Bloody 21 YO Male

H

Handsome Robb

Youngin'
Premium Member
Messages
9,736
Reaction score
1,174
Points
113
Nothing complicated

Dispatched out as Priority 1 Hemorrhage. We arrive on scene to find the fire department assessing the patient.

Pt states he was supposed to wake up early for work then was planning on coming home and going to sleep. The last thing he remembers is going to bed. Grandma found him wandering around the front yard this morning covered in blood.

C/C of a splitting headache and "feeling like I'm going to die"

We find ~200 ccs of blood in his closet in his room where it appears he went headfirst through the closet door. 3 cm full thickness laceration from right in between his eyes running vertically. Pt was pretty well covered in blood. If I had to estimate I'd say 400-500 ccs total blood loss.

The bullets:
GCS 14 - 4/4/6 (you could argue 13 - 3/4/6) , AA&Ox2 (person and place, keeps thinking it's 12/2012) Pupils reactive but sluggish at 4mm.
HEENT - appears atrauma except for the laceration, no fluid from the ears/nose present no depressions or abnormalities noted.
Neck - midline pain on palpation, no JVD, trachea midline
Chest - equal bilaterally, no complaints, clear breath sounds bilaterally
ABD- SNT
Pelvis - stable, no complaints, pt ambulatory.
Extremities - good distal CMS, no numbness/tingling, ambulatory, equal push/pull and grip strength.

Pt and his grandmother both repeatedly deny any ETOH use or drug use. Per grandma "I've never seen him even drink one beer in my life, we have lived together for 4 years." House is clean and well kept, same goes for the Pt's room, nothing that really jumped out at me as unusual minus the broken closet door and all the blood :rofl:

H: ADHD
A: NKA, NKDA
M: Ritalin

Vitals:
132/84
110 sinus tach without ectopy on the monitor, strong, equal, bilateral pulses
RR 32 unlabored and regular
96% on RA
BGL 213

So we are on scene, where do you go from here? I'll answer questions as the are asked :D
 
It can't be as simple as DKA can it? Stimulant OD?
 
exodus said:
It can't be as simple as DKA can it? Stimulant OD?
Click to expand...

I'd expect to see the BGL much higher for DKA.

No evidence of drug use in the house but it can't be ruled out. According to grandma and a phone conversation with mom he's an outstanding student and a a very hard worker. No abnormal behavior has been noted recently.
 
n7lxi said:
DKA? You mean hypoglycemia, right?
Click to expand...

DKA / Hyperglycemia = Above average BGL.
Hypoglycemia = Below average BGL.

IIRC at least.

And good point NV. I'm unsure at my level what his could be, those are the two that jumped out at me. tachypnea and tachyardia would lead me to the OD, Tachypnea would lead me to DKA. But as you said It's almost certainly not DKA.
 
n7lxi said:
DKA? You mean hypoglycemia, right?
Click to expand...

at 213?? :unsure:

I see your thought process exodus but I was looking for horses not zebras on this scene.

I'll give some people more time to respond before I starting giving up more info :P
 
That's what I get for looking quickly, I looked at GCS, and saw CBG. CBG is the abbreviation we use here for capillary blood glucose.

Doh.

Forgive me. :( I'm not really an idiot, honest.
 
Last edited by a moderator:
Figured you made a mistake! I'm eager to see what's going on.
 
It seems like this is one of those "we ain't gonna know til we see bloods and a CT".

I'm curious if he OD'd on his meds, or mixed them with alcohol/other drugs at a holiday party. Seizure? Or, just drunk and clumsy? Maybe he got up to pee and had a syncopal episode?

People do not just get up and crash through the closet door in the middle of the night for no good reason. :) (At least at my house...)

I'm not seeing any zebras here.

zebra-coloring-pages-9.jpg
 
Last edited by a moderator:
Well, something isn't adding up. He either got hammered and fell into the closet, or some sort of DV happened. Guess it could be a head inj from the fall through the closet door, it can take a pretty good hit to break a door...

I had a pt break a the holding tank of the toilet water with her head... that was a good fall lol. But i'm think granny doesnt know whats going on, or perhaps he took some of her meds?
 
Last edited by a moderator:
My first thought was drugs as well, but being on scene it never seemed like a viable option to me.

My partner and I both came to a similar conclusion as you n7. Seizure -> fall -> bleed. I suggested syncopal as well but he didn't remember ANYTHING from the time he was getting ready for bed. I would think that he would have some recollection of what happened minus the syncope itself. Also I agree, this thread wont get a definitive answer until I work tomorrow and can try to follow up on it.

