Cold, diaphoretic and dizzy diabetic??

[LucidResq]

I have a case study assignment for class that’s confusing the hell out of me:

56 y/o male at work – secretary calls 911 because of how awful he looks. Awake, alert, oriented. Skin is ashen, diaphoretic and cold. Chief complaint is dizziness and nausea, also c/o not feeling well for several days with flu-like symptoms: achy, indigestion, no energy or appetite.

Pt was diagnosed with adult-onset diabetes 6 months ago and has hypertension and ulcers. Taking gilipizide, cimetidine, and atenolol; compliant.

Glucometer reads “high”… had toast and tea for breakfast.

Denies any pain, vomiting, diarrhea, or fever.

HR 66, BP 74/40, RR 18 – lung sounds faint in bases, clear in upper lobes

So the only things I can think of are left-side heart failure and diabetic ketoacidosis, but neither of them really makes complete sense or explains all of his s/s. Am I going down the right path? Is there something I’m missing?

Thanks in advance for any help.

 

[Epi-do]

I think you are probably on the right track with the ketoacidosis. If you have to come up with potential reasons for why the ketoacidosis occurred, try looking at your meds and researching any possible drug interactions. (hint, hint

 

[skyemt]

think about it... your diabetics are notorious for atypical presentations for MI's... the neuropathy that accompanies the diabetes affects there ability to feel that "crushing chest pain", and they may have no complaints of chest pain or discomfort whatsoever.

diabetics having MI's often present with lethargy, indigestion, nausea, dizziness, flu like symptoms... basically what you are describing.

DKA could present with AMS, extreme thirst, increased urine output, deep and fast breathing, fruity odor on the breath, and other S/S, none of which you have described...

without knowing, of course, i can tell you that atypical presentations of MI's are missed all too often by EMT's.... the elderly, women, and diabetics are notorious for this.

 

[Ridryder911]

Remember, DKA is usually associated with an illness that causes the patient to loose too much insulin, i.e. vomiting, fever, diarrhea, illness, etc.
The symptoms as well are usually found over several days, the patient usually presents in very grave condition (unless the patient has a hx. of DKA and knows what to do). The skin is usually hot & dry, patient respiratory rate is usually deep and fast. Such as the patient having Kussmaul's Respiration to blow off acid ( hence the usual smell of acetone).

Since the patient is diabetic, there is several diagnosis that could be made. Anything from having an AMI or again just gastroenteritis (viral flu like s/s) with dehydration and remember diabetics s/s of an AMI may not be that of a normal presentation. Good chance it might also be a AMI!

Most Glucometers only read up to about 500 mg/dl and anything over that usually reads "high". Remember, glucose will increase with illnesses especially in AMI, also the use of steroid use as well.

In regards of CHF, a very good possibility as well.

Confused yet? LOL.....

Now here is new one for you, truthfully it does sound a lot alike hyperosmolar hyperglycemic or another term that is Non-DKA. This is a life-threatening emergency presented by high blood glucose, hyperosmolarity, and little or no ketosis (acid). Although the causes are numerous, underlying infections are the most common. Other causes include certain medications, also being non-compliant to medications, undiagnosed diabetes, substance abuse, and other diseases. Physical findings of hyperosmolar hyperglycemic state usually presents symptoms associated with profound dehydration and various neurologic symptoms such as vertigo, hypotension, confusion.

Of course more in-depth assessment and use of ECG, EtCO2, etc. can help assist in making the diagnosis. Truthfully, on these type of symptoms, we have to assume the worst and cautiously treat. One is going got have to treat accordingly of course.

Since the pulse rate is not tachycardia, I really would like to see an ECG. The patient maybe compensated already, and my first course would be fluid therapy and possible vassopressors.

Again, what may appear as a simple flu like (which it might be) can actually be a life threatening illness.

R/r 911

 

[Airwaygoddess]

I wonder about that BP that the patient presents with..... So what would your course of treatment be to support this patient?

