Interesting one for you...

[Fox800]

Well at least I thought so at the time.

Dispatched for a 55/M having a seizure. Upon arrival, you find the pt. supine on the living room floor with fire department on scene for about 10 minutes before you got there. Family advises that pt. was sitting in the recliner hanging out...he then stood up, and started shaking all over. Son ran over and grabbed him and assisted him to the ground, where he continued to shake. Pt. shook for about 30 seconds then came around. He felt weak so he laid on the floor for 30-45 minutes to rest. He then tried to get up, and had a second, nearly identical episode of shaking for about 30 seconds. This is when the family decided to call 911.

BP: 80/40, HR 120, RR 16, SPO2 98% room air, ETCO2 25, BGL 330, oral temp 96.0. GCS=15.

Hx: Hypertension, alcohol abuse, thrombocytopenia. NO seizure history, NO diabetic history.
Meds: Typical unremarkable hypertension meds (can't remember)
NKDA

Physical examination: Pt. has a black bruise to the lower lip. He says it happened this morning but he doesn't remember how. It is now 19:00. No neurologic deficits. Skin looks pale but is warm and dry. Pt. denies any complaints of pain, only complaint is generalized weakness. You notice numerous bruises to the arms and legs. Pt. explains a large group of leg bruises, "I had a waterskiing accident last week". Pt. denies any bleeding disorders or blood thinners.

And...go.

 

[firetender]

When was the last time he had a drink?

 

[Fox800]

When was the last time he had a drink?

Pt. and family tell you that he's been off the bottle for about two weeks. No ETOH odors noted. Pt. denies any drug use, either.

 

[8jimi8]

man i'm terrible with neuros unless it's a stroke. i'm gonna wait for someone to ask the right questions, so i can clue in!

 

[Fox800]

A big thing here is are you going to trust your patient? That he really has been sober? If so is he having withdrawals? Or has he relapsed and is saying that he hasn't been drinking because his wife and son are in the room with you. When it's just you and him in the back of the ambulance, he still says he hasn't had a drink.

 

[firetender]

The thread I'd follow here is DTs. If his family claims he hasn't had a drink in 2 weeks, he may be trying and failing and slipping in and out of DTs along the way.

 

[Fox800]

Cool. What's your treatment plan? Considering the hypotension, tachycardia, hypocapnia, hyperglycemia, and hypothermia?

 

[8jimi8]

Cool. What's your treatment plan? Considering the hypotension, tachycardia, hypocapnia, hyperglycemia, and hypothermia?

low flow O2, Hyperglycemia is fine for the hospital ride. Could bolus the hypotension, that should also help w/ the tachycardia. get him some warm blankets and be ready w/ the ativan. Cardiac monitor and let's go buy him a banana bag!

I'm curious about the ETCo2. He's not hyperventilating, what is the patho on the hypocapnia?

 

[Fox800]

low flow O2, Hyperglycemia is fine for the hospital ride. Could bolus the hypotension, that should also help w/ the tachycardia. get him some warm blankets and be ready w/ the ativan. Cardiac monitor and let's go buy him a banana bag!

I'm curious about the ETCo2. He's not hyperventilating, what is the patho on the hypocapnia?

Could be related to the hypotension.

 

[8jimi8]

interesting. Amazing that in the hospital, we really don't access ETCo2. Even in the ICU, when the patient's are intubated, usually have to get an ABG, when modern technology could easily allow us due vigilance.

 

[Fox800]

interesting. Amazing that in the hospital, we really don't access ETCo2. Even in the ICU, when the patient's are intubated, usually have to get an ABG, when modern technology could easily allow us due vigilance.

I've always wondered about that. We use ETCO2 on pretty much anyone, unless it's blatantly obvious that it's not necessary...and the hospital doesn't use it at all! It's an amazing tool, for so many applications...

 

[MrBrown]

Cool. What's your treatment plan? Considering the hypotension, tachycardia, hypocapnia, hyperglycemia, and hypothermia?

Sounds like this guy needs the works.

I concur he probably has DTs.

Hmm, 3-4 litres of oxygen on a cannula, slip in an 18g and run 500ml of fluid, move him to the recliner or the stretcher and cover him up with a blanket.

How has his urine output been lately.

 

[Fox800]

Sounds like this guy needs the works.

I concur he probably has DTs.

Hmm, 3-4 litres of oxygen on a cannula, slip in an 18g and run 500ml of fluid, move him to the recliner or the stretcher and cover him up with a blanket.

How has his urine output been lately.

Pretty much exactly what I did. Urine output normal, per pt.

 

[MrBrown]

Pretty much exactly what I did..

Great minds think alike ..... how would you like to work with Brown in the big white van and drag people into it strapped to a gurney after they have been given drugs?

It's the best I can offer at the moment, being classmates with one of the HEMS pilots only gets you so far. And it's not far enough!

 

[Fox800]

Great minds think alike ..... how would you like to work with Brown in the big white van and drag people into it strapped to a gurney after they have been given drugs?

It's the best I can offer at the moment, being classmates with one of the HEMS pilots only gets you so far. And it's not far enough!

I have an old coworker that moved to NZ to be a paramedic...that's right (gasp) a Yank paramedic working in the valhalla of NZ prehospital medicine! She works at Wairarapa DHB. Got any info on it?

 

[Aidey]

Why is everyone putting him on O2 when his SpO2 is fine and his ETCO2 is low?

 

[Fox800]

Why is everyone putting him on O2 when his SpO2 is fine and his ETCO2 is low?

Welp...hypotension + tachycardia + hypocapnia means perfusion/cardiac output is a bit crap. Might be a good idea.