts presenting like this and like I said, I don't think anyone would suggest this pt didn't need to go to ED.

Maybe we've run into another cultural difference here, but we generally consider it a pretty important part of the job to at least try to ascertain how sick out pts are, and have a rough idea of the investigations required such that we can take them/direct them to the right place with the right urgency and communicate the point to triage nurses/receiving doctors in the case of ED transport.

I don't think it is a culteral difference. I am also not suggesting my response applies to only US EMS or even EMS at all.

geriatrics require considerable workups in many cases. I don't think it is unreasonable in this case to simply admit that it could be anything. Even in the ED, I have rarely seen a geri patient get a complete and total workup. It is usually a medicine case.

"I have a geri with nonspecific symptoms XYZ, I attempted to help with DEF, here she is for you..."

Actually sounds like an extremely competent provider acknowledging the diagnosis of this particular patient population is actually out of reach of EMS diagnostic capability.


A working diagnosis is pretty key to this. For example if a pt has chest pain, I'm not looking to say this pt has had a large nSTEMI and will want flying down to the city, I'm wanting to settle on Acute coronary syndrome or something else, eg pneumonia.

I'm confused as to why this has been a sticking point in this thread. Is it not part of American EMS to settle on some rough idea of whats wrong with a pt before treatment and transport decisions are made?

Maybe it is just a disconnect between how the question is answered. Once you have a working Dx, the treatment is obvious.