Scenario - For students

NomadicMedic

EMS Educator
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Dispatched for shortness of breath at IHOP.

You find a 56 year old female sitting in a booth in the restaurant, diaphoretic, pale and a respiratory rate of 40. Hands are cool, almost cold, with poor perfusion. Cap refil of >4 seconds.

Her husband says it just happened, with no warning. They were traveling north on I95 from Orlando, heading to NJ. They're about 300 mies into the trip.

Tell me what you want, your treatment, differential DX, and what you might expect to have happen while en route to the ED.
 
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NomadicMedic

NomadicMedic

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IMG_6898.JPG
 

Gurby

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Pulmonary embolism. I take her to the hospital. I cross my fingers, clench my buttocks and hope she stays alive until we get there. Maybe I'd take some vitals and ask about her history or something too.
 

DesertMedic66

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Pulmonary embolism. I take her to the hospital. I cross my fingers, clench my buttocks and hope she stays alive until we get there. Maybe I'd take some vitals and ask about her history or something too.
Are you a student? Haha
 

Gurby

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Are you a student? Haha

School of hard knocks baby. I'm very "hands on" and I don't take well to book learning. I'm a go-getter. You need chutzpah if you're gonna make it in business. Thinking about differentials is for people who lack confidence and decisiveness IMO.
 

Old Tracker

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I'd want history, any priors? What if any meds is she on? I'd be thinking NS IV asap, I'd also put her on the LifePak and get a 12 lead going.. I'm just a basic and still constantly learning. Any lower on the bradycardia I'm calling for ALS to medicate her and pace her. I have an hour wait for a plane and 90 miles to the nearest hospital.
 

DesertMedic66

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I'd want history, any priors? What if any meds is she on? I'd be thinking NS IV asap, I'd also put her on the LifePak and get a 12 lead going.. I'm just a basic and still constantly learning. Any lower on the bradycardia I'm calling for ALS to medicate her and pace her. I have an hour wait for a plane and 90 miles to the nearest hospital.
May want to read the OP a little closer. It does not state the patient is bradycardiac. The respiratory rate is 40.
 

DesertMedic66

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For me I would get the normal AMPLE questions with any associated symptoms. Hx of PE, MI, DVT, CVA? Any blood thinners or ASA? Does it feel like she can't take a deep breath in or that she can't get enough oxygen in?

A set of vitals (RR, lung sounds, SpO2, EtCO2, BP, pulse). Get a 12-lead and look for the possibility of a S1Q3T3 (however it's only present in something like 20% of cases), the presence of a tachy rhythm and a RBBB would also help in confirming my Dx for this patient.

Treatment would be: some O2, IV (bolus depending on pressure), rapid transport to the ED. That's really all I can do here.
 

CALEMT

The Other Guy/ Paramaybe?
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VOMIT... vitals, oxygen, monitor, IV, and transport. With the limited info the first thought that popped into my head is a DVT that developed into a PE. Like Desert said, AMPLE would be a good start.
 

DesertMedic66

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And yet @NomadicMedic said "for students".

Lol, just goes to show how hard of a time us more seasoned paramedics have sitting back, watching, and observing.

...carry on.
Well to be fair I did wait a while before I posted. For me after 8 hours of no one really saying anything it becomes fair game. This patient needs to live!!
 

shelvpower

Forum Crew Member
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Dispatched for shortness of breath at IHOP.

You find a 56 year old female sitting in a booth in the restaurant, diaphoretic, pale and a respiratory rate of 40. Hands are cool, almost cold, with poor perfusion. Cap refil of >4 seconds.

Her husband says it just happened, with no warning. They were traveling north on I95 from Orlando, heading to NJ. They're about 300 mies into the trip.

Tell me what you want, your treatment, differential DX, and what you might expect to have happen while en route to the ED.
A set of vitals ASAP as well as an AMPLE history.
Any adventitious lung sounds?



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NomadicMedic

NomadicMedic

EMS Educator
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This is a scenario for new providers. Please let the new folks have at it.

HR: 120, sinus tach. No ectopy.
Resp: 44, no adventitious breath sounds.
SpO2 on room air: 84
ETCO2: 14

No significant history, no meds. No allergies.
Last ate 4 hours ago.

STUDENTS: what is happening, why is it happening, what can you do to improve the patient's condition?

What are three differential diagnoses?
 

VFlutter

Flight Nurse
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A lot of cool patho with the potential diagnosis.

Anything you want to look for on the EKG to increase your index of suspension?
 

CWATT

Forum Lieutenant
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What's the Pt's BP? Any pain?

1. PE
(Low ETCO2 is throwing me off here - if V/Q mismatch, I would expect high ETCO2 + low SPO2)

2. Thoracic or Aortic Dissection
(Symoathetic response for absolute hypovolemic state; no hemoglobin to transport O2 and low CO2 b/c transported via bicarbonate buffer system, so blown off c/ tachypnea).

3. Ruptured Ectopic Pregnancy
(I know, I know - 56yrs old. Still possible though...)
 
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