Dispatched: Unknown Incident

[MrBrown]

*sticks his nose back in his 12 lead book

 

[Dominion]

*sticks his nose back in his 12 lead book

Gonna go ahead and agree with you here.

 

[boingo]

Look at lead I, aVr and the precordial leads....does the r wave progression look kind of backwards? Look at the chest x-ray....something seems to be where it shouldnt....

 

[emtjack02]

Well it's official...I do feel lost. CXR: possible left pneumo, probable pneumopericardium. Lack of ETT that sasha placed. I do not see the ERAD so if someone could throw me a bone that'd be great.

 

[boingo]

Its dextrocardia. If you look at the cxr, you'll notice the heart is on the right, also, the ekg shows reversed r wave progression and a negative complex in I and upright in avr.

 

[emtjack02]

Its dextrocardia. If you look at the cxr, you'll notice the heart is on the right, also, the ekg shows reversed r wave progression and a negative complex in I and upright in avr.

I guess I've forgotten to look at avR. That is pretty cool.

 

[daedalus]

Yea, the dextrocardia is really interesting and all, but I am just not seeing how it has anything to do with a drinking a few beers and passing out. Granted I did not read the whole thread but this scenario makes little sense to me.

 

[Brandon O]

You should read the whole thread.

 

[daedalus]

You should read the whole thread.

Yea, no. I am still not seeing any relevance. I read the thread, maybe I am tired and missing something very obvious. This head injury patient is uncomplicated by any cardiac problems. While he may have RAD, it may be from improper lead placement, and if it actually is present, it will not change the diagnosis or treatment of this patient (other than to change paddle position in the event of a cardiac arrest if a confirmed history of dextrocardia situs inversus is present). The patient is hemodynamicly stable with a good pressure and normal heart rate, and the EKG shows a regular sinus pacemaker without ectopy or evidence of acute ischemic changes. That is a strong case for ruling out a cardiac etiology for his unresponsiveness.

 

[daedalus]

In fact, the care of this patient is also pretty routine and unremarkable, so I am not sure how any one would "fumble" on this one. The patient should get good airway control, be placed into c-spine precaution, and monitored in route tot he hospital while a detailed survey is done, managing any additional injuries found. He should be transported to a facility with trauma/CT scan services are available. And that is about it. B)

 

[sdadam]

Ummm

I hate to break it to your doctor, but an AED would have no problem analyzing a PT with dextrocardia.

Looking at the 12 lead that you posted an AED would simply say "shock not indicated".

If the PT happened to be in vFib or vTach, the fact of the matter is that there is NO difference on an EKG between those two rhythms in a dextrocardia PT and a normal patient.

See the recent post "Dextrocardia" and I wrote ALOT of info on dextrocardia and pad placement.

Also keep in mind that an AED will work perfectly even if you put the pads on reversed in a normal patient.

Now people with dextrocardia often have other health problems, but there is nothing inherent to dextrocardia that is a health risk, so this would be a PT with something else going on who just happened to have dextrocardia too.

 

[Brandon O]

I guess ceej has been banned for a bit, so I'll answer best I can...

The way this plays out in full (at least as it did for me) is supposed to be:

LOC was caused by the diabetic condition. This is otherwise a red herring; you're just supposed to treat it and move along. Airway problems are similarly just an obstacle, do what you need to do. (Apparently in the original material OPAs were supposed to be contraindicated because of the swelling tongue and NPAs because of the head trauma -- not sure I agree with either of those but oh well, it's an ALS scenario.) The respiratory changes are Kussmaul secondary to the hyperglycemia.

however

When he went down and hit his head, he began to hemorrhage (no further info here). Your index of suspicion was supposed to be the Heparin -- and vitals should have exhibited Cushing's Triad as things moved along, which we never got to. (When I went through this the vitals didn't say anything, so that's where things went south for me.)

The timeline is tight on this, so no matter how you treat or transport, the patient codes en route (or on scene if you're slow). Whereupon the dextrocardia becomes relevant, which you hopefully diagnosed earlier (or figure out now). As for me I just kept getting "pads misplaced" and scratching my head; maybe with a manual defib you could be more intelligent about it.

Buuut that's all I know. Dextrocardia's new to me so I'm no expert.

 

[Brandon O]

Just caught the dextrocardia thread sdadam, good info.

 

[ceej]

Ummm

I hate to break it to your doctor, but an AED would have no problem analyzing a PT with dextrocardia.

Looking at the 12 lead that you posted an AED would simply say "shock not indicated".

If the PT happened to be in vFib or vTach, the fact of the matter is that there is NO difference on an EKG between those two rhythms in a dextrocardia PT and a normal patient.

See the recent post "Dextrocardia" and I wrote ALOT of info on dextrocardia and pad placement.

Also keep in mind that an AED will work perfectly even if you put the pads on reversed in a normal patient.

Now people with dextrocardia often have other health problems, but there is nothing inherent to dextrocardia that is a health risk, so this would be a PT with something else going on who just happened to have dextrocardia too.

