Dispatched for Dizziness and Vomiting

[bnn987]

The arriving BLS crew arrived to find a 65 y/o female laying down on the couch in her home. The patient's family member states that she has had a sudden onset of vomiting and dizziness.

After determining the level of consciousness of the patient the BLS crew finds the patient to be disoriented alert to her first name only, family names, but does not know where she is. The patient states that she had a mild MI 1 year and 6 months ago and that the symptoms are very similar to her MI. The patient also has a HX of diabetes. The patients glucose level was 117 on her test with the BLS crew. On further assessment the patient states that she has pain radiating from her stomach to her chest. The BLS crew also reports that the patients skin color is very pale and the family confirms that she is no where nearly as pale on a normal day. The crew attempts to keep talking to the patient, however the patients LOC becomes altered to the point that she does not remember her name or where she is going.

An ALS unit was not assigned to the call due to the initial chief complaint of nausea, vomiting, and dizziness. The BLS crew immediately requested an ALS unit to the scene, however due to proximity the ALS was cancelled and transport was immediately started to the medical center 8 minutes away.

Vitals:

BP 182/92
Pulse 98 / strong/ regular
Pulse Ox: 99% on room air
Skin: Pale, warm
Breathing: 18 / normal

History: Mild MI 1 year and 6 months ago, Diabetic

What do you guys think? Ask away if you have any questions as I am writing this mobile with very minimal sleep!

 

[Sublime]

Facial drooping? Did you do any stroke testing?

Would be nice to see an EKG also.

Was the pain radiating anywhere? Was the patient able to localize it?

What about her abdomen, did you palpate it? Did it feel normal?

 

[MaxExam]

Keep in mind im a new guy with zero field experience (start precptor training 06 Aug) But im studying alot so i want to take a shot at this scenario, all from memory so please excuse the spelling ...well, some info that i would prefer to have is missing, like any specific pain in the chest beyond coming from the stomach? How about neck, face, arms, legs, or back?...also is she diaphoretic. Anyway lets dive in 1) I dont think this is a new MI, because of preload, afterload & contractility changes, i wouldn't expect those current VS to have lasted very long if it was...2) With her diabetic history i consider that but seeing her BGL at the high-end of normal, i temporarily move on. 3) could it be pump failure shock(cardiogenic or obstructive ie,cardiac tamponade & or tension pneumothorax)? well, even without a new MI, past damage combined with a new stressor could be her problem, but i don't think so..would also expect faster & deeper respirations(but im not cookbooking it either lol) SO tension pnemo or tamponade? Did she have any recent coughing fits or blunt trauma? doesn't sound like any penetration injury happened, right? At the very least(or worst) its compensating shock...BUT 5) This sounds to me like GERD, from what i understand...columnar cells somehow transform to squamis cells, which does 2 things, it causes the channel from the stomach to the small intestine to be stenotic (closes) and also the LES (lower esophageal sphincter) dilates and "sticks" open....so the net effect is stomach acids and other contents go the only place they can..UP! Obviously i could be wrong, overall i do however know for sure, she needs the help of Vene & Mr.Brown(or some other guys like them )

 

[MaxExam]

If my assessment is wrong then this add on obviously isn't necessary to your scenario but i enjoy being thorough (unless i forget which brings me to this add on :huhGERD(gastro esophageal reflux disease) i think would give you the signs & symptoms in this scenario & non-hemorrhagic hypovolemic shock could be the result (obviously, i guess?) man i really hope EMS works out for me so i can try Medic school.. because i have no idea beyond guessing fluid replacement,(but i dont know how that works..time 4 interweb soul surfer,lol) Anyway GL2U

 

[Aidey]

Horses, not Zebras.

Edit: When you hear hoof beats, think simple and obvious before complex and rare.

 

[JPINFV]

Wait, there's someplace teaching EMTs how to do differentials? WTF? However strong work.

1) I dont think this is a new MI, because of preload, afterload & contractility changes, i wouldn't expect those current VS to have lasted very long if it was...

I don't think there's anyway to avoid having an MI being a consideration in a 65 y/o diabetic female. That pretty much screams atypical MI presentation.