 

[fma08]

couple other questions, RR is 18 but whats quality? deep? shallow, fruity odor? also is the pt. running a temp at the moment. i'd want a second blood sugar check also just to be safe since there are a few things that can throw the glucometer off and a 12 lead. but like the other guys said, you are on the right track and it can be several things from gastro to AMI to hyperglycemia. i'm guessing the guy's dehydrated a bit too. but i'm a bit worried of a pt that has a Hx of HTN yet has a BP of 70's over 40's... let me know what you find out pls if you get the info on the study.

 

[LucidResq]

Hey thanks for all the help! After some more research, reading these posts and talking with my partners for this case study we are leaning towards either an AMI, bleeding ulcer, or hyperosmotic nonketotic state.

As BLS we decided that our further action would be to call ALS, ask a lot of questions, especially about his poo (bloody? melena?) and history. We'd want to palpate the abdomen and put him on o2 in case the issue is cardiac and transport rapidly in trendelenburg's because of his BP.

PS: one of the most frustrating things about these case studies is trying to figure out what's going one without actually being able to see the pt. and ask questions. It drives me nuts.

 

[Ridryder911]

transport rapidly in trendelenburg's because of his BP..

You were going great! Until this... please, read my posts on the myth of Trendlenburg, especially on a possible GI problem...

Otherwise, glad to see you thinking outside the box.

R/r 911

 

[Grady_emt]

without knowing, of course, i can tell you that atypical presentations of MI's are missed all too often by EMT's.... the elderly, women, and diabetics are notorious for this.

And dont forget the Acute Renal/Dialysis and Sickle Cell anemia pts as well for atypical presentation.

 

[LucidResq]

You were going great! Until this... please, read my posts on the myth of Trendlenburg, especially on a possible GI problem...

Otherwise, glad to see you thinking outside the box.

R/r 911

Can you direct me to these posts? I can't find them. I googled a little bit and found some of the debates about Trendelenburg's, but nothing about using it when the pt may have a GI problem.

I think I've heard it mentioned that Trendelenburg's was worthless, but obviously it's still being taught religiously.

 

[LucidResq]

And dont forget the Acute Renal/Dialysis and Sickle Cell anemia pts as well for atypical presentation.

I haven't heard of this... can you explain why physiologically? I believe you, I just want to know why they would present atypically. And you are referring to them presenting atypically for an MI, right?

 

[Grady_emt]

I haven't heard of this... can you explain why physiologically? I believe you, I just want to know why they would present atypically. And you are referring to them presenting atypically for an MI, right?

As for the Sickle Cell, we know that it is a disorder of the Red Blood Cells that causes them to take on a "Crescent" or irregular shape. Pts that are experienceing a crisis are having an slowing/stopping of blood flow. This is what causes the painful crisis that they experience. The slowing occurs as the sickled cells catch on each other, the vessle walls, a valve and then other blood cells/platelets may latch onto the sickled cell and obstructing blood flow. These Pts are succeptable (sp) to having these in any vessle in their body including the coronary vessles, however the pain may be no different than a normal crisis to the pt. It is crucial to obtain an early 12lead in these patients to r/o any cardiac involvement and keep the pt on the monitor.


As for the Dialysis Pts, they are personally my least favorite type of call to run due to the many variables. Remember that a Pt on dialysis is having their blood artificially filtered and its only every 2-3 days not constantly like you and I. This allows for the buildup of many toxins, excess electrolytes, potassium, sodium, etc in the bloodstream that our kidneys normally filter out and flush from the body in urine. This can cause profound changes in the EKG, especially is a person is non-compliant with their treatments. Dialysis pts also do not compensate well and are subject to septic shock from even a simple infection.

Also, they are prone to having a pulomnary embolus/thrombosis more than a "regular" pt due to the potential for air bubbles to enter the blood stream following an improperly discontinued dialysis session, or the formation of clots in/around their shunt.

Hope I answered it without confusing you too much:wacko:

 

[Ridryder911]

..found some of the debates about Trendelenburg's, but nothing about using it when the pt may have a GI problem.

