A call that is baffling me!!

[VirginiaEMT]

I had a call that went like this

Dispatch- altered mental status

arrival- elderly (76) female patient sitting in a chair alert to verbal stimuli

D-stick- 72

Pulse Ox- 86 spo2 (immediately placed on NRB at 15lpm which increase spo2 to 93) pulse 224

I thought I would have to cardiovert so we immediately loaded on stretcher and placed in unit where I immediately did a 4 lead- regular rhythm at 78 BPM ( I was thinking maybe she converted on the way out of the house). 12 lead was NSR with an occasional PVC

Capnography- R- 24 good waveform ETCO2 22-29

Vitals BP-164/110 pulse-78 skin-normal 2nd d-stick 74

The patient had become less responsive. During transport the patient's O2 sats continued to drop even on NRB. Her blood pressure continued to climb ( I was thinking head bleed). He tidal volume was good, a little tachypneic, but her 02 sats continued to drop eventually to 72 by the time we reached the hospital. Nothing I could find pointed me to why this lady was unresponsive.

At the E.R her d-stick read 57. The doctor said that he would give here some D50 and she would come around. It appeared everyone else was thinking CVA. When I went back to the E.R I asked about her and the doctor said he gave her some D50 and she came around and was having some more test done.

I felt like a fool.

1. Why would hypoglcemia make her BP increase on a continual basis. Her SPB was 234 at the hospital I checked it 4 times en route and each time the SBP was higher.

2. She had no history of diabetes according to her daughter and her drug list had no clues that would point to a Hx of diabetes.

3. Why would her 02 sats drop to such a low level if she had good tidal volume, was not severely tachypneic, and no history of any lung disease. V/Q mismatch?

I guess my question is this. Why would hypoglycemia have this effect on the body?
I'm sure I've left something out but I hope you understand what I getting at.

 

[mycrofft]

Give it a try first. Share your reasoning.

"I felt like a fool.

1. Why would hypoglcemia make her BP increase on a continual basis. Her SPB was 234 at the hospitl I checked it 4 times en route and each time the SBP was higher.

2. She had no history of diabetes according to her daughter and her drug list had no clues that would point to a Hx of diabetes.

3. Why would her 02 sats drop to such a low level if she had good tidal volume, was not severly tachypneic, and no history of any lung disease. V/Q nismatch?

I guess my question is this. Why would hypoglycemia have this effect on the body?
I'm sure I've left something out but I hope you understand what I getting at. "

Felt foolish? Join the club, but don't for too long. A good sign.

Let m ask you some questions (respectively):

1. HAVE you ever read anything about hypoglycemia causing ACUTE HTN AND tachycardia? (I assume the pulses were regular; were they apical, radial, or pulse-ox?). Or anything which might cause BOTH?....

2. Why do you equate hypoglycemia with diabetes? Untreated diabetes presents with hyperglycemia, ALTHOUGH some folks manifest paroxysmal hypoglycemia before they settle into good old fashioned Type 2 IDDM...but usually they are younger, if I remember. OVERTREATED diabetes, or diabetics who suddenly cut back their diet or up their exercise, might get a drop in serum glucose. But nothing to do with ACUTE HTN and tachycardia.

3. Low O2 sats...was she clinically hypoxic? Normal respiration rate and nature (depth, muscles etc)? Cyanosis? Altered mentation? Is there a possibility your monitor was being fooled by something like peripheral vascular constriction, etc.?

And just for giggles and grins, did she complain or was less comfortable supine versus sitting up? What was her self-selected stance when encountered? DId she have any other complaints at all? Has she been eating or drinking more/less/same, c/o being cold or hot...

Think about it, ask questions. Good scenario.

 

[sir.shocksalot]

At the E.R her d-stick read 57. The doctor said that he would give here some D50 and she would come around. It appeared everyone else was thinking CVA. When I went back to the E.R I asked about her and the doctor said he gave her some D50 and she came around and was having some more test done.

Was their d-stick via finger stick? Or did they use their lab? How were the skin signs? Recent illness or injury? Any focal motor deficits? How was her speech? Any lingual trauma? What's her medical/surgical history? How long has she been altered like she is? Any change in behavior prior to this? Last time seen normal?

I have a hard time believing hypoglycemia was the cause of her problems. 57-70 is not all that low in my book, not to mention the lack of other signs of hypoglycemia. Besides how dialed in is this doctor if he is going to push D50 on an elderly lady with symptoms of a stroke?

I would get some further follow up from the hospital. It sounds like there is much more going on here. To me it sounds more like it could be a TIA. Unless the hospital found some occult cause of hypoglycemia like my croft mentioned or an insulin secreting tumor (astronomically unlikely).

 

[VirginiaEMT]

"I felt like a fool.

1. Why would hypoglcemia make her BP increase on a continual basis. Her SPB was 234 at the hospitl I checked it 4 times en route and each time the SBP was higher.

2. She had no history of diabetes according to her daughter and her drug list had no clues that would point to a Hx of diabetes.