2) With her diabetic history i consider that but seeing her BGL at the high-end of normal, i temporarily move on.

Agreed... 117? Yawn.

3) could it be pump failure shock(cardiogenic or obstructive ie,cardiac tamponade & or tension pneumothorax)? well, even without a new MI, past damage combined with a new stressor could be her problem, but i don't think so..would also expect faster & deeper respirations(but im not cookbooking it either lol) SO tension pnemo or tamponade? Did she have any recent coughing fits or blunt trauma? doesn't sound like any penetration injury happened, right? At the very least(or worst) its compensating shock...BUT

I have a hard time thinking heart failure/tamponade/tension pneumo with hypertension like this. Tamponade has a narrowed pulse pressure, while it's 90 here. Similarly, a tension pneumo would result in a lower BP due to decreased venous return which would cause hypotension (Starling mechanism).

5) This sounds to me like GERD, from what i understand...columnar cells somehow transform to squamis cells, which does 2 things, it causes the channel from the stomach to the small intestine to be stenotic (closes) and also the LES (lower esophageal sphincter) dilates and "sticks" open....so the net effect is stomach acids and other contents go the only place they can..UP! Obviously i could be wrong, overall i do however know for sure, she needs the help of Vene & Mr.Brown(or some other guys like them )

Barrett's esophagus/metaplasia is the squamous->columnar change seen in patients with GERD, and can lead to adenocarcinoma. Similarly, it sounds like you're describing in the second half like you're describing pyloric stenosis. The classical presentation is a newborn who has non-bilious vomiting relatively soon after eating along with an olive shaped mass in the epigastric region. It isn't really something I would expect to find in a 65 y/o female with no prior complaints.

 

[Anjel]

she needs the help of Vene & Mr.Brown(or some other guys like them )

:glare::glare::glare::glare::glare: Really? And paragraphs would be helpful to read your responses better. They were full of good info. But hard to follow.

Anyways.....

I really would of jumped to the fact that she was having an MI. But with the vitals I am not sure. What was she doing when all this started. Did she eat anything that day? Does she take insulin? ( I may of missed that)

She said it feels like her last MI? Why? What in particular feels like that? The chest pain? Or the sudden onset dizzy// nausea.

I am going with MI. Because that is all I can think of that would match every single symptom she presented with.

And around here for a 60 something year old Diabetic with sudden onset of dizzy/nausea an ALS unit would of been sent. No question about it.

 

[fast65]

I would be looking at an MI on this one. It seems like an atypical MI to me, and with those vitals, she very well could be in the early stages of it, and just be compensating well.

Did ya get a temp? Repeat set of vitals? Any complaints of dyspnea?

 

[Doczilla]

Keep in mind im a new guy with zero field experience (start precptor training 06 Aug) But im studying alot so i want to take a shot at this scenario, all from memory so please excuse the spelling ...well, some info that i would prefer to have is missing, like any specific pain in the chest beyond coming from the stomach? How about neck, face, arms, legs, or back?...also is she diaphoretic. Anyway lets dive in 1) I dont think this is a new MI, because of preload, afterload & contractility changes, i wouldn't expect those current VS to have lasted very long if it was...2) With her diabetic history i consider that but seeing her BGL at the high-end of normal, i temporarily move on. 3) could it be pump failure shock(cardiogenic or obstructive ie,cardiac tamponade & or tension pneumothorax)? well, even without a new MI, past damage combined with a new stressor could be her problem, but i don't think so..would also expect faster & deeper respirations(but im not cookbooking it either lol) SO tension pnemo or tamponade? Did she have any recent coughing fits or blunt trauma? doesn't sound like any penetration injury happened, right? At the very least(or worst) its compensating shock...BUT 5) This sounds to me like GERD, from what i understand...columnar cells somehow transform to squamis cells, which does 2 things, it causes the channel from the stomach to the small intestine to be stenotic (closes) and also the LES (lower esophageal sphincter) dilates and "sticks" open....so the net effect is stomach acids and other contents go the only place they can..UP! Obviously i could be wrong, overall i do however know for sure, she needs the help of Vene & Mr.Brown(or some other guys like them )

