Chime in and diagnose...

Stephanie.

Stephanie.

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Okay.. I'm gonna run this by you and let me know what you think, and what you would do in this situation.


You are dispatched to a call, to a 62 yom who fell and hit his head on the counter. He never lost consciousness and when you arrive he is sitting up in the floor stating that his stomach and left flank hurt. The first responders take C-Spine, because it was a fall, and you note a small cut on the top of his forehead. The patient is alert and oriented. His vitals look a little something like this...

BP- 80P
RR- 32 bpm
HR- 148
BGL-314
O2- 99%

He has NKDA and not much of a medical history.
His current medications are; Nicorette and Propecia.

You load him into your rig. Start him on O2 15mL via NR. The paramedic starts a line and hooks him up to saline. The patient then tells you that last night when he was using the restroom (#1) he gets a sharp pain in his abdomen and he drops to his knees.

You collect another set of vitals which look like this.
BP- 102/74
RR- 28 bpm
HR- 132
O2- 99%


... Chime in.. and let me know what you think.. what you would do? I am not a Paramedic, so I am not sure about any drugs, but I would like to know what everyone thinks, what they would have done.. This one gets a little tricky one we drop them off at the ER..
 
O2 is fine, so I wouldn't do the NRB, unless they have a low SpO2 initially, but then i think an NC would be more comfortable for the pt.

How are eyes? Did the pt only feel the pain while excrementing? Or did it keep coming back? How's the colors or texture of the stool? Is he in any pain at the moment? If so, lets get some MS onboard after we assess him. What is his general appearence? Healthy, proper weight, etc. Does he drink water, or his he a soda drinker?

I'm thinking kidney stones. So just Zofran and MS till we get to the ED. I'm also gonna grab a 12 lead if he doesn't know if he tripped over something.

I'm also thinking possibly a syncapole episode from a drop in BP when he stood up. How does my abdomen look? Is it distended and rigid? Maybe it is a tear somewhere.

His BP coming up in the rig makes sense form the NS bolus you gave him.

That's all for me :P *prods you, pssst* O2 is lpm, not ml ;)
 
Slight change in pressure with posture position might indicate some sort of shock. The pain in the abdomen could be caused by a septic condition such as a burst appendix.

My uninformed opinion as a basic student would be give O2, watch for shock, and get to the hospital fast. Could also be cyanide poisoning...
 
exodus said:
O2 is fine, so I wouldn't do the NRB, unless they have a low SpO2 initially, but then i think an NC would be more comfortable for the pt. We pretty much did NRB because of the respiration rate.

How are eyes? Did the pt only feel the pain while excrementing? Or did it keep coming back? How's the colors or texture of the stool? Is he in any pain at the moment? If so, lets get some MS onboard after we assess him. What is his general appearence? Healthy, proper weight, etc. Does he drink water, or his he a soda drinker? Patient is fairly healthy for a 62 yo. He recently quit smoking. He also said that the pain in his abdomen and flank are constant. Scale of 1-10 7. His skin is warm and dry and pink. Eyes are PERRLA.

I'm thinking kidney stones. So just Zofran and MS till we get to the ED. I'm also gonna grab a 12 lead if he doesn't know if he tripped over something. that was my initial thought as well.....

I'm also thinking possibly a syncapole episode from a drop in BP when he stood up. How does my abdomen look? Is it distended and rigid? Maybe it is a tear somewhere.Abdomen are distended and rigid. Maybe..maybe not.

His BP coming up in the rig makes sense form the NS bolus you gave him.

That's all for me :P *prods you, pssst* O2 is lpm, not ml ;)
Click to expand...
I knew SOMEONE would catch that.. :-P
 
jjesusfreak01 said:
Slight change in pressure with posture position might indicate some sort of shock. The pain in the abdomen could be caused by a septic condition such as a burst appendix.

My uninformed opinion as a basic student would be give O2, watch for shock, and get to the hospital fast. Could also be cyanide poisoning...
Click to expand...

Would it ever occur to you that this should be a flight patient?
 
Hmm. It'd be nice to have capnography to see what their ETCO2 was, probably wouldn't have done too much for this scenario, because probably doesn't relate to the matter at hand. ANYWAYS. I got a really good feeling, something went boom internally.
 