3. Why would her 02 sats drop to such a low level if she had good tidal volume, was not severly tachypneic, and no history of any lung disease. V/Q nismatch?

I guess my question is this. Why would hypoglycemia have this effect on the body?
I'm sure I've left something out but I hope you understand what I getting at. "

Felt foolish? Join the club, but don't for too long. A good sign.

Let m ask you some questions (respectively):

1. HAVE you ever read anything about hypoglycemia causing ACUTE HTN AND tachycardia? (I assume the pulses were regular; were they apical, radial, or pulse-ox?). Or anything which might cause BOTH?....

2. Why do you equate hypoglycemia with diabetes? Untreated diabetes presents with hyperglycemia, ALTHOUGH some folks manifest paroxysmal hypoglycemia before they settle into good old fashioned Type 2 IDDM...but usually they are younger, if I remember. OVERTREATED diabetes, or diabetics who suddenly cut back their diet or up their exercise, might get a drop in serum glucose. But nothing to do with ACUTE HTN and tachycardia.

3. Low O2 sats...was she clinically hypoxic? Normal respiration rate and nature (depth, muscles etc)? Cyanosis? Altered mentation? Is there a possibility your monitor was being fooled by something like peripheral vascular constriction, etc.?

And just for giggles and grins, did she complain or was less comfortable supine versus sitting up? What was her self-selected stance when encountered? DId she have any other complaints at all? Has she been eating or drinking more/less/same, c/o being cold or hot...

Think about it, ask questions. Good scenario.

1. I took radial pulses which were equal at both wrist. The original 224 BPM was on the pulse ox that I used to see if she was hypoxic. Trying to figure out the altered mental status at this point.

2. I was thinking more along the lines of too much insulin as I really didn't have a baseline number to go on, or history.

3. Her capnogram showed a normal waveform but her rate was a little rapid. She was definitely hypoxic as her hands and lips were blue upon arrival at the hospital. She was became unconscious so she couldn't answer any questions for me.

She couldn't complain but she had clear, equal bilateral lung sounds. I transported her in a semi-fowlers position too.

 

[VirginiaEMT]

Was their d-stick via finger stick? Or did they use their lab? How were the skin signs? Recent illness or injury? Any focal motor deficits? How was her speech? Any lingual trauma? What's her medical/surgical history? How long has she been altered like she is? Any change in behavior prior to this? Last time seen normal?

I have a hard time believing hypoglycemia was the cause of her problems. 57-70 is not all that low in my book, not to mention the lack of other signs of hypoglycemia. Besides how dialed in is this doctor if he is going to push D50 on an elderly lady with symptoms of a stroke?

They used a finger stick. No illness or injury. She was basically unresponsive the whole time with moans if spoken to but this went south during transport. Couldn't do a stroke test on her. Last time seen normal was 15 minutes before our arrival.

I was with this patient for maybe 12-15 minute transport.

 

[46Young]

Perhaps catecholamine release in response to hypoglycemia could be to blame for the patient's presentation. This could explain the rising BP, the lack of peripheral perfusion, and the mental status changes. If the pt has any vascular disease, that high BP can cause a TIA or myocardial ischemia, both of which can affect the pt's mentation and overall neurological status.

Was a 12-lead/15 lead done, and if so, what were the results?

 

[jwk]

To the OP - did you count an actual pulse, or just go by the readout on the pulse ox device? You should ALWAYS check a pulse. It's not uncommon at all for a pulse ox to "double count" some waveforms.

 

[mycrofft]

Perhaps catecholamine release in response to hypoglycemia could be to blame for the patient's presentation. This could explain the rising BP, the lack of peripheral perfusion, and the mental status changes. If the pt has any vascular disease, that high BP can cause a TIA or myocardial ischemia, both of which can affect the pt's mentation and overall neurological status.

Was a 12-lead/15 lead done, and if so, what were the results?

Ooh, yeah. Usually see agitation and sweating too, maybe tremor. Was she skinny? Small overall (short and slight)? (Poor energy reserves).

I'm wondering about her thyroid levels, any other endocrine levels, too. But those might be zebras.

Catecholamines are a simpler answer and the lability of her fingerstick related to age and degree of her ability to perform gluconeogenesis (plus possible deficiency of her dietary intake).

OP, you are one of the first people here to be able to recount some significant CLINICAL observations beyond short of breath and c/o pain.

 

[VirginiaEMT]

To the OP - did you count an actual pulse, or just go by the readout on the pulse ox device? You should ALWAYS check a pulse. It's not uncommon at all for a pulse ox to "double count" some waveforms.

the 224 pulse was on a pulse ox but I was using it to see if she was hypoxic
not to take a pulse.

all other pulses were radial confirmed with the Lifepack monitor

I never use the pulse ox for a pulse. That is what lazy people do LOL!

 

[VirginiaEMT]

Perhaps catecholamine release in response to hypoglycemia could be to blame for the patient's presentation. This could explain the rising BP, the lack of peripheral perfusion, and the mental status changes. If the pt has any vascular disease, that high BP can cause a TIA or myocardial ischemia, both of which can affect the pt's mentation and overall neurological status.

