Moo

[MrBrown]

You are dispatched in your awesome looking orange jumpsuit with "PARAMEDIC" written on it to intercept a ground Ambulance crew who have what is has said to be a seizure.

Upon landing you find a 40 yof who is conscious and in extreme pain suffering generalised muscle spasms saying she suffers from "hypocalcium" and that somebody is crushing her chest making it very hard to breathe.

No allergies and not recently unwell, does take IM Calcium daily which is at home in the fridge, an hours drive away.

BP 160/120
PR 100
RR 30 fast shallow
GCS 12 E4 V5 M2
SPO2 99% RA
Temp 37C
ECG Sinus tach
Skin hot and flushed

You are a 15 minute flight to the regional Level 1 hospital.

Some dude in an orange jumpsuit with "DOCTOR" written on it is hanging around if you wish to use him ... but what would he know?

 

[Melclin]

You are far too sneaky to let this be as simple as "transport and supportive care".

If I were to tap on her face just forward of her tragus, do I notice any facial twitching? Where I was auscultating her BP, did I notice any twitching in her wrist when I left the cuff inflated above her SBP for a short while?

If the answer is yes to these questions then we might proceed with calcium replacement but that's is the doctors business, and certainly not mine.

Any diaphoresis?

Do iStats do serum or ionized calcium?


Normal history type questions while we're knocking out some vitals. Has she been taking her calcium properly? Does it feel like when/if she has been hypo in the past? Other S&S. Onset time and duration of symptoms, recent changes to her regime, thyroid or parathyroid treatments, trauma to the head/thyroid area, what doctor does she see about the 'hypocalcium', diabetes?, etc.

Other than that I personally would:

- 100% O2. Check for stridor or abnormal breath sounds - treat appropriately.
- Methoxyflurane + morphine/fentanyl titrated to pain and conscious state.
- Hop in my chopper and take her somewhere that can do a U&E.
- 12 lead just before we take off. QT prolongation?

Then I would ask Doc Brown, what he wanted to do.

I don't remember having really looked at a hypocalaemia case study...don't really know what they look like but this all seems to make sense and I can't for the life of me think of what else would be going on.

 

[MrBrown]

You are far too sneaky to let this be as simple as "transport and supportive care".

Of course I am, what did you expect?

If I were to tap on her face just forward of her tragus, do I notice any facial twitching? Where I was auscultating her BP, did I notice any twitching in her wrist when I left the cuff inflated above her SBP for a short while?

No, but she does have generalised spasms in her arms extremeties

Any diaphoresis?

No

Do iStats do serum or ionized calcium?

Not sure

Has she been taking her calcium properly?

Yes, states she is on IM calcium daily

Does it feel like when/if she has been hypo in the past?

This has never happened before

Onset time and duration of symptoms

About 20 minutes ago

recent changes to her regime, thyroid or parathyroid treatments, trauma to the head/thyroid area, what doctor does she see about the 'hypocalcium', diabetes?, etc.

No changes or trauma. She is one of only a small number of people who have this condition apparently.

- 100% O2. Check for stridor or abnormal breath sounds - treat appropriately.
- Methoxyflurane + morphine/fentanyl titrated to pain and conscious state.
- Hop in my chopper and take her somewhere that can do a U&E.
- 12 lead just before we take off. QT prolongation?

No ECG changes.

Oxygen seems to help a bit but the patient is unable to hold the methoxy due to her severe spasming.

1mcg/mg (~60mcg) of fentanyl takes away some of the anxiety however she states it is still feels like somebody is crushing her chest and throat and it is hard to breathe.

Despite this for the moment her SPO2 is still 99%

Then I would ask Doc Brown, what he wanted to do.

Apparently he wants to build a time machine

 

[Melclin]

I'll hold the penthrane for her h34r:

Hyper or hypocalaemia. Could be some other electrolyte issue too I suppose. Continue current treatment and go somewhere with for a U&E/serum calcium.

I'm not sure whats going on to be honest. Calcium issues seem the most obvious, but it just doesn't feel right. Other than the fact that it seems to obvious for the scenario, something else doesn't feel right.

Foreign body? There are no other meds or med history right? Hyponatraemia 2ndry to Ectasy/alchohol abuse? I'm not sure, prompt transport seems the best option.

Apparently he wants to build a time machine

Ahh, I walked into that one.

 

[thegreypilgrim]

Any chance of strychnine exposure?

Has she not had a tetanus shot in a while and then incurred some sort of injury recently (even a minor one)?

 

[JCEMTB]

I'm going to take a guess and say she took her calcium incorrectly causing hypercalcemia. That would at least explain the muscle twitches and generalized severe pain, and it could account for her HTN as well. Just my guess though.

 

[MrBrown]

Any chance of strychnine exposure?

Has she not had a tetanus shot in a while and then incurred some sort of injury recently (even a minor one)?

Nope

I'm going to take a guess and say she took her calcium incorrectly causing hypercalcemia. That would at least explain the muscle twitches and generalized severe pain, and it could account for her HTN as well. Just my guess though.

Could you not explain the HTN as a normal physiological response to her being anxious and in pain?

I'll hold the penthrane for her h34r:

Hyper or hypocalaemia. Could be some other electrolyte issue too I suppose. Continue current treatment and go somewhere with for a U&E/serum calcium.

I'm not sure whats going on to be honest. Calcium issues seem the most obvious, but it just doesn't feel right. Other than the fact that it seems to obvious for the scenario, something else doesn't feel right.

Foreign body? There are no other meds or med history right? Hyponatraemia 2ndry to Ectasy/alchohol abuse? I'm not sure, prompt transport seems the best option. some

No foreign body or med hx.

I am not sure where I am really going with this either, there is no real answer I am wanting to see how we would all treat this lady really.

She seemed to have a very hard, straining time with breathing and was very agitated and in pain over the spasm/seizures.

Personally I'd have loved to have somebody in an orange jumpsuit with "DCOTOR" on it rock up to knock her out and intubate.

 

[Outbac1]

Hmmmm. A bit of a thinker here. A GCS of M2 with a E4 & V5 is a bit unusual. No ECG changes but chest heavyness making or contributing to some SOB. Takes her meds regular and not really acting like hyper or hypocalcemia.
Whats the day like? Very hot? Has she been working out/excercising or doing a lot of physical work? I'm thinking, as did Melcin, perhaps Hyponatraemia. Any other symptoms of dehydration?
I think the O2, IV, pain meds and perhaps a small N/S bolus and transport is appropriate. No sense standing around, (even in a cool orange jumpsuit), with your thumb up .... trying to figure out a chinese puzzel. No matter how much we can do on scene we are still in the transportation business.