Just looking for some thoughts on this call the other day.

RanchoEMT

RanchoEMT

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ALS Ambulance and ALS Fire Engine arrive on scene at the same time to residence for a reported "Diff Breather". At front door is reporting party(patient's daughter) directing crew into the kitchen. Crew enters kitchen to find 57 year old male lying left lateral in mild to moderate distress. Patient is awake and tracking. Patient is able to answer questions and states "I had trouble breathing in, I passed out and went down to the floor. Its never happened before."
Daughter reports "He was playing racket ball earlier and has had a gradual onset of difficulty breathing since playing. Patient has no medical Hx, no allergies and no meds. 911 was called when patient passed out about 10 minutes ago and started shaking. Patient started to wake up when EMS arrived."
Patient denies any other pain/Discomfort, nausea/Vomitting, no other complaints
------Initial Assessment---------------------------
GCS=E4,V5,M6(15) Pulse(Carotid Only)=132 Weak/Irregular
Automated Blood Pressure=Unreadable Manual Blood Pressure=UnReadable.
Respirations= 30/min and Shallow SPO2=94% RA
Lung Sounds=Clear BiLaterally
Skins= Cyanotic, Moist, Cool. Pupils= PERRL. Cap Refill= Below 2 Sec.
ECG=A-Fib w/o Ectopy 12-LEAD=Non-Stemi.
-----------------------------------------------------
Administered oxygen NRB, SPO2=94% NRB
IV 18G left AC NS Flowing
Positioned Patient Semi-Fowler's

Patient states- "Thanks guys your the best....PAUSES..... I think im getting worse"

At this point patients skin color from clavicle level up turns blue. Patient passess out and pupils dilate fully. Patient goes into PEA Arrest. At this time a newly presenting stiff mass has become visible at patients epigastric area. ACLS is started. ET-Tube is placed. Patient transported code3 to the hospital where rescusitation efforts are later stopped.
 
Sounds like a pulmonary embolism except for the "stiff mass" business. Can you elaborate?

And why 15lpm NRB?
 
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Aidey said:
Sounds like a pulmonary embolism except for the "stiff mass" business. Can you elaborate?

And why 15lpm NRB?
Click to expand...

Why not the NRB?

spo2 is at 94% with shallow resperations at 30/min and the patient has cyanosis.
 
Aidey said:
Sounds like a pulmonary embolism except for the "stiff mass" business. Can you elaborate?

And why 15lpm NRB?
Click to expand...
When we sat patient up he said his statement, passed out, a clear distinction of dark blue skin color from clavicle up could be scene. The rest of the body remained pale white. We had his shirt still up from the twelve lead and noticed at this time a mass form about fist-size in the patient's epigastric area. Fire medic felt it and said it was stiff. Layed patient back down for cpr and it dissipated.

Aidey said:
And why 15lpm NRB?
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Iunno, I think fire threw it on, dont remember. This all happened very quickly. Almost immediately following initail vital signs. Why do u ask? CPAP?
 
SoCal911 said:
Sounds like an internal bleed out. All the symptoms fit.
Click to expand...

What about the blue from clavicle up? Why would this happen? The reported seizure like activity reported from the daughter(i might have down played that) initially in the OP. he was GCS15, but looked kinda postictal. Smelled incontinant.
 
Aidey said:
Sounds like a pulmonary embolism except for the "stiff mass" business.
Click to expand...

Based on my limited knowledge I would say I agree with a possible PE.

My mother had a PE and all her symptoms area exactly the same as what has been described except for the stiff mass and luckily the PEA.
 
firefite said:
Based on my limited knowledge I would say I agree with a possible PE.

My mother had a PE and all her symptoms area exactly the same as what has been described except for the stiff mass and luckily the PEA.
Click to expand...

Dark Blue from clavicle up too??? I stress the clavicle up b/c there was such a visible distinction between skin colors superior/inferior to the clavicle line.
 
RanchoEMT said:
Dark Blue from clavicle up too??? I stress the clavicle up b/c there was such a visible distinction between skin colors superior/inferior to the clavicle line.
Click to expand...

No, luckily she didn't have that.
 
Well why did you sit him up if he had clear l/s and only a carotid pulse at 132? Sounds smart..
 
Supertampon5 said:
Well why did you sit him up if he had clear l/s and only a carotid pulse at 132? Sounds smart..
Click to expand...

I didn't my medic did. But i think that gets into the subjective vs. objective do i position patient in a way that will help what i think is going on or what the patient is telling me is wrong??? I assume u mean why raise the head above the heart with a 'probably' low bp... Again i can only assume it was to see if patients subjective complaint of "difficulty breathing" was elevated with the positioning.
 
RanchoEMT said:
I didn't my medic did. But i think that gets into the subjective vs. objective do i position patient in a way that will help what i think is going on or what the patient is telling me is wrong??? I assume u mean why raise the head above the heart with a 'probably' low bp... Again i can only assume it was to see if patients subjective complaint of "difficulty breathing" was elevated with the positioning.
Click to expand...

This may or may not of been what killed him. I'm aware.
 
I doubt anything you guys did killed him.

I agree with the PE. If it was a PE positioning wouldn't really matter.

The discoloration almost sounds like traumatic asphyxiation but I don't see how this would be the case in the scenario you presented.
 
*facepalm* I bet $10 the guy had an umbilical hernia totally unrelated to anything going on. That is the only thing I can think of that would be in that spot and would show up when sitting up and disappear when lying down.


And when was the last time anyone heard of a patient with an SpO2 of 94% and non-localized cyanosis?
 
Googling "supraclavicular cyanosis" raises it as a symptom of blunt force trauma cardiac tamponade. Not sure about blunt trauma (sidebar: would CPR count as blunt trauma and how does blunt trauma cause "cardiac tamponade"?....), but similar mechanisms tend to create similar signs and symptoms, and cardiac tamponade can be caused by a number of mechanisms.
I don't think raising the head somewhat (30 degrees) killed anyone. Fowler's can improve respiration and decrease related anxiety. If BP was that delicate turning a corner rapidly could have done it, or tipping the litter as the pt was removed out from the ambulance.
 
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