feels like falling but has not fallen.

NomadicMedic

NomadicMedic

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It's 20:30, about 85 degrees and humid. Responding to a "general sickness" call at a private residence.

You arrive to find a somewhat frail woman, about 65 or so, lying on the couch, groaning. There's a trash can next to her, where she's vomited. Her husband said she stumbled coming down the stairs and said she felt like she was falling. Then she started vomiting. Sudden onset. No recent illness, she takes no meds except a multivitamin. Saw her doc about 10 days prior for a check up, no issues.

What would you like?
 
A taxi voucher.

No? How about all the vitals to start. And maybe a stroke screen.
 
Then see if increased "falling" sensation with positional change to r/o BPPV.


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Vitals. Anything in the vomit that should be there? Mawmaw bump her head? Bad Chinese food?
 
Pulse is 60, regular and strong at the wrist. Respiration 16 with no obvious increase in her work of breathing and lungs are clear bilat. BP is 92/70. Blood sugar is 61. SpO2 is 97%. Skin is pink and a bit diaphoretic.

She is unable to talk to you, so she can't contribute anything to this patient history gathering q&a. She is just groaning and retching. The husband says she is pretty active, runs a 5k almost every weekend, still works in an office, hadn't been sick in years.

The husband is very worried and doesnt really know much more than what he's told you. He's a active guy too. He was out golfing all day, went in to the office after that and just came home a couple of hours ago. They had a quick bite to eat, got cleaned up and were getting ready to go out with friends.
 
BP is low-normal, sugar is very low. How do her pupils look? Let's get a temperature while we are at it. Is this a BLS crew right now? If we are ALS, let's try to see what a 12-lead shows and start IV dextrose. Administer oral glucose buccally if BLS, and transport her. Assess for the possibility of a head bleed during transport, vitals and monitor enroute, see if she improves after the sugar.
 
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Converted her BGL is about 3 mmol which is quite low. I'd give her some glucose.

There is something at play here. What, I don't know.

She requires referral to a doctor for further investigation however I don't see any clinically compelling reason why this must be immediate or why it requires ambulance transport (provided her hypogylcaemia resolves).
 
After the obvious mild hypotension (without a cardiac rate increase, making it likely normal for her and not shock), the mild blood sugar issue, I'd love to screen for an inner ear infection/ virus, vestibular neuritis or labyrinthitis, CBC and I'd like a vitamins/minerals panel. Take the obvious likely candidates before looking for small potatoes in her head, bleeds, etc. Pre-hospitally, we'd do a 12ld just because we can and electrodes are pretty cheap. She'd likely get popped with 4mg of odansetron for the nausea/vomiting and a little fluid.
 
All sounds like a good plan.

12 lead is unremarkable, you start a line (18g in the left AC) and give 4mg of Zofran and hang a 500 bag of NS and grab the D50 from your bag.

As you and your partner move her to the stretcher, she begins to seize...
 
Any change in pulse pressure? Bradycardia, bradypnea?

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Bradycardia in the 40s. Now unresponsive, but has an intact gag. Gaze deviates to the right and pupils are not reactive to light. Snoring respirations.
 
Gonna have to brush up on the various gazes, but stroke/trauma seems to be ringing a bell for causes. Kinda feels like some increased ICP. Also feel like a tube is climbing my to do list along with working on that bradycardia.
 
Stroke! Non-contrast CT to R/O hemorrhagic stroke. She came in at 2030, so what time is it now? Probable TPA candidate if within 3.5 hours.

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She needs to be tubed due to snoring resps.
 
MackTheKnife said:
Stroke! Non-contrast CT to R/O hemorrhagic stroke. She came in at 2030, so what time is it now? Probable TPA candidate if within 3.5 hours.

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She needs to be tubed due to snoring resps.
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I'd suspect a bleed over a block... But C3 to stroke center either way.


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I'm a knife coming to a gun fight, but...

Did the husband see what immediately happened before he saw her stumble down the stairs? (Any indications to rule in/out trauma?)

I'd of course have ALS and an ambulance coming emergent, originally give oral glucose if there was a gag reflex... and while you're up in her face, any noticeable droop in the semi conscious woman?

I'd be curious to see what happened to the blood pressure if she sat up, but I wouldn't risk that maneuver. Keep her in a recovery position?

I think the O2 stat of 97% looks good for now, but some of my colleagues would go for O2 15 L by mask, and others 2-4 L by N/C.

Once she starts snoring, make sure the airway is open and ventilations are adequate, if not, reposition, use an NPA, and ventilate if needed.

Once she starts to seize... keep her from hitting anything / falling off the couch, keep an eye on breathing (though I'm not sure how you'd deal with that if she was flailing about), and get an ETA on the paramedics!

(Make sure the seizure is not, in fact, cardiac arrest... someone shared a video on here some time ago that indicated that cardiac arrest can initially mimic seizure). If you don't feel a carotic pulse for 5-10 seconds, CPR/AED.
 
Hypoglycemia can cause seizures. Versed for the seizure, D10 for the hypoglycemia, if the seizure stops I might give her a minute while moving to the truck to see if symptoms start resolving after correcting the hypoglycemia but if she doesn't improve rapidly she's going to get intubated, ketamine and roc for the tube, I'd like to see her pressure a little higher as her ICP is more than likely very high and we need to ensure adequate cerebral perfusion pressure, which she more than likely doesn't have with her current MAP. Did we get a BP after the bradycardia started?

The odd part though is bradycardia in head bleeds is secondary to the hypertension and she's not hypertensive.

With the hypotension and bradycardia it definitely may involve the brainstem.

She needs a quick ride and to ensure she doesn't become hypoxic as hypoxia with bleeds sends their mortality through the roof, and needs her head spun at a facility capable of neurosurgery.


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I just realized I didn't finish this up.

It did, infact, turn out to be a catastrophic bleed.I intubated her en route with no medications aside from some D50 (No RSI here in GA.) I suspected a bleed due to the sudden onset and vomiting followed by the seizure and unresponsiveness. Sadly, she never regained consciousness and died a few hours later once the family said goodbye. The symptoms that persented were not textbook SAH, so I thought it was worth sharing. She didn't have any hx of HTN or any other risk factors that her husband was aware of, nor did she complain of that thunderclap headache.
 
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You all are educating me on lots of things here. I appreciate y'all posting these, thanks for your time.
 
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