Was a 12-lead/15 lead done, and if so, what were the results?

12 lead showed a normal sinus rhythm at 78 bpm with no ST abnormalities, occasional PVC (hypoxia probably), no S1Q3T3. I thought maybe a PE since her breathing was rapid but her 02 sats kept dropping.

I chased a lot of rabbits LOL

 

[VirginiaEMT]

Ooh, yeah. Usually see agitation and sweating too, maybe tremor. Was she skinny? Small overall (short and slight)? (Poor energy reserves).

I'm wondering about her thyroid levels, any other endocrine levels, too. But those might be zebras.

Catecholamines are a simpler answer and the lability of her fingerstick related to age and degree of her ability to perform gluconeogenesis (plus possible deficiency of her dietary intake).

OP, you are one of the first people here to be able to recount some significant CLINICAL observations beyond short of breath and c/o pain.

She was sweating, especially in the face, and was a thin woman.

Thanks for the compliment. I have come up through the ranks from EMT-B to EMT-I/99 to Paramedic. Well actually I have taken the paramedic course and passed it, taken the NREMT Paramedic written and passed it. I do my practicals on the 17th of this month.

But to be honest, I wasn't prepared for this one. I saw her turning blue right before my eyes and I couldn't come up with a way to stop it. This is the first call that has bothered me this much and I need to find answers so it doesn't happen again.

 

[TheLocalMedic]

I think that perhaps all of what you were seeing were equipment issues.

Lifepacks have a weird thing about their BP cuffs occasionally where they think the BP is high so it keeps hyper-inflating the cuff and spitting out higher and higher numbers on the screen.

Pulse ox devices are notoriously inaccurate at counting pulse rates... I think someone already mentioned the double counting thing.

Was the pulse ox on the same side that had the BP cuff on it? Super tight BP cuff would decrease perfusion in the hand and give you a low reading.

AND THE BIG ONE>>> How well did you clean that finger before you did the BG stick? And sugary residue (like from juice or food) if not removed can give you a false high reading. Had this happen to me a few months ago, known diabetic that looked hypoglycemic but the BG read in the normal range until I tried a different finger.



It's easy to get spun up as a new medic and start getting worried about what the machines are telling you. But remember, the machines are not always right, so really look at your patient and get hands on to confirm those numbers.

 

[mycrofft]

Machine glitches. Worth a thread.

Irregular and accelerated pulses, especially irregularly irregular ones, baffle the machines' software. Don't most pulse, BP or thermometer machines use predictive software (i.e., they don't measure for a minute but take a snapshot and use that to predict what the measurement is...unless they have a "MONITOR" function, then they go to straight reporting.

I know many people who will defer their personal observations to a machine's. I would report them in parallel.

 

[VirginiaEMT]

I think that perhaps all of what you were seeing were equipment issues.

Lifepacks have a weird thing about their BP cuffs occasionally where they think the BP is high so it keeps hyper-inflating the cuff and spitting out higher and higher numbers on the screen.

Pulse ox devices are notoriously inaccurate at counting pulse rates... I think someone already mentioned the double counting thing.

Was the pulse ox on the same side that had the BP cuff on it? Super tight BP cuff would decrease perfusion in the hand and give you a low reading.

AND THE BIG ONE>>> How well did you clean that finger before you did the BG stick? And sugary residue (like from juice or food) if not removed can give you a false high reading. Had this happen to me a few months ago, known diabetic that looked hypoglycemic but the BG read in the normal range until I tried a different finger.


It's easy to get spun up as a new medic and start getting worried about what the machines are telling you. But remember, the machines are not always right, so really look at your patient and get hands on to confirm those numbers.

I understand what you're saying and appreciate the advice but I loathe BPs from the Lifepack AND getting pulses from a pulse ox. It drives me nuts to see EMT's or Medics do this when it is not imperative for one reason or another. Sometimes when I'm by myself in the back I will use them to do follow-up vitals if I'm busy with IV's, drugs, etc.

My BP's were manual, one while on scene, one while en route, and one just before arrival at the hospital. I never get my pulses from a pulse oximeter and only saw the 224 because I was checking for hypoxia. I teach EMT's to always take at least the first set of vitals manually, and if possible ALL of them.

I really didn't use a machine for anything other than the 12 lead and capnography, and the pulse ox to measure the 02 sats, which I am certain was on the other hand.

I had gloves on for the d-stick and definitely had not eaten with them on, but I really like the point you made regarding dirty hands.

 

[EMT2B]

I had gloves on for the d-stick and definitely had not eaten with them on, but I really like the point you made regarding dirty hands.

Correct me if I'm wrong, but I think TheLocalMedic meant that there could be residual food/juices on the patient's finger that would mess with the bgl reading.

 

[VirginiaEMT]

Correct me if I'm wrong, but I think TheLocalMedic meant that there could be residual food/juices on the patient's finger that would mess with the bgl reading.

Oops....