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firemedic0227

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Called to a sick person call the other day. The engine company beats us there, I walk in and ask the Captain what's going on (He's a medic also). He looks up at me and says, I have no clue what's going on, we don't have much to go on. I see a middle aged woman laying in the hallway of her residence. She is only moaning every time we move her and not responsive. I look down at the patient and noticed she has swelling on her left side from her chin down to her left foot none on the right side. She has JVD on the left side only. No known medical history and husband's story is not reliable. Basically he said the PT wasn't feeling well on friday night so he layed her on the couch. Saturday she wasn't feeling well so he left her on the couch, Sunday same thing. He went to pick up the PT to take her to the bathroom but couldn't carry her all the way so he left her in the hallway at 0300 Monday AM and called 911 at 0715. She had no bowl movements and passed no urine during any of this time. Vital signs were normal,breathing was rapid but sats were 94% on a non rebreather, eyes were equal and reactive, ECG showed NSR with no Ectopy. IV was started Patient was taken Code 3 to the Hospital. While enroute to the hospital we notice that her sats were going down and that her arms were starting to get cyanotic. Myself and the other medic noticed that she had stopped breathing but was still NSR on the monitor. Started bagging her and sats come up and she starts breathing on her own again. BGL was 84 also. The Patient was transferred to the ED.

You guys have any idea what's going on with this patient? (After talking to the doctor after another patient later I finally figure out whats going on)
 
Was she lying with her left side lower than right? I am thinking if it was only left sided edema than there it might be some sort of gravitational interstitial expansion thing going on.

A bit of dehydration from being sick is going to cause the level of coma found in this patient.

My main thinking would be a stroke? or if not some sort of massive intracranial catastrophe ... not sure why but thats just what comes to mind at the moment.
 
Ok bare with me here, Im just kind of pulling this out of nowhere.

But first off what was her BP?

And did the swelling go down(redistribute when she was moved to the cot?

Potentially thinking edema due to fluid build up, and metabolic acidosis causing AMS. Sats dropped when fluid shifted.

A stretch I know. Probably much simpler but I got nothing else :D
 
Headscratcher. But what do you guys think the underlying pathology is? I'd like more info, obviously - did the pt ever have any complaints other than AMS/lethargy? CVA doesn't make sense based on progression. I'm thinking possibly UTI to start, perhaps with rhabdomyolysis around when the husband called. Rhabdo would result in metabolic acidosis, explaining the resp alkalosis here.

I know rhabdo is more common with crush injury, but I've seen it once when an older pt was on his floor without moving for 6 hrs. He was close to unresponsive and went into cardiac arrest shortly after our arrival at the ER.

I'm not gonna get hung up on unilateral JVD when I have no idea what it signifies (vascular anomaly?). Huh. What did it wind up being? Don't have time to run a full DDx right now...
 
Maybe major fluid retention due to blood pressure meds?

or if overweight or unhealthy, it could be a major DVT issue or vein blockage?

just off top of my head.
 
MountainMedic said:
Headscratcher. But what do you guys think the underlying pathology is? I'd like more info, obviously - did the pt ever have any complaints other than AMS/lethargy? CVA doesn't make sense based on progression. I'm thinking possibly UTI to start, perhaps with rhabdomyolysis around when the husband called. Rhabdo would result in metabolic acidosis, explaining the resp alkalosis here.

I know rhabdo is more common with crush injury, but I've seen it once when an older pt was on his floor without moving for 6 hrs. He was close to unresponsive and went into cardiac arrest shortly after our arrival at the ER.
Click to expand...

+1 on the Rhabdo. I had a patient on the floor for only a couple hours who had a CK of 50K with pretty substantial AKI. With an underlying infection or disease process added to the equation you can get very sick very fast. Respiratory failure was probably due to exhaustion from being tachypneic for days.
 
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Vitals? What was her skin color / temperature? Could you describe the swelling a bit more? How swollen was she / any pitting edema / redness?
 
Without knowing anything else it sounds like sepsis. What were her vitals.

Third spacing fluid and it all ended up on one side due to her positioning, just like dependent lucidity.

That's my bet.
 
chaz90 said:
I love phone auto corrects. I can just imagine documenting a DOA with dependent lucidity :D
Click to expand...

Damn iPhone! Didn't even see that.
 
Sorry guys, it was a busy week for me. I'll try to answer all the questions at once. BP was 140ish/90ish. Skin was warm to the touch but not diaphoretic. Besides her rapid breathing to begin with to not breathing very well while enroute to the hospital all other vitals were normal, BGL was 85ish. The woman was not overweight either.

Later on in the day after bringing another patient to the ER we asked the ER doc what was going on with our patient. He stated "she's a train wreck, she has liver failure due to excessive ASA intake which then led to her going into kidney failure, and at some point had a mild heart attack." Which all makes sense why she was swollen on one side of her body which happens to be the side that her husband lefter her lay for a long time before calling 911.
 
How does this lead to the unilateral swelling? Pathophys never was my strong subject
 
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EMT B said:
How does this lead to the unilateral swelling? Pathophys never was my strong subject
Click to expand...

She's retaining fluid due to the renal failure and it has to go somewhere so it goes into the interstitial space which would generally cause bilateral peripheral edema but since she's laying on her side gravity pulls all the interstitial fluid to that side causing unilateral edema.
 
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If she is in renal failure and has fluid backup, wouldn't you see a more elevated blood glucose level due to SIRS/Sepsis?
 
EMT B said:
If she is in renal failure and has fluid backup, wouldn't you see a more elevated blood glucose level due to SIRS/Sepsis?
Click to expand...

Huh? Renal failure/fluid retention and SIRS/Sepsis are two independent disease processes.

But yes, you will typically see hyperglycemia in sepsis or most systemic disease processes for that matter.
 
Wont toxic fluid backup casue a systemic inflamitory response if not sepsis?
 
EMT B said:
Wont toxic fluid backup casue a systemic inflamitory response if not sepsis?
Click to expand...

Nope. Sepsis is an immune/inflammatory response to an invasive infection not an build up of intrinsic waste. Metabolic acidosis, hyperkalemia, elevated BUN/Cr, Etc will not cause sepsis and should not cause SIRS unless there is some necrosis or infarction going on.
 
Chase said:
Nope. Sepsis is an immune/inflammatory response to an invasive infection not an build up of intrinsic waste. Metabolic acidosis, hyperkalemia, elevated BUN/Cr, Etc will not cause sepsis and should not cause SIRS unless there is some necrosis or infarction going on.
Click to expand...

Ya what he said.
 
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