Like I said, I am a student and this is what I was told. Thanks for the clarification.

 

[paccookie]

I guess ceej has been banned for a bit, so I'll answer best I can...

The way this plays out in full (at least as it did for me) is supposed to be:

LOC was caused by the diabetic condition. This is otherwise a red herring; you're just supposed to treat it and move along. Airway problems are similarly just an obstacle, do what you need to do. (Apparently in the original material OPAs were supposed to be contraindicated because of the swelling tongue and NPAs because of the head trauma -- not sure I agree with either of those but oh well, it's an ALS scenario.) The respiratory changes are Kussmaul secondary to the hyperglycemia.

however

When he went down and hit his head, he began to hemorrhage (no further info here). Your index of suspicion was supposed to be the Heparin -- and vitals should have exhibited Cushing's Triad as things moved along, which we never got to. (When I went through this the vitals didn't say anything, so that's where things went south for me.)

The timeline is tight on this, so no matter how you treat or transport, the patient codes en route (or on scene if you're slow). Whereupon the dextrocardia becomes relevant, which you hopefully diagnosed earlier (or figure out now). As for me I just kept getting "pads misplaced" and scratching my head; maybe with a manual defib you could be more intelligent about it.

Buuut that's all I know. Dextrocardia's new to me so I'm no expert.

Disagree with you on the kussmaul respirations. Sounds more like central neurogenic hyperventilation...which looks just like kussmaul but has a neurological basis (staving of herniation in the face of IICP). I've never seen a diabetic have such several symptoms in the 200's, so I'm not convinced that the LOC and the respirations are to be blamed on the blood glucose.

 

[daedalus]

Disagree with you on the kussmaul respirations. Sounds more like central neurogenic hyperventilation...which looks just like kussmaul but has a neurological basis (staving of herniation in the face of IICP). I've never seen a diabetic have such several symptoms in the 200's, so I'm not convinced that the LOC and the respirations are to be blamed on the blood glucose.

I agree with pacookie. This whole scenario is just strange.

 

[Brandon O]

Just going on what I was told, fair enough guys.

 

[mycrofft]

More scene questions.

Was he wearing synthetic socks and was there Armorall on the floor?

 

[fiddlesticks]

well i would suction first to clear the airway then put in an opa and get my partner to bag the guy. then get the guy out to the truck and start and iv and put him back on the monitor, i would only take him to the er casue well i dont see a need to add that much time on to the call. is there anything else you would like added?

 

[thowle]

Cspine and LBB are done.

Intubation failed times 3 attempts. Too much blood and too many broken teeth obstructing the airway.

Would you like to break out the Mcgills and try to clear it? It'll cost you another 4 minutes.

Edit: Helicopter takes 25 minutes to get here and it's 10 minutes to nearest viable LZ. HEMS is moving.

A - Airway is being partially obstructed by broken teeth and blood. He bit his tongue on the way down and it is swelling fast.
B - 4/min and shallow when you find him.
C - Pulse is 89 and strong.
S - Appears to be in respiratory distress, first vitals are below.
A - Sulfa, NSAIDs.
M - Daughter can't vocalize; you find Lipitor, Prednisone, Albuterol and Coreg. You find a glucagon kit, but cannot locate any other medications related to Diabetes.
P - She says daddy has been taken by the paramedics before because of his heart.
L - He finished off his 12 pack about an hour ago.
E - He was getting up off the couch to make himself a sandwich when the daughter heard the crash.
O - Daughter called when she couldn't wake him up, it took you 18 minutes to get there. Onset is believed to be within the last 25 minutes.
P - Unknown
Q - Unknown
R - Unknown
T - Unknown

Vitals:
Unresponsive, cannot be aroused.
Skin is wet and cool.
BP: 140/98
Pulse: 89
RR: 4/min and shallow.
Pupils: ERRL

Clearing the airway and tubing will cost you 3 minutes.
CSpine + LBB will cost you 2 minutes.
Combitube will cost you 2 minutes.

Hospitals:
Level III Trauma Center: 22 minutes hot. (Out of the city)
Level I Trauma Center: 21 minutes hot. (Out of the city)
ER with no trauma classification: 13 minutes hot (Into the city)

Other considerations:
It's 4:30PM on a Friday and traffic is BAD. You might consider adding 15-20 minutes to your hot run times if you decide to go out of the city...

Hints:
Zebras have stripes.

On Scene:
Suction airway, establish; re-evaluate airway and breating; bag valve, OPA, c-spine, move to ambulance...

In Ambulance (enroute to ED):
Intubate (failed 3 times), King Airway LTD, 100% Oxygen, Bag Valve -- I guess he's breating 30/m now, or still 4/m? Either way -- BVM. Keep eye on skin condition, temp, BP, and pulse, treat for shock as neeed, Monitor, IV started, ready to push as needed, transport ALS to "Level I Trauma Center: 21 minutes hot. (Out of the city)" -- (Possible trauma causing additional airway obstruction) initially, if subject deteriorates much, consider transport to another ED or radio to local area and request air transport and setup LZ wherever closest to; depends on location.