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arbrow06

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This scenario is based on real life events and no details are used to pinpoint the patient or NH etc.

Code 1 call to a NH for AMS. Toughbook down and dispatch busy you head to the floor and you know the room number. You walk past the room on the way to the nurses station and something doesn't look right.

Pt. has respirations of >20 with intercostal and accessory muscle use. Pt. is on 5lpm of O2 via NRB and has according to paperwork 70s O2 Sat and tachycardia on the pulse. Full code patient. Pulse present and still breathing on her own. Unresponsive to painful stimuli and constricted pupils. IV with a drip of something to combat abnormal lab results. Also right lung isn't passing air (possibly collapsed or obstructed due to an past medical ailment).

Try your best with this one guys. No ALS near by and nearest hospital 10 minutes out lights and sirens.

What would you do?
 
Sounds septic. Is this going to end up some kind of zebra?... If so, more details would be beneficial- or is that all you've got?
 
And there's no ALS available? Transport the patient.

The end.
 
Umm HTN but that's about it. And if zebra you mean a lot of symptoms but no idea what the primary is yup that's about right. Pt. usually is verbal with full sentences. Outcome given tomorrow at 2000? Sounds good?
 
No, a zebra is when all signs point to a simple diagnosis, but it turns out to be something totally out in left field.

See also: Occam's razor and "it's never Lupus".

Again, if this is a BLS scenario, there is not much to it. Turn up the 02. Put patient in truck. Drive truck to hospital. Put patient in hospital. End of scenario.



Do you have any other info? Blood sugar? Is the PT on opiate pain meds? Recently sick? Foley? What are the abnormal lab values?
When was the PT last seen well?
 
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I like this. NYS protocols by the way if that changes any answers. Also, during transport since most of you are just packaging there's a color change to pale to a bluish.
 
Zebra is a diagnosis that shows up from left field. "If you hear hoof beats look for horses not zebras"

Without a better PHI, med history, meds, vitals, assessment, ECG we can't give you any type of educated answer.

Since STX took sepsis I'll say allergic reaction to "something to combat abnormal labs".

Of course they turned blue, you're asphyxiating them with the NRB mask and inadequate flow.


Not all of us know NYS protocols and at the BLS level beyond a ride and some o2 there's not much you can do for this patient unless you have an expanded scope of practice.
 
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No one thinks it's cardiac? Just trying to promote some discussion ;). Pt. is 93 year old as well.
 
arbrow06 said:
I like this. NYS protocols by the way if that changes any answers. Also, during transport since most of you are just packaging there's a color change to pale to a bluish.
Click to expand...

Did you ever crank up their oxygen from 5lpm?
 
Oh yeah I chose the BVM route due to her respirations not conducive with life being that she was working with one lung and is gasping for air. And she still started to change ting from the pale we saw to a slight blue back to pale.
 
arbrow06 said:
No one thinks it's cardiac? Just trying to promote some discussion ;). Pt. is 93 year old as well.
Click to expand...

Have you got more symptoms or findings to lead to other DDx's? We don't even have a BP yet. More info will lead to more discussion. If you want a cardiac DDx, then heart failure with pulmonary edema.
 
What was the medication in the IV?

What was her blood pressure? Temp? Was she warm and dry? Ok she is bluish aka cyanotic. She isn't getting enough O2. You bagged her. Did you get good compliance with the BVM? What was her pulse? Was it strong and regular? Weak and thready? When was the last time she was seen normal?
 
Anjel said:
What was the medication in the IV?

What was her blood pressure? Temp? Was she warm and dry? Ok she is bluish aka cyanotic. She isn't getting enough O2. You bagged her. Did you get good compliance with the BVM? What was her pulse? Was it strong and regular? Weak and thready? When was the last time she was seen normal?
Click to expand...

BP PTA is 114/42 P 112 O2 77%

BP U/A is unobtainable via NIBP and via auscultation P 118 O2 77%

Pulse attained at the carotid. No temp (non protocol) BVM had adequate chest rise with little resistance. Pulse regular and weak. Last time seen normal was the previous shift so could be any where from 1 to a few hours. Call came in maybe 30 PTA due to system triage. The medication I don't recall sorry. That actually could be useful, (are you suggesting an epi?).
 
STXmedic said:
Have you got more symptoms or findings to lead to other DDx's? We don't even have a BP yet. More info will lead to more discussion. If you want a cardiac DDx, then heart failure with pulmonary edema.
Click to expand...

If I remember correctly I dont see any edema or CHF on the chart. Can't recall alot of the seemingly minor stuff on the chart right now.
 
What you consider seemingly minor may be vital to the diagnosis- especially that medication. I'm going to stick with sepsis/septic shock. I'll also agree with DE in regards to your "What would you do" question. We're assuming BLS, so oxygenate and transport.
 
The outcome of this scenario is the patient dies from cardiac arrest( the one where the heart just gives out). May she RIP.

ALS would have been super useful to maintain an airway and get a better look at the heart but when there's none available you just got the crap end of the stick.
 
:blink:
 
Go figure.... :unsure:
 
There wasn't really any closure. You present this as a scenario that you want people to work through, then just tell us that a really sick patient dies. Go figure. Typically when you propose a scenario, there's a definitive diagnosis involved (and a lot more information to go on, but that sentiment has already been expressed).
 
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