Tunnel vision strikes again?

[Amber Lance]

Call for a 22 y/o female c/o vomiting. Arrive to find pt sitting on couch, unable to sit still, with a bucket containing about 1/2 Liter of vomited stomach fluid (bile, etc. - no food).

Pt states she had one beer and one shot the night before on an empty stomach and has not been able to stop vomiting today. She denies allergies or previous medical history.

Vital signs: Pulse 74 strong and regular, SpO2 96% on room air, BP 100/80, temp 97.9, pupils PERRL at 3mm.

Go! h34r:

 

[Emtsgv]

Call for a 22 y/o female c/o vomiting. Arrive to find pt sitting on couch, unable to sit still, with a bucket containing about 1/2 Liter of vomited stomach fluid (bile, etc. - no food).

Pt states she had one beer and one shot the night before on an empty stomach and has not been able to stop vomiting today. She denies allergies or previous medical history.

Vital signs: Pulse 74 strong and regular, SpO2 96% on room air, BP 100/80, temp 97.9, pupils PERRL at 3mm.

Go! h34r:

easy i call for ALS and eat my dinner while i wait

 

[Amber Lance]

Why ALS?

 

[Akulahawk]

What's the patient had to eat/drink in the past 24 hours besides EtOH? Any recent travel? Dizziness/lightheadedness? Recent abdominal pain, tenderness, distention?

 

[Angel]

Recent illness (family, friends. tis the season)? Why hasn't she been eating? I second the abdominal assessment and if shes had diarrhea and HAVE to ask about LMP to rule that out. what are skin signs? bp is on the lowish side

and I also want to know what else shes been eating/drinking ie Anything besides alcohol
shes been vomiting for how long? and hasn't taken anything for it?

has this ever happened before, if so when? was it diagnosed and how was it treated

what do we feel when we palpate her abd

This might be a dumb question but why is she unable to sit still...id expect her to be lethargic

 

[Kevinf]

The amount of alcohol is negligible, though it could have upset a pre-existing condition with her liver I suppose.

BP is well within normal limits if she is a smaller female, ask is that normal for her.

Pt is afebrile, so while infection isn't ruled out it's lower on my list though I'll consider it more strongly if she says she is somewhat hypotensive (or doesn't know her normal BP).

What is her CBG?

Any other unusual outward signs? Bug bites? Unexplained lesions? (agree with a need for Abd and other assessment)

How do the lungs sound? How's the heart sound?

Any edema?

What was your impression of her mental status in general? Who called?

For non-stop vomiting she's still going to the hospital regardless

 

[mycrofft]

PAin? Abodominal exam?

Alcohol abuse (drinking without eating is not a good piece of lifestyle), think liver, gallbladder, pancreas.
(Pancreas…not a word you read here that often).

Comfort, trip to hospital, support VSs.

 

[Amber Lance]

Pt complains of severe stomach pain, and also says "everything hurts."
She called 911 herself and is unable to give any other information as she is becoming increasingly drowsy. She loses consciousness and is unresponsive to verbal and painful stimuli (sternum rub). She spontaneously regains consciousness about 20 seconds later but is still difficult to communicate with due to drowsiness. HR has decreased to 52, all other vital signs remain the same.

ALS arrives and assumes patient care, pushes Zofran and transports (about a 45 minute transport time). Patient is able to stand and walk a few steps to the gurney.

A few hours later we found out she had a seizure at the hospital. They had noted a prolonged QT interval on the 12-lead.

I wish we'd had a chance to do a more thorough assessment. The seizure really threw us off and left us wondering what was actually going on.

My thoughts:
-Poisoning (maybe some type of pesticide?)
-Alcohol withdrawal (she only said how much she had last night, not how much she normally drinks)
-Possibly some type of meningitis (I have been suspicious for some time now that our thermometer is jacked and reads really low), although no complaints of headache or stiff neck
-Gastroenteritis plus a severe electrolyte imbalance from the vomiting
-There's always the possibility that the vomiting and the seizure were two unrelated events, although that seems unlikely given that she had no history of seizures.

Anyone have any insight?

 

[VFlutter]

Hyponatremia/Hypocalcemia.

 

[mycrofft]

Honestly, are there (m)any abdominal complaints you can do much for except pain relief and an IV JIC (just in case) before the hospital?

 

[Amber Lance]

I suppose it's not so much a question of what else could we have done (because, as basics, there's not much). I mean, we should have gotten a better assessment, but I don't know that it would have changed our handling of the situation much.
At this point, it's an effort to understand what may have happened so that I can hopefully go into future calls like this with a more open mind and lower the risk of missing something really important.

 

[mycrofft]

To repeat my anatomy instructor's statement, "The abdomen is a dark and mysterious place full of danger" or words to that effect.

 

[teedubbyaw]

Hyponatremia/Hypocalcemia.

What I'd guess. She'd have gotten a NS bolus, zofran, and transport.

 

[VFlutter]

What I'd guess. She'd have gotten a NS bolus, zofran, and transport.

Agree with a NS bolus but I would be cautious with IV fluids until labs are obtained. If this patient is truly hyponatremic enough to have seizures then they need to be corrected precisely over days. You should not have have a problem unless you have a long transport time and decide to dump multiple liters.

Central Pontine Myelinolysis :excl:

 

[teedubbyaw]

Always learning something new. Thanks, Chase.

 

[mycrofft]

Agree with a NS bolus but I would be cautious with IV fluids until labs are obtained. If this patient is truly hyponatremic enough to have seizures then they need to be corrected precisely over days. You should not have have a problem unless you have a long transport time and decide to dump multiple liters.

Central Pontine Myelinolysis :excl:

Transport time: the zone where you can save a life, or do pointless things which need to be documented, or make the receiving facility's evening more complicated than they expected it to be. Or worse.

 

[chaz90]

Transport time: the zone where you can save a life, or do pointless things which need to be documented, or make the receiving facility's evening more complicated than they expected it to be. Or worse.

Probably true for every other part of medicine too. Replace "Transport Time" with "Time in ED" and "receiving facility" with "floor."

 

[usalsfyre]

Hyponatremia/Hypocalcemia.

How in the flaming hades are you figuring that?

If anything I'd be more suspicious for a hypernatremia from volume contraction. I'm betting more along the lines of substance withdrawl/ingestion.

 

[mycrofft]

Probably true for every other part of medicine too. Replace "Transport Time" with "Time in ED" and "receiving facility" with "floor."

Potentially, but in the field you don't have the benefit or excuse of recent diagnostics (lab tests, X-rays) and attention from definitive practitioners (doctors) so you either follow a protocol, or you wildcat it. The is why protocols can be maddening, to try to think of stuff which may benefit the pt, while reining back the tech's need to feel they are doing something.

On the floor, the danger is crummy service, bad staffing ratios, germs, etc. In the ED your worst enemy besides being forgotten or lost in transport, is being left waiting without treatment.

 

[Ewok Jerky]

medical history?
diabetes?
lithium toxicity?
pregnant?
any abdominal pain?

the differential is pretty large. I would like a CBC and BMP to start, maybe some imaging. hard to tell if the seizure is related or secondary to electrolyte imbalance from vomiting.

as far as prehospital goes, start a line, zofran, deisal.