So he ended up in full spinal motion restriction and an IV. We started transport and he began to complain of nausea, needless to say I'm a little grumpy I didn't drive a bit faster, I lolligagged a little bit to try and smooth the ride out for him. PT projectile vomits all over the back of the unit. Roof, walls, the radio in the box, everywhere. The vomiting breaks the clot in his lead lac which proceeds to squirt with every heave, all over everything he just puked on while I try to get parked and my partner scrambles for an emesis bag and 4x4s all the while attempting to avoid a shower of bodily fluids.

So it's looking more and more like a bleed to me but the vitals don't exactly point to increased ICP although we could have caught it early enough. Any thoughts on that?

Also per grandma when she found him wandering around he "wasn't himself, at all". Points to drugs or TBI or both.
 
Well, the "altered female" in the scenario thread had normal VS too... Absolutely normotensive, normal sinus on the monitor and respirator of 18. So... Who's to say. I'd be curious to see results of his blood and his CT.

And no Zofran on that truck? It can do wonders for nausea. ;) and keep you from becoming the "covered with puke guy". Also, did you start a line with fluid running, or just a saline lock?
 
Last edited by a moderator:
n7lxi said:
Well, the "altered female" in the scenario thread had normal VS too... Absolutely normotensive, normal sinus on the monitor and respirator of 18. So... Who's to say. I'd be curious to see results of his blood and his CT.

And no Zofran on that truck? It can do wonders for nausea. ;) and keep you from becoming the "covered with puke guy". Also, did you start a line with fluid running, or just a saline lock?
Click to expand...

That's very true about your altered girl.

This is were mine and my partner's views differed, respectfully though and he explained his reasoning later to me.

He has lost volume and is presumably compensating with his tachy rate, also with the BGL being elevated at 213 I was on the train of a 500mL bolus and see how that did for him. Although I also wasn't sure if it was appropriate with a presumed increase in ICP. My partner, the medic elected to leave it as just a lock seeing as we were about 7 minutes from the Level II.

I also started to get the zofran out when he started complaining of nausea right before we started transporting and was shut down by my partner. "If it is a TBI zofran wont do anything for him". It was my first day riding with him and he's been a medic for about as long as I have been alive so I didn't want to pick an argument at the beginning of a 16 hour shift, especially being the FNG at my agency. Even if he is correct I still felt it was appropriate to trial it. If it works it works, if it doesn't it doesn't. It wasn't contraindicated although there aren't many contraindications to begin with.

The more I work in the field the less I feel I know.
 
Last edited by a moderator:
A seizure fits the ritalin as well. It's a side effect of regular usage. I know very well of the side effects of that drug having developed tourettes because of it at a very young age.
 
Do you not routinely give anti-emetics to spinally immobilised pts?
 
Melclin said:
Do you not routinely give anti-emetics to spinally immobilised pts?
Click to expand...

If it were my patient he would have gotten it. Working ILS in NV anti-emetics are out of my scope and my ALS partner decided against it.

Now had I been the ALS intern on the truck this PT definitely would have gotten 4mg of Zofran.
 
NVRob said:
So it's looking more and more like a bleed to me but the vitals don't exactly point to increased ICP although we could have caught it early enough. Any thoughts on that?
Click to expand...

I would honestly say that you are correct, the vitals do not in any form point to an increase in ICP. I would be interested to see the results of a tox screen, but with the blood loss, it could be masking the expected change in vitals for ICP due to the volume lost. To be honest, I would have given him the zofran and expedited transport, maybe titrate a fluid bolus to bring his rate down a little and keep his volume up. Not really a whole heck of a lot else we can do for this patient.
 
Tripped getting out of pants, fell into the closet door, TBI and deep bloody lac.

And DKA will not have a normal respiration.
 
Nervegas said:
I would honestly say that you are correct, the vitals do not in any form point to an increase in ICP. I would be interested to see the results of a tox screen, but with the blood loss, it could be masking the expected change in vitals for ICP due to the volume lost. To be honest, I would have given him the zofran and expedited transport, maybe titrate a fluid bolus to bring his rate down a little and keep his volume up. Not really a whole heck of a lot else we can do for this patient.
Click to expand...

The bolded section was my thought process as well. Your treatment plan was where I was headed as well if it had been my patient.

I will try to poke my nose around tomorrow and find out what I can about him. It was tough to talk to his gma and mom, I could hear the fear and sadness in mom's voice on the phone. I think that's one thing they need to add to EMT and Medic curriculum is family care and communications.
 
mycrofft said:
And DKA will not have a normal respiration.
Click to expand...

You never cease to amaze me with your down to earth, logical explanations of events. That never even crossed my mind but it makes perfect sense.

As for DKA and respirations. In the few "good" DKA cases I have seen they all had deep, normal, rapid respirations ie Kussmal's
 
You must log in or register to reply here.
Back
Top