Stephanie. said:
Okay.. I'm gonna run this by you and let me know what you think, and what you would do in this situation.


You are dispatched to a call, to a 62 yom who fell and hit his head on the counter. He never lost consciousness and when you arrive he is sitting up in the floor stating that his stomach and left flank hurt. The first responders take C-Spine, because it was a fall, and you note a small cut on the top of his forehead. The patient is alert and oriented. His vitals look a little something like this...

BP- 80P
RR- 32 bpm
HR- 148
BGL-314
O2- 99%

He has NKDA and not much of a medical history.
His current medications are; Nicorette and Propecia.

You load him into your rig. Start him on O2 15mL via NR. The paramedic starts a line and hooks him up to saline. The patient then tells you that last night when he was using the restroom (#1) he gets a sharp pain in his abdomen and he drops to his knees.

You collect another set of vitals which look like this.
BP- 102/74
RR- 28 bpm
HR- 132
O2- 99%


... Chime in.. and let me know what you think.. what you would do? I am not a Paramedic, so I am not sure about any drugs, but I would like to know what everyone thinks, what they would have done.. This one gets a little tricky one we drop them off at the ER..
Click to expand...

Did he fall from a standing position? Breath sounds? Trach deviation? Abd assessment? Tender? What kind? Rebound? Point tenderness? Where? How bad (?/10)? Pale? He's tachypneic and tachycardic. We need more information to make a more informed decision.

Define "flight criteria". What are the capabilities in your area? Why would you even mention flight?
 
MSDeltaFlt said:
Did he fall from a standing position? Breath sounds? Trach deviation? Abd assessment? Tender? What kind? Rebound? Point tenderness? Where? How bad (?/10)? Pale? He's tachypneic and tachycardic. We need more information to make a more informed decision. he did fall from a standing position. He said the pain in his stomach caused him to collapse. His abd is rigid and distended. His pain scale is about a 7 and it is his left abdomen and left flank.

Define "flight criteria". What are the capabilities in your area? Why would you even mention flight?
Click to expand...
Flight is very common in my area, we are rural with mainly volunteer FRs. I am south of Dallas/Fort Worth. Average transport time is at least 30 minutes to any hospital. Most of our flight patients are STEMI, stroke, occasional pedi, and trauma
 
exodus said:
Hmm. It'd be nice to have capnography to see what their ETCO2 was, probably wouldn't have done too much for this scenario, Someone once told me that it would be epic to have on every patient though.. lolbecause probably doesn't relate to the matter at hand. ANYWAYS. I got a really good feeling, something went boom internally.
Click to expand...
Hmmmm I wonder where you got THAT feeling from. Cheater. LOL :P ::prods you back::
 
We dropped the Pt off at the ED, on a later transport we were told by the nurses that the Pts vitals looked a little something like this.

BP: 148/106
RR: 26 bpm
HR: 134
O2: 99%

He was then rushed and flown to a more advanced hospital to be sent to the cath lab.. He coded halfway in flight and wasn't brought back.


Any other guesses?
 
Stephanie. said:
We dropped the Pt off at the ED, on a later transport we were told by the nurses that the Pts vitals looked a little something like this.

BP: 148/106
RR: 26 bpm
HR: 134
O2: 99%

He was then rushed and flown to a more advanced hospital to be sent to the cath lab.. He coded halfway in flight and wasn't brought back.


Any other guesses?
Click to expand...

If I understand your reply. He had lower Abd pain, a distended abd and signs of shock.

AAA and Pseudo (formerly incorrectly known as dissecting) aneurysm are the glaring differentials.

Acute pancreatitis that ruptures secondary to a gall stone possibly.

Obstructed bowel.

Thrombus/embolus of the celiac, mesenteric or branched arteries.

Ruptured hemorrhoid or esophageal varices.

Liver failure

unconventional MI presentation

ruptured appendix or gut.

Ruptured ureter

upper GI bleed.

More specific findings than a few sets of vitals and non specific findings would be required.

Was there Caput medusae?

Goss Blood?

rapidly distending abd?

involuntary muscle guarding?

Purpura?

Traumatic injury signs from the fall? bruising?

Family history of aneurysm?

