Scenario

[Rykielz]

This is a two part scenario based off an actual call I ran. I'll post the second part tomorrow.

You are dispatched for a patient complaining of slurred speech. Upon arrival you find a 59 y/o female sitting on the porch of her apartment with some slightly slurred speech, apparently hallucinating, and oriented only to person. She is able to follow commands and her skin is pale, cool, and moist. Upon loading the patient into the ambulance, her neighbor approaches you and advises that she called 9-1-1 and has not seen the patient outside of her apartment for 6 months.
You attach the patient to the monitor and find that she's in regular sinus rhythm without ectopy. She has equal grips/pushes and an asymmetrical smile. The patient adamantly denies overdosing on any of her medications and states that she has been compliant with them (she's still altered). The patient also denies any alcohol or drug use.

Initial VS:
GCS: 14
Rhythm: RSR, no ectopy
12-lead: Regular sinus rhythm. Normal ECG.
HR: 64
BP: 124/73
RR: 14
SpO2 on RA: 96%
Pupils: 5mm bilateral and sluggish
Blood sugar: 89

Hx: Depression, GERD, HTN, IDDM
Rx: Lamictal, Lisinopril, Insulin, and TUMS. (None of the medications appear to be missing)
Allergies: NKDA

What would your treatment for this patient be? Is there any additional tests or assessment you would perform? Are you going to a stroke center? Why or why not?

 

[46Young]

Initiate txp to stoke center even though the time of onset is unknown. Get better Hx from pt if possible. IV access pref. 18g left or right ACF. ETCO2 monitoring via NC. Repeat BGL with pref. a second glucometer if available. Do 15 lead ECG if time permits just to be thorough. Second line if time permits. Have arrest meds and intubation equipment readily accessible should the pt arrest. What were her L/S and effort of breathing?

 

[Handsome Robb]

First off, what made the neighbor call?

When you say "asymmetrical smile" are you saying she has facial droop?

With her slurred speech is she making sense and just slurring or is she using inappropriate words/sentence structure?

When you say apparently hallucinating what do you mean? Did she say she's hallucinating? Auditory or visual or both?

You said pale cool and moist, what's her temp if you got one?

Any evidence of a seizure? Oral trauma? Urinary or bowel incontinence? Lamictal is used to treat seizures and/or bipolar disorder. So she potentially has a hx of a seizure disorder or a psychiatric disorder, both of which could present like this.

Time of onset? Activity at onset? Sudden or progressive onset? Recent trauma, illness or medication changes?

Any evidence of ETOH? I know you said she denied it but people lie all the time. How's her home? Well kept? A disaster?

Do you have a copy of the 12-lead you can scan and attach?

Any improvement of the signs and symptoms throughout the patient contact? Any family hx of CVA, DVTs, AMIs, PEs?

What's her lifestyle? What does she do for work? Is she sitting around at a desk or is she active? Just because her neighbors haven't seen her doesn't mean she hasn't been out and about, maybe she works a night schedule and is out and about at different times than her neighbors...

Smoker? Overweight?

1/3 criteria being met in the CPSS which generally indicates ~70% probability of an acute CVA. She has slurred speech and facial droop (if I'm understanding you correctly) which means she has 2/3 criteria met in the CPSS which further increases the probability of this being a CVA.

With what I know from the information you've provided, yes I'd be going to a stroke center. If that's going to be unreasonable a hospital with CT capabilities would be fine for now considering we don't have a reliable time of onset although the 3 hour rule is being extended out much further than that for fibrinolytic therapy as of late. She has indications of an acute CVA as well as risk factors for it. Depending on your stroke protocol you may be required to administer o2, not going to argue about that since it's been beaten to death, ECG monitoring, ETCO2 if you're feeling frisky, not high on my list though, IV access (bilateral preferred, our stroke protocol wants three lines, 2 locks and one TKO rate), vitals q10-15 seems fine to me, transport in POC preferably with the HOB elevated.I like 46's idea bout a different glucometer or check your own CBG to ensure this isn't a simple diabetic emergency with a malfunctioning glucometer. I don't personally think this patient is going to crump on us but nothing wrong with having it ready and not needing it than needing it and not being ready for it.

DDx list: CVA (ischemic > hemorrhagic personally), psyc, postictal after a seizure, potential diabetic emergency if your glucometer isn't functioning correctly.

 

[VFlutter]

How far away is the stroke center compared to the closest hospital? I wouldn't divert if there was a significant time difference. With an unknown onset time they will probably not be very aggressive with treatment and not really benefit the patient more than most community hospitals.

 

[Aidey]

Does her forehead wrinkle?

 

[Merck]

I'd be cautious before throwing my hat in with a CVA. While it certainly is near the top of a DDx list there are other considerations.

The hx obtained from a person with apparent hallucinations and unaware of where/when they are is likely to be faulty. Trust in their statement of regular compliance with medications may be misplaced. Also, a lot of people only consider Rx meds to be 'medications'. She may be quite compliant with her regular meds but have eaten 2 bottles of Tums.

