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vquintessence

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Had a call Christmas Eve and was wondering if someone could offer any insight as to what happened to the pt.

Dispatched for unknown medical, and U/A found 91 Y/O female CAOx4 speaking full coherent sentences and sitting upright.
HPI: Pt stated she rolled in her sleep and fell out of bed, a hematoma the size of a baseball is already present above her L orbit. Other bruises of various ages are present on her face, which she attributes as falls from earlier in the week.

Anyways pupils PERRL, pt denies LOC, -N/V, -pain, and denied being on blood thinning Rx's (caretaker stated she only takes Zocor and atenolol). Family and caretaker deny any medical history, so we just inferred HTN from her Rx's. She is fully oriented, and actually pretty witty; initially refuses to be seen at hospital. After about 5 min coaxing, she agrees to be seen.

At this point she is still CAOx4 and denying any problems, so we collar and board the poor 91 Y/O woman per protocol. She remained alert while strapping her in, however by the time we carry her down the stairs and onto the stretcher (2 min max) she loses consciousness. We take another moment to quickly get her into the truck and at which point she goes out [~GCS 6] with ataxic respirations.

Pt gets bagged, ECG was NSR with unremarkable 12 lead, BS was ~200 mg/dL, BP ~180/70, unremarkable physical exam, pupils remained PERRL en route. She buys a tube and couple lines, but otherwise the only other treatment I gave was 5mg Versed to facilitation intubation.

I ran into the family hours later at the ED and they said her CT and MRI were both clear. They were still waiting for an answer.

My question: What the hell happened that would cause such a rapid decline? I assumed that after getting boarded a head bleed let loose, but with the clear CT & MRI that would get ruled out? Very confused and I'm not very happy with my co-workers opinions on what happened.
 
Consider positional asphyxia.

If you put me supine on a spineboad and lay me flat I'd go into respiratory arrest through airway embarassment. My EKG would be normal (well, as normal as mine gets), my labs would be good, but I would be dead in minutes. Really bugs my dentist.

I've seen a few pts who went west as soon as they were placed flat/supine.
 
mycrofft said:
If you put me supine on a spineboad and lay me flat I'd go into respiratory arrest through airway embarassment. My EKG would be normal (well, as normal as mine gets), my labs would be good, but I would be dead in minutes. Really bugs my dentist.

I've seen a few pts who went west as soon as they were placed flat/supine.
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She was talking to us and not indicative of distress; she spoke clearly and was pretty particular about the board being too cold despite the blankets we tossed on it (it was in the low teens that night). The collar was appropriately sized (no neck like almost everyone else) eyes level, no extension, the good stuff. She wasn't a little old humphback, and besides she still got padding on the board. Her airway certainly wasn't kinked or anything.

In the max of two minutes it took to carry her downstairs, she was, oh how would you describe it, lets say not upside down backwards with all her weight resting on the neck and smacking her head on every step. In fact, she was initially still talking and attempting to reach out to grab the wall/railing/anything down the damn 90 degree stairwell.

I mentioned all the other findings to hopefully narrow down possibilities of the etiology behind her quick demise. You seem convinced it was airway. It's not like we just saw her condition and decided to tube without checking possibilities. Why was her respiration pattern so abnormal? She wasn't breathing with any distress you'd expect of a kinked airway. We were able to bag her without resistance and no, a quarter didn't fall out of my pocket and down her throat.

Laur68EMT said:
What do they feel happened?
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One opinion was we just witnessed an ischemic CVA.

Another opinion was closed head trauma, and they still believe it with the clean CT MRI.

PE was another.
 
I'd suspect something else got knocked loose or was bleeding in her brain--or, more accurately, around it. The elderly have decreased brain mass, a bit of extra space around, dig, so it might take a bit to present. The abnormal respirations tell me that there may be some medullar compromise. My guess: subdural bleed. I don't think the airway was the problem--I think the respiratory center was. I'd feel better about saying so if she was on a blood thinner of some type, but that's still my best guess, for what it's worth.

Either way, I hope you find out what exactly happened, and you have my sympathies.


Later!

--Coop
 
My guess is ischemic stroke. It may take a while for CT show positive on those.
 
Just some SWAG as I wasn’t there and can’t see the film.

