what's your take on this call

[piranah]

possible she was septic and that had effected her ability to control her temp(say an infection had gone to her brain)..along with her weight and being on the floor....i would done the same,fluids(warm) and the tracing was prolly the shivering....did you by any chance get ahold of the labs from the er?

 

[knxemt1983]

Did I read this correctly?

b/p 64/p, pulse is regular but ranged from 140 bpm down to about 40, and back up at varying times. only two meds that we could find were macrobid and atenolol.

BP is 64 palp?

atenolol overdose?

thought about that, pill count was right on for atenolol. I thought maybe if she had been taking it and not excreting it correctly maybe she had built up toxicity to it.

 

[knxemt1983]

possible she was septic and that had effected her ability to control her temp(say an infection had gone to her brain)..along with her weight and being on the floor....i would done the same,fluids(warm) and the tracing was prolly the shivering....did you by any chance get ahold of the labs from the er?

I;m back on tonight so if I can get a transport that wants to go back to the same ed then I'll get a good follow up report on her

 

[knxemt1983]

My guess would be septicemia secondary to the UTI that she is/was on the Macrobid for. Which would explain the hypotension, and the -lol beta blocker would explain the no increase in HR even though her pressure had fallen. The macrobid may not have covered the microorganism that caused the infection in the first place, especially if it wasn't cultured and followed up on.

As to the ECG tracing you probably caught her at the end of her compensating abilities and she was no longer visibly shivering from her septic hypothermia. Though she was still having small muscle fasiculations which were not visible to the eye.

Fluid therapy for sure, as dopamine is not going to be very effective is she is fluid depleted. Can squeeze the pipes and increase pump rate, but if theres no fluid to move it would be ineffective


Corky

that is the same track I'm thinking now, probably septic from uti, and not having visible shivering.

 

[ksEMTbabe]

My first thought with the temp regulation problem coupled with the pinpoint pupils was that she has some sort of neurologic dysfunction - possibly related to her hypothalamus? That would explain the hypothermia and since the hypothalamus also controls some autonomic functions it could have an effect on her cardiac rhythm. You also mentioned that she was very thin... undernourishment in the elderly can cause a significant decrease in the working cells of the hypothalamus. Just a thought, maybe I've just been watching too many episodes of House

 

[knxemt1983]

verdict form the ED is lung ca, coupled with the hypothermia, and cardiac tamponade. once she was warmed with the bear hugger the EKG became clearer. The doc agrees that it must've been internal shivering w/o external signs.

 

[VentMedic]

verdict form the ED is lung ca, coupled with the hypothermia, and cardiac tamponade. once she was warmed with the bear hugger the EKG became clearer. The doc agrees that it must've been internal shivering w/o external signs.

How much fluid did they tap with a pericardial centesis?

That could also explain part of the EKG if the caridac tamponade gave low volts and electrical alternans.

 

[DrankTheKoolaid]

re

Wow thats a bummer for sure.

Corky

 

[CH47Doc]

How much fluid did they tap with a pericardial centesis?

That could also explain part of the EKG if the caridac tamponade gave low volts and electrical alternans.

coulda just did antibiotics depending on how far along it was.

 

[lizhiniatsos]

...you guys and gals are good! Along with all of the aforementioned items the thought did cross my mind that she could've sustained a head injury secondary toa fall (found on the floor...right?) thereby causing neurologic deficits....
anyway...sad news on the true nature of her problem....and great care on your part~

 

[knxemt1983]

How much fluid did they tap with a pericardial centesis?

That could also explain part of the EKG if the caridac tamponade gave low volts and electrical alternans.

that's pretty much exactly what the problem was. I don;t know how much fluid was removed though, the doc that did it wasn't there so I just talked to one of the ed nurses who was not the pt's nurse

 

[knxemt1983]

...you guys and gals are good! Along with all of the aforementioned items the thought did cross my mind that she could've sustained a head injury secondary toa fall (found on the floor...right?) thereby causing neurologic deficits....
anyway...sad news on the true nature of her problem....and great care on your part~

yeah I went through all kinds of ideas. bgl, fall and head injury, overdose of something unknown, stroke, I was leaning toward some type of dysrythmia while I was on the call, but couldn't tell what it was. After the call I came up with and was helped with some stuff by you guys, and have learned alot from this call, thanks for all your all's help in thinking through this one.

thanks for the compliment, it means alot with me being only a 6 month paramedic, I can tell I have learned alot since school was out and that I still have an enormous amount to learn throughout the rest of my career.