Her sugar (translated into Canadian) is right around 5mmmol/L. While this is generally 'normal' perhaps it is not for her - worth a look if there is a way (i.e. a log book).

Her being on the lamictal suggests a seizure D/O so that should be considered.

The concerning thing to me is the sensorium changes - not as common in a CVA, though you must be careful not to confuse dysphasia with an underlying mentation problem.

18g in the ACF and a 15 lead might be a little over the top but no real harm I guess. The EtCO2 might not be necessary either given a decent RR and I'll assume Vt but can't hurt to check I suppose.

Just a few thoughts

 

[VFlutter]

Her being on the lamictal suggests a seizure D/O so that should be considered.

Agreed but it is also used for bipolar disorder and less commonly depression which given the context of the patient's living situation is probably more likely.

 

[Merck]

Agreed but it is also used for bipolar disorder and less commonly depression which given the context of the patient's living situation is probably more likely.

Sure, fair enough.

 

[Aidey]

What about her living situation says bipolar or depression is more likely? For all we know the neighbor hasn't seen her for 6 months because she has been working nights, or staying with a boyfriend.

 

[Handsome Robb]

What about her living situation says bipolar or depression is more likely? For all we know the neighbor hasn't seen her for 6 months because she has been working nights, or staying with a boyfriend.

I was looking at meds to get to that Hx... Bipolar sounds more likely than depression. Maybe she spends most her time at home because he's introverted... Introvert =/= depression.

Edit: disregard, misread your post I need some sleep.

I'm still not understanding these "apparent" hallucinations. Is she talking to something that isn't there? Stating she's hallucinating whether it be visual, auditory or both?

I agree being altered makes her an unreliable source of information but im not doing to discredit everything she says. Without evidence if Rx or OTC medication abuse I'd be very cautious about signing her off as a psyc patient.

From personal experience a patient with a gcs of 14 can still provide information, you just need to be wary of believing everything they say.

Also agree with not getting tunnel visioned on a CVA but it's near if not at the top of my DDx list. Psyc patients can have CVAs as well.

Going back to ETOH, she denied it but like I said and learned for Dr. House everyone lies I've been in plenty of extremely clean, well kept, beautiful homes only to find a load of black trash bags full to the brim with empty bottles of liquor or beer cans stashed away in a corner. Does that indicate ETOH abuse? Not necessarily, maybe she's a recycler, but it's definitely something if look for and would definitely ring alarm bells if I found them.

Yet another edit: I completely missed depression as a listed history. With this, I'd agree that it's probably the case and what chase said below it makes sense, however it doesn't mean she doesn't have a seizure disorder and isn't listing it because she's altered...have ha plenty of very obvious seizure patients say they've never had a seizure while they're postictal then when they wake up completely come back and say "oh yea I have them all the time, I'm an epileptic".

 

[VFlutter]

What about her living situation says bipolar or depression is more likely? For all we know the neighbor hasn't seen her for 6 months because she has been working nights, or staying with a boyfriend.

Well the patient stated a history of depression and I am guessing the neighbor would not randomly call 911 unless they somewhat knew the patient and had a reason to be worried.

I am just saying that I would not automatically assume she has a history of a seizure disorder just because she is on Lamictal. Most of the anticonvulsants are also used as mood stabilizers and given the context the latter seems more likely, in my opinion.

 

[Aidey]

I don't think the neighbor called purely because she hasn't seen the pt in 6 months. It seems more likely that the neighbor noticed the pt sitting outside, went to say hello, noticed something was wrong and then called.

 

[Summit]

Everyone else has hit it pretty well...

My biggest question is what is normal for this lady? Is this normal for the pt? Do they have a caregiver or family member that comes over regularly? Ya the neighbor hasn't seen the patient outside in 6 months... does that neighbor interact with the patient regularly?

 

[med109]

I took the scenario to mean the patient asked the neighbor to call 911 cause the patient felt she had slurred speech.

I can't think of anything different I would do that hasn't been posted. Are any of her meds new (like the Dr started or changed them recently)? I would grab her glucose monitor and check past readings. Did she have a low blood sugar 10 minutes ago and she took some orange juice and it is just now starting to climb?

IV with blood draws, 12 lead, O2, monitor vitals, make sure that BG is correct. Is she in pain, did she have trauma recently? I am kind of leaning towards something ingested. We had a patient who had taken Angel's Trumpet that presented exactly like this.

 

[Rykielz]

First off, what made the neighbor call?

When you say "asymmetrical smile" are you saying she has facial droop?

With her slurred speech is she making sense and just slurring or is she using inappropriate words/sentence structure?

When you say apparently hallucinating what do you mean? Did she say she's hallucinating? Auditory or visual or both?

You said pale cool and moist, what's her temp if you got one?

Any evidence of a seizure? Oral trauma? Urinary or bowel incontinence? Lamictal is used to treat seizures and/or bipolar disorder. So she potentially has a hx of a seizure disorder or a psychiatric disorder, both of which could present like this.

Time of onset? Activity at onset? Sudden or progressive onset? Recent trauma, illness or medication changes?