I think I've heard it mentioned that Trendelenburg's was worthless, but obviously it's still being taught religiously.

It might still be taught religiously, as so is CISD, which has been proven to cause more harm than good, as well as fluid resuscitation, and treatment using PASG for shock, all proven myths. In other words, just because it is taught, does NOT make it right. Remember, textbooks are written at the minimum of three to five years advanced before they are published. So in reality they maybe outdated before they are even printed Just think, the Paramedic curriculum last update was over 12 years ago.... a lot has change since then.

Look at current research and treatment modalities. It is part of our responsibility to address these issues and inform our Medical Director to make changes as necessary.


* remember increasing pressure on internal organs, causes what?

site references:

http://www.ems1.com/Columnists/brya...e-Current-Slant-on-the-Trendelenburg-Position


http://www.merginet.com/index.cfm?pg=trauma&fn=TrendelenburgPosition


Literary references:

Martin JT. The Trendelenburg position: A review of the current slants about head down tilt. Journal of the American Association of Nurse Anesthetists. 1995;63:29-36.
Taylor J, Weil MH. Failure of the Trendelenburg position to improve circulation during clinical shock. Surgery, Gynecology and Obstetrics. 1967; 124:1005-1010
Sibbald WJ, Patterson NAM, Holliday RL, Baskerville J. The Trendelenburg position: hemodynamic effects in hypotensive and normotensive patients. Critical Care Medicine. 1979;7:218-224
Bivins HG, Knopp R, De los Santos PA, Blood volume distribution in the Trendelenburg position. Annals of Emergency Medicine. 1985;14:641-643
Bivins HG, Knopp R, Tiernan C, dos Santos PA, Kallsen G. Annals of Emergency Medicine1982;11(8):409-12
SingRF, O’Hara D, Sawyer MAJ, Marino PL. Trendelenburg position and oxygen transport in hypotensive adults. Annals of Emergency Medicine 1994;23:564-567
Terai C, Anada H, Matsushima S, et al. Effects of mild Trendelenburg on central hemodynamics and internal jugular vein velocity, cross –sectional area, and flow. American Journal of Emergency Medicine. 1995;13:255-258.

 

[LucidResq]

Oh I know, I realize that the textbooks aren't necessarily right. It's just something that's obviously a problem. Pretty sad.

Thanks for all the info, by the way. Both of you.

 

[Ridryder911]

This allows for the buildup of many toxins, excess electrolytes, potassium, sodium, etc in the bloodstream that our kidneys normally filter out and flush from the body in urine. This can cause profound changes in the EKG, especially is a person is non-compliant with their treatments. Dialysis pts also do not compensate well and are subject to septic shock from even a simple infection.

Remember they are "pulling fluid" off by the way of osmosis filtration ( remember that term in acid/base and fluid and electrolytes) with a "bath" solution of a determined electrolyte solution. The problems encountered in EMS many times is the "bath solution" has changed, thus causing a shift in the cations (K+, Mg+, Na+, Ca+) yeah all the plus and anions (Cl-etc).

Always ask if there has been a recent change in the bath solution, as well now remembering "they are pulling fluid off" how much did they pull? They always weigh prior and should weigh afterwards or some can give you exactly how much fluid they pulled off on the dialysis machine itself in liters. Again, it may be too much in a short amount of time. As well as a major electrolyte imbalance.

I challenge anyone that has a sick dialysis patient to observe their "labs". I can almost attest that they will always be "critical value" on BUN, Na+, Cl-, Creatinine, Mg+ , etc.. and on. They are a train wreck.

I have responded a lot to cardiac arrest at dialysis centers. In fact I find it the most interesting and best calls. I have a great percentage of "saves" with those patients. Usually they are in aystole or IVR/PEA. I will administer Epi or vasopressin, Mg+, possibly NaHco3 (for the Na+), and about 150-250 ml NSS (dependent on fluid taken off), also check FSBS (since most are DM) treating the underlying cause of the arrest. I have a better percentage of responses. Many EMS have separate Dialysis treatment regime.

R/r 911