As we age, the ability of our chest wall to expand and facilitate breathing diminishes. I am not saying you did anything wrong, but you may want to ask for some selective spinal criteria or use modified spinal precautions. Putting people on boards, even when well padded, can restrict chest expansion.

A subdural should definitely show up on a head CT. Pretty clearly if it were to explain a sudden decompensation. I have seen subarachnoid bleeds lower in the skull near the cribiform plate of the ethmoid bone from the anterior septal branch of the anterior ethmoidal artery. If somebody was looking just at the higher films of the skull it is likely they misinterpreted that the film was clear. Most neuro, radiology, and EMs would not miss that though as it is one of those occult findings specifically searched for.

The fact they did an MRI would lead me to believe they were looking for early ischemic damage because the CT was clear. It is very difficult to see early ischemic damage in both CT and MRI.

If she was actually compliant with her atenolol and her BP was 180/70 I would be on the lookout for something causing cranial compartment syndromes as well as an aneurism or pseudoaneurism somewhere else in her body. This BP also supports ischemic CVA

What exactly was her HR? did it ever increase or decrease? Was she visibly stressed from being on the board carried down the steps? That might have caused some vasoconstriction or made an embolus or thrombus worse.

With her history of recent falls I would be suspect of a partial occlusion anyway. With the ataxic respirations I would suspect that the occlusion was coming from a branch of the vertebral artery or basilar artery. (same artery different location)

Infact the more I think about it, I cannot think of anything that might be remotely likely except ischemic CVA or my distant second choice, aneurism beneath the neck. There are some really remote possibilities from rare diseases, but are so unlikely it is not worth typing them up.

I think you got there in time to see a partial occlusion become a full occlusion. Good story to relate to the junior guys.
 
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Oh and you can also get a secondary hemorrhagic CVA from an ischemic one. So serial CT would be in order.
 
vquintessence said:
Other bruises of various ages are present on her face, which she attributes as falls from earlier in the week.
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Kind of odd don't you think? How many times in a week would a normal person fall on their face?
 
Anomalous said:
Kind of odd don't you think? How many times in a week would a normal person fall on their face?
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a good line of thought, but many older people, my family included, think the hospital is where you go to die, so it takes a fair bit of convincing to get them to go.

"this chest pain feels like my last heart attack, don't call 911"

There is also an all consuming fear of older people that healthcare providers will put them in a nursing home. If she is 91 she is from a generation of people far tougher than ours.

So while I agree it is suspicious, it doesn't sound outrageous. I wasn't there though, so I am not the best perosn to judge abuse based on the informaton presented here.
 
Christmas mystery

vquintessence said:
HPI: Pt stated she rolled in her sleep and fell out of bed, a hematoma the size of a baseball is already present above her L orbit. Other bruises of various ages are present on her face, which she attributes as falls from earlier in the week.


I'd wonder about the old bruising. Did you get a chance to expose and look for bruising elsewhere? Any other significant marks on chest, abdomen, back? Falls, elder abuse...either could have caused an internal injury that was contributing to her instability on her feet. It may be that your orbital hematoma was the distracting injury and her real problem was hidden and just cropping up symptomatically - maybe when you inverted her to go down the stairs? For instance, Thoracic Aortic Aneurysm can present with just a slow trickle, nicely pinched off between the spinal column and the organs in the cavity, until a shifting of body weight changes the way things are lying internally, allowing the TAA to leak in varying degrees. TAA is not really likely here, but it's a good example of the sneaky things that can go on when you're looking in another direction entirely.

I'd think distracting injuries as well as the (very probable) head insults.
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Interesting case. With the recent falls, and the sudden decrease in LOC you have to wonder if she's jumping into some sort of arrhythmia.

I'm also wondering if the c-collar and board could have had something to do with it. Some folks will desat pretty quickly, maybe a vagal response.

Who knows. Let us know if they come up with a definitive cause.
 
All interesting thoughts, and I am in agreement with the ischemic stroke thought. The bleed would show up immediately as long as it was in the field that they were looking. The ischeminc stroke damage won't show until 24-48 hours later. There are some cases where it is actually 72 hours before it is seen on a CT. Let us know if you are able to find out more. I would be interested in learning what the outcome was.
 
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