:blink:

 

[MaxExam]

:blink:

Lol, i know i know...if i had to write that first comment again i definitely would structure it better. I was mostly trying to say what i didn't think it was, but i forgot to finish the thought on a few points (not even saying i was correct) like i knew while typing the first comment that in tamponade, becks triad- of JVD, muffled heart & merging BP didn't fit this scenario..or in T-pneumo, can lead 2 vena cavae compression & hypotension, etc...Plus, meh GERD i dunno. Im starting to realize just how much i dont know...sooo many signs & symptoms overlap possible etiologies. Im curious & hope OP says if the vomiting was bloody, because i still think its some kind of GI issue.

 

[Aidey]

A diabetic female is saying she has the same symptoms as her last MI. The best place to start is at another MI.

 

[Doczilla]

Diabetic neuropathy Plus female gender can skew the perception of referred or visceral pain.

Furthermore , "epigastric" complaints rank pretty high in those presenting with atypical MI. Even if the initial ECG is nonspecific (about 50% of them do not meet stemi criteria initially) , you should still watch these people pretty closely,do serial 12-leads, and transport to a cardiac facility.

I've had these patients go from "negative" ECG, to tombstone elevation to arrest within 5 mins.

 

[medicman14]

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Thanks!

I'm with you...inferior wall mi, anterior branch is likely seeing the vitals. Back in the day we'd give a ntg and duck. Now we do v4, 5, and 6r evals to preempt the bp dump. Inferiors tend to have diaphragmatic irritation s/s like n/v.
Hard to truly say sitting here, but it is entertaining to see the variety of guesses - which btw, is all I'm providing as well.
Thanks for sharing,
Are you able to research and determine the true issue?
If so, please share.

 

[crispy91]

I know this explanation has already been posted, but sounds like AMI to me. Remember that Older Pts and diabetics have more of a chance of experiencing a silent MI. Put two together, and that should definitely raise the index of suspicion for AMI. However, I wasn't on the call, so this is only my opinion.

 

[jroyster06]

. . .

 

[jroyster06]

Why is everyone already ruling out a CVA? 60 something yo female who is a Diabetic? Screams AMI or CVA. Any seizure history? I would need a full neuro exam before I made the transport decision. Hemmoragic strokes can do funny things including acute onset of N/V and dizziness. Plus she is hypertensive.

So:
Acute onset of N/V dizziness.
Elderly diabetic.
Previous history of MI
Hypertensive now.
Assuming she has a HTN history here.

Im thinking MI OR CVA


PLUS she has a rapidly decreasing LOC. And is disoriented. Im leaning harder to CVA than an MI. The abdominal pain could be from an MI or it could be from the vomiting. . . Unless im the only one who's guts hurt after vomiting.

 

[Veneficus]

Why is everyone already ruling out a CVA? 60 something yo female who is a Diabetic? Screams AMI or CVA. Any seizure history? I would need a full neuro exam before I made the transport decision. Hemmoragic strokes can do funny things including acute onset of N/V and dizziness. Plus she is hypertensive.

So:
Acute onset of N/V dizziness.
Elderly diabetic.
Previous history of MI
Hypertensive now.
Assuming she has a HTN history here.

Im thinking MI OR CVA


PLUS she has a rapidly decreasing LOC. And is disoriented. Im leaning harder to CVA than an MI. The abdominal pain could be from an MI or it could be from the vomiting. . . Unless im the only one who's guts hurt after vomiting.

or both...

I agree with JP though.

 

[jroyster06]

Im just saying just because you initial thought is an MI dont stop there keep scrounging and searching until you are all but postive its an MI or a CVA. If it was a CVA and you treated her for an MI when she wasnt having one you could cause some SERIOUS hemmoragic issues in the brain.

 

[Aidey]

No one was arguing that it definitely was an MI, just that it is the best place to start. We don't have enough information to have anything beyond an initial thought. We have no 3 lead, no 12 lead, no full neuro exam, no repeat vitals, no full past medical history, no meds, etc.