Any evidence of ETOH? I know you said she denied it but people lie all the time. How's her home? Well kept? A disaster?

Do you have a copy of the 12-lead you can scan and attach?

Any improvement of the signs and symptoms throughout the patient contact? Any family hx of CVA, DVTs, AMIs, PEs?

What's her lifestyle? What does she do for work? Is she sitting around at a desk or is she active? Just because her neighbors haven't seen her doesn't mean she hasn't been out and about, maybe she works a night schedule and is out and about at different times than her neighbors...

Smoker? Overweight?

1/3 criteria being met in the CPSS which generally indicates ~70% probability of an acute CVA. She has slurred speech and facial droop (if I'm understanding you correctly) which means she has 2/3 criteria met in the CPSS which further increases the probability of this being a CVA.

With what I know from the information you've provided, yes I'd be going to a stroke center. If that's going to be unreasonable a hospital with CT capabilities would be fine for now considering we don't have a reliable time of onset although the 3 hour rule is being extended out much further than that for fibrinolytic therapy as of late. She has indications of an acute CVA as well as risk factors for it. Depending on your stroke protocol you may be required to administer o2, not going to argue about that since it's been beaten to death, ECG monitoring, ETCO2 if you're feeling frisky, not high on my list though, IV access (bilateral preferred, our stroke protocol wants three lines, 2 locks and one TKO rate), vitals q10-15 seems fine to me, transport in POC preferably with the HOB elevated.I like 46's idea bout a different glucometer or check your own CBG to ensure this isn't a simple diabetic emergency with a malfunctioning glucometer. I don't personally think this patient is going to crump on us but nothing wrong with having it ready and not needing it than needing it and not being ready for it.

DDx list: CVA (ischemic > hemorrhagic personally), psyc, postictal after a seizure, potential diabetic emergency if your glucometer isn't functioning correctly.

Hopefully this will answer some of your questions.

-There was no facial droop, however, she was unable to move the right side of her face. She seemed unphased by it when I made the observation.

-I'll just give you a clip of her dialogue for the hallucinations, "He raped me!... The clown in the hot air balloon put worms inside me!... You're so beautiful, do you know that?... My baby told me that it's my mother..." She didn't appear to be talking to people who weren't there, however, she would periodically stare off into space and only come around when I talked to her.

-98.4 F taken at the hospital. I didn't do it enroute.

-She was taking the Lamictal for depression. No S/Sx of a seizure. No incontinence. No oral or other signs of trauma either.

-As far as onset and duration, that is unknown. The patient appeared to be a recluse from what we gathered. Unknown on much about the medications, they were thrown into a bag from her apartment. All the medications were over a month old.

-No signs of ETOH. No smell of it on her breath. No alcohol found in the apartment. Her apartment was a mess (uncleaned dishes in the sink, trash throughout the apartment, her clothes were strewn throughout).

-Do not have a copy of the 12-lead, the physician however, stated nothing was abnormal about the original.

-Her situation will change drastically when I post what happened during transport. Unknown on the family Hx.

-I don't know about her lifestyle. From what I'd gather she stayed indoors most of the time. This call came out around 1 AM.

-She doesn't appear to smoke. Yes, she is overweight. I estimated her around 5'4", 110 kg.

Background on the neighbor

The neighbor has lived in the apartment complex for over a year. She came outside to throw away her trash and found the patient sitting on the porch of her apartment in a nightgown, "staring off into space." When she approached the patient, she noticed her speech seemed a little slurred, "like she was speaking in cursive." She also stated that, something didn't seem right with the patient because she wasn't making any sense. She hadn't seen the patient leave her apartment in 6 months but knows that she is normally "with it." The patient likes to keep to herself from what the neighbor knows about her.

 

[Aidey]

That isn't hallucinating. That would be delusions or psychosis.

At this point I can come up with at least 10 neurological causes for her symptoms. Without more info its hard to narrow it down.

 

[Rykielz]

Treatment I administered

1) O2 via NC at 2 LPM.
2) 12-lead
3) 18G IV NS lock in left hand.

I'll post the second part of the scenario tomorrow.

 

[abckidsmom]

That isn't hallucinating. That would be delusional or psychosis.

The pattern of speech he described is called flight of ideas, right?

 

[Aidey]

Flight of thought is how I've seen it documented, but it might be an either/or thing.

 

[Rykielz]

Second part of the scenario:

You begin transporting the patient. She's on 2 LPM O2 via NC and has an 18G NS lock established in her left hand. You contact the base hospital (stroke center and also the closest hospital) to give them a report. In the middle of the report you glance over and find the patient is now unconscious and unresponsive. You are now 15 min out code 3.

Vital signs:
GCS: 3
Rhythm: Sinus Bradycardia without ectopy
12-lead: Sinus Bradycardia. Otherwise normal.
HR: 39
BP: 69/43
RR: 14. Good tidal volume.
SpO2 on 2 LPM: 94%
Pupils: 6mm fixed and dilated
BS: Not reassessed. Original was 89.

Your medications are readily available. All other equipment will take time to set up. What do you do? Are there any additional assessments you would perform? What is your field diagnosis?