It seems like there is definately a shock state, that from the outcome seems like it was not aggresively managed.
 
exodus said:
Hey, I said it before you said it. So I win!
Click to expand...
rofl

Stephanie. said:
You load him into your rig. Start him on O2 15mL via NR. The paramedic starts a line and hooks him up to saline. The patient then tells you that last night when he was using the restroom (#1) he gets a sharp pain in his abdomen and he drops to his knees.

QUOTE]

hmm...I too agree kidney stones would be your best bet. Was ab pain the cause of this fall as well?
Click to expand...
 
Dissecting aortal aneurysm or allied disaster.

PS: I'm ignorant (and obsolete), what is "HR" if not heart rate? But BPM (beats per minute) is also posted. Or is that "Breaths per minute"? Or is HR the electrocrdiographic rate while BPM is a palpated or pulseox pulse rate?
Bowel sounds for gut pain is pretty good to do, especially since, if in this case it was an aneurysm, you might have heard the bruit as the blood swished past the site. Palpaton would have been good to localize it; but, bad if you jabbed into the dissection.
 
Renal calculi leading to code?

Well, anyone could have calculi casuing pain and another more lethal condition.
 
Stephanie. said:
We dropped the Pt off at the ED, on a later transport we were told by the nurses that the Pts vitals looked a little something like this.

BP: 148/106
RR: 26 bpm
HR: 134
O2: 99%

He was then rushed and flown to a more advanced hospital to be sent to the cath lab.. He coded halfway in flight and wasn't brought back.


Any other guesses?
Click to expand...

I have a feeling you're asking for one of two reasons. A), you're curious as to what could have caused it, or B.) you wonder if there was more you could have done to change the outcome.

The answer to B.) is almost certainly No. This guy's problem was definitely something surgical, and there's nothing else that could have been done in the field to fix it.

As for possible Dx... I think only an autopsy could say the actual cause of death. But from what you're describing, I'm going to agree with everyone else, something tore open/off and he bled out internally.
 
mycrofft said:
Well, anyone could have calculi casuing pain and another more lethal condition.
Click to expand...

Ureters are very vascular, a ruptured one can create significant bleeding.
 
"Gross blood" or "grossly bloody"

Substitute "obviously" for "grossly". In stool or a clear fluid like urine or CSF, there may be blood you need guiac (Hemoccult) to detect, or blood which is obvious.

Yeah, a ureter will bleed pretty good but the pt would have an acute peritoneal or retroperitoneal thing going on (shocky, constant pain, guarding) with free blood and maybe urine in there, no?

A simlar case near me: obese man in a mobile home making a sandwich, heard something fall down in the kitchen behind him, felt a sharp pain in his flank to his gut and he went down. Got up, pain there but ok enough for him to get wedged into his customary lounger, then called for 911.

A small caliber bullet had punched through the wall (the sound like something falling down), entered his flank, missed all the vital goodies and lodged almost midline after nicking the peritoneum. Had to do dressing changes for one long time, they had to debride the entire bullet track and most of it was through slow-healing adipose tissue.
 
Last edited by a moderator:
mycrofft said:
Substitute "obviously" for "grossly". In stool or a clear fluid like urine or CSF, there may be blood you need guiac (Hemoccult) to detect, or blood which is obvious.
Click to expand...


I speak medicine my friend :)

Gross: able to be seen with the naked eye. Like Gross anatomy. (opposed to microscopic anatomy)

If you need guiac, it is not gross.




mycrofft said:
Yeah, a ureter will bleed pretty good but the pt would have an acute peritoneal or retroperitoneal thing going on (shocky, constant pain, guarding) with free blood and maybe urine in there, no?
Click to expand...

For sure, but "last night" is plenty of time for an acute peritonitis, less likely than a retroperitoneal event due to the ureter location. The peritoneal pain is often from expansion though, so a compression from retroperit. may not cause constant pain. Guarding is inoluntary and that specific finding I did not see as part of the exam here.

One of my earliest calls was for a guy who was cutting down a tree in his yard the day prior, woke up with "unbearable back pain" called 911. On physical exam he had ecchymosis that looked like a massive Grey Turner's sign. Shipped from ED straight to surgery for a small rupture in the myocardium. No pain until the next moring following event.
 
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