Still trying to figure out this call.

Hunter

Hunter

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Called to a patient at a bunch on a street corner, called by a family member, we arrive to find an approx 50 y/o f pt, aaox3, who threw up a few minutes before we got there, she was obviously pale, diaphoretic, cool clammy, initial vitals were something around; BP:150/88, P80, R16, 97% SAo2.

As we're loading the patient up she tells us she really has to use the bathroom and poop. We ask her to try and hold it until we get to the hospital as we were about 5 minutes from the closest one, start an IV, Monitor, 12 lead is sinus rythm, with the occasional PVC about 1 every 1-2 minutes. Patient denies any drug use other than her hypertension meds. After we arrived she threw up one more time, by the time we got an IV in her she wasn't throwing up anymore and she wasn't complaining of Nausea so we didn't push Zofran but we had it ready.

Just before we left the scene the patient and our noses told us she had defecated on herself,During transport to the hospital the patients BP drops to 80something/40something, start fluids, ecg remains the same, patient doesn't complain of any chest pain, sob, dizzyness, ect. We ran a 12 lead 3 times during the whole call, once on scene, once en route and once at the hospital before we DCed her, they all came back the same. Me and my partner talked about it trying to figure out what could've been wrong with her, we thought heat stroke/exhaustion but that there has to be more wrong with her than that to cause the diarreah.

Anything you guys would've done differently, question's you would've asked, ect.?
 
How was her abdomen? My differentials would include some sort of GI bleed at the very least.
 
I would've laid her flat along with fluids. Otherwise, no.

There are 3 differentials possible here. All 3 are GI. GI bleed, Acute Gastrointeritis, and borferline constipation that tripped the vagus nerve. GI bleed orders are not necessarily obvious each and every time. And was there diarrhea? All 3 can drop the blood pressure.
 
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Wes said:
How was her abdomen? My differentials would include some sort of GI bleed at the very least.
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Abdomen was SNT, no pain, no blood in the vomit none in the stool.

MSDeltaFlt said:
I would've laid her flat along with fluids. Otherwise, no.

There are 3 differentials possible here. All 3 are GI. GI bleed, Acute Gastrointeritis, and borferline constipation that tripped the vagus nerve. GI bleed orders are not necessarily obvious each and every time. And was there diarrhea? All 3 can drop the blood pressure.
Click to expand...

I thought about the vagus nerve, but her bp didn't drop until about 5 minutes after she defecated. Her HR was also the same since we arrived until we dropped her off at the ER, the only change was BP.
 
Another zebra diagnosis would be a leaking aneurysm. The hypertension history would explain that.
 
Hunter said:
Abdomen was SNT, no pain, no blood in the vomit none in the stool.



I thought about the vagus nerve, but her bp didn't drop until about 5 minutes after she defecated. Her HR was also the same since we arrived until we dropped her off at the ER, the only change was BP.
Click to expand...

4 words. Beta blockers and fluid shift.
 
Vomiting means valsalva.
Precipitate hypotension (orthostatic) can cause dizziness->nausea.
Straining at stool means valsalva (if and when).
Whatever caused the nausea can be toxic.
Three or four patients I saw code c/o needing to defecate.
 
Did you take both blood pressures? Or did you do one and then your partner?
 
Wes said:
Another zebra diagnosis would be a leaking aneurysm. The hypertension history would explain that.
Click to expand...

I can see how this would make sense, but wouldn't an aneurysm cause pain somewhere?

MSDeltaFlt said:
4 words. Beta blockers and fluid shift.
Click to expand...
Care to elaborate? I see where you're going.


mycrofft said:
Vomiting means valsalva.
Precipitate hypotension (orthostatic) can cause dizziness->nausea.
Straining at stool means valsalva (if and when).
Whatever caused the nausea can be toxic.
Three or four patients I saw code c/o needing to defecate.
Click to expand...

Hmm, how long does a Valsalva take to affect people usually? It wa aout 5 minutes from when she defecated to when the bp dropped. Monitor automatically takes it every 5 minutes.

tchristifulli said:
Did you take both blood pressures? Or did you do one and then your partner?
Click to expand...

Monitor took both, and both were confirmed manually. First one by me, second one by partner as I was driving. I don't look at the one the monitor gives me before I check a manual.



