Aidey
Community Leader Emeritus
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Literally, her condition occurs in one in a million people in the US in a year....totally nuts.
Called for a 75 year old female, CC of sudden onset of midline back pain between her shoulders, radiating down her L arm and into her neck. Pain is a 8/10, accompanied by nausea and just feeling generally unwell. The pt was sitting down when it started, no trauma.
History of HTN and hypothyroid, takes atenolol and synthroid, and states she is compliant with meds. Last oral intake was about 45 minutes before onset of symptoms.
Pulse in the 90s, sinus rhythm. Her BP, which was checked in both arms was 220-230s over 120-130. SpO2 of 91-92% on RA, lungs clear, up to 97% on 4lpm. No diaphoresis.
The pt denied COPD or any history of respiratory problems, however she did have some mild clubbing of her fingers, so she probably has an undiagnosed respiratory condition and the SpO2 is normal. Or in the mess of things she forgot she had a respiratory history.
The 12 lead was borderline. There was about 1.5 boxes of elevation in the lateral leads, but the QRS was .124. We were stuck 50/50 between ischemia or LBBB since it was so borderline (it did end up being a LBBB ).
The pt had taken 2 baby ASA and 1 adult ASA prior to our arrival, so we did not give her more. She was given 3 nitro over 15 minutes without change in her BP or pain. Her BP was checked in both arms and found to be comparable.
So, as you can see, we treated for cardiac. The back pain down the L arm and into the neck with nausea is what really made me think cardiac, since that is a fairly common way for females to present. Her age and BP added to my line of thinking.
When we got to the hospital, about a hour, hour 15 after the onset of symptoms the pt told us she was too weak to move, however, she had helped us get her shirts off on scene. The MD assessed her and stated that he felt the 12 lead was a LBBB, not ischemia and that he was almost 100% sure she was dissecting.
So, a few hours later we make it back to that hospital and I see the charge nurse. I ask her about my PT and she tells me that I need to go talk to the doc, which was strange since she has always given me the basic info before.
I track down the doc, and he updates me. Our patient had a spontaneous C7 epidural bleed, and by the time they found it she had no movement or sensation from the nipple line down, and no movement or sensation in any of her extremities. They tried to get her BP down with a couple things, and finally had to give her "a big dose" (didn't ask exact mg) of Labetalol, which got her pressure down to the 140s/80s-90s. After that happened she regained some sensation in her chest, and was able to slightly move the fingers on her R hand.
The doc was totally floored, he said that in 25 years it was the first spontaneous spinal epidural bleed he had ever seen, and would probably be the only one. He said that as far as he was concerned our pre-hospital treatment was fine because she was presenting like a cardiac, and there was no way we would have figured out what was going on.
I did some research when I got home that night, and it turns out spinal epidural bleeds happen in about 1 in a million people in the US in a year. The vast majority of these cases are trauma induced. Most commonly they occur as a complication of an anesthesia epidural, spontaneous cases make up a very small percent of the cases in a year.
Called for a 75 year old female, CC of sudden onset of midline back pain between her shoulders, radiating down her L arm and into her neck. Pain is a 8/10, accompanied by nausea and just feeling generally unwell. The pt was sitting down when it started, no trauma.
History of HTN and hypothyroid, takes atenolol and synthroid, and states she is compliant with meds. Last oral intake was about 45 minutes before onset of symptoms.
Pulse in the 90s, sinus rhythm. Her BP, which was checked in both arms was 220-230s over 120-130. SpO2 of 91-92% on RA, lungs clear, up to 97% on 4lpm. No diaphoresis.
The pt denied COPD or any history of respiratory problems, however she did have some mild clubbing of her fingers, so she probably has an undiagnosed respiratory condition and the SpO2 is normal. Or in the mess of things she forgot she had a respiratory history.
The 12 lead was borderline. There was about 1.5 boxes of elevation in the lateral leads, but the QRS was .124. We were stuck 50/50 between ischemia or LBBB since it was so borderline (it did end up being a LBBB ).
The pt had taken 2 baby ASA and 1 adult ASA prior to our arrival, so we did not give her more. She was given 3 nitro over 15 minutes without change in her BP or pain. Her BP was checked in both arms and found to be comparable.
So, as you can see, we treated for cardiac. The back pain down the L arm and into the neck with nausea is what really made me think cardiac, since that is a fairly common way for females to present. Her age and BP added to my line of thinking.
When we got to the hospital, about a hour, hour 15 after the onset of symptoms the pt told us she was too weak to move, however, she had helped us get her shirts off on scene. The MD assessed her and stated that he felt the 12 lead was a LBBB, not ischemia and that he was almost 100% sure she was dissecting.
So, a few hours later we make it back to that hospital and I see the charge nurse. I ask her about my PT and she tells me that I need to go talk to the doc, which was strange since she has always given me the basic info before.
I track down the doc, and he updates me. Our patient had a spontaneous C7 epidural bleed, and by the time they found it she had no movement or sensation from the nipple line down, and no movement or sensation in any of her extremities. They tried to get her BP down with a couple things, and finally had to give her "a big dose" (didn't ask exact mg) of Labetalol, which got her pressure down to the 140s/80s-90s. After that happened she regained some sensation in her chest, and was able to slightly move the fingers on her R hand.
The doc was totally floored, he said that in 25 years it was the first spontaneous spinal epidural bleed he had ever seen, and would probably be the only one. He said that as far as he was concerned our pre-hospital treatment was fine because she was presenting like a cardiac, and there was no way we would have figured out what was going on.
I did some research when I got home that night, and it turns out spinal epidural bleeds happen in about 1 in a million people in the US in a year. The vast majority of these cases are trauma induced. Most commonly they occur as a complication of an anesthesia epidural, spontaneous cases make up a very small percent of the cases in a year.