P.S. I talked to one of the nurses, earlier today and found out more info, she left out a piece of information and it makes perfect sense had she told us this when we talked to her. I wanna see if anyone can figure it out because I didn't even think of it.
 
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Beta blockers, that would be why the HR didn't increase.

Fluid shift, sometimes hypotension is not immediate. It might take a few minutes. Remember, the human body is 3 dimension not 2. It will also attempt to compensate with sympothetic responses until it can no longer continue said compensation.
 
Wes said:
Another zebra diagnosis would be a leaking aneurysm. The hypertension history would explain that.
Click to expand...

The two AAAs I've seen have both had huge episodes of diarrhea just prior to coding. Not really sure why it happens... The older more sour guys keep telling me its the "death poop".

Hunter, the last aortic aneurysm I had didn't complain of pain.
 
Robb said:
The two AAAs I've seen have both had huge episodes of diarrhea just prior to coding. Not really sure why it happens... The older more sour guys keep telling me its the "death poop".

Hunter, the last aortic aneurysm I had didn't complain of pain.
Click to expand...

Hmm Good to know, I kind of figured the only one that wouldn't complain of pain might be a diabetic.

Anyways, the pt took laxatives to try and "lose weight", even though she was like 5% body fat. Electrolyte imbalance with 90+ Degree heat walking around outside caused, heat exhaustion which caused the N/V, and it explains the random PVCs every once in a while as well as the sudden changes in blood pressure. At least that's the logic we came up with.
 
Hunter said:
Hmm Good to know, I kind of figured the only one that wouldn't complain of pain might be a diabetic.

Anyways, the pt took laxatives to try and "lose weight", even though she was like 5% body fat. Electrolyte imbalance with 90+ Degree heat walking around outside caused, heat exhaustion which caused the N/V, and it explains the random PVCs every once in a while as well as the sudden changes in blood pressure. At least that's the logic we came up with.
Click to expand...

Ah, and the "what had happened was..." reveals itself.
 
Fascinating call! We were all a bit off. Thanks for sharing it.
 
Hunter said:
Called to a patient at a bunch on a street corner, called by a family member, we arrive to find an approx 50 y/o f pt, aaox3, who threw up a few minutes before we got there, she was obviously pale, diaphoretic, cool clammy, initial vitals were something around; BP:150/88, P80, R16, 97% SAo2.

As we're loading the patient up she tells us she really has to use the bathroom and poop. We ask her to try and hold it until we get to the hospital as we were about 5 minutes from the closest one, start an IV, Monitor, 12 lead is sinus rythm, with the occasional PVC about 1 every 1-2 minutes. Patient denies any drug use other than her hypertension meds. After we arrived she threw up one more time, by the time we got an IV in her she wasn't throwing up anymore and she wasn't complaining of Nausea so we didn't push Zofran but we had it ready.

Just before we left the scene the patient and our noses told us she had defecated on herself,During transport to the hospital the patients BP drops to 80something/40something, start fluids, ecg remains the same, patient doesn't complain of any chest pain, sob, dizzyness, ect. We ran a 12 lead 3 times during the whole call, once on scene, once en route and once at the hospital before we DCed her, they all came back the same. Me and my partner talked about it trying to figure out what could've been wrong with her, we thought heat stroke/exhaustion but that there has to be more wrong with her than that to cause the diarreah.

Anything you guys would've done differently, question's you would've asked, ect.?
Click to expand...

Did you look at her stools?
 
Interesting, its always that hidden piece of info that the patient doesn't tell you about that leaves you baffled. I was thinking more of a GI Bleed myself.

OTOH speaking of Triple A's I had one that baffled everyone. The guy complained of back pain. Just back pain by the kidney. No radiation, just dull pain one spot. He told me he thought it may have occurred from sleeping with the window open the previous night and that was the patients self diagnosis.

Anyways, down at the ED doc checked him out did an xray and a few other tests and just on a hunch did a Doppler and a ultrasound. To find he had a slow Aortic drip. shipped him to the OR and he was discharged later.
 
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I've had a patient present similar to this almost to a T. She actually took 2 liters of fluid in short order to even maintain a Bp of 80. Acute Crones flair up with massive fluid shift and dump was her final diagnosis
 
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