Jump to content


Photo
* - - - - 1 votes

Case #51 "i Feel Cold"


  • Please log in to reply
97 replies to this topic

#1 STPEMTP

STPEMTP

    Advanced Member

  • Members
  • PipPipPip
  • 44 posts

Posted 01 March 2010 - 12:54 PM

Hello everyone.



Welcome back to the case presentations! SerendepitySaki and myself will be the moderators for this case.


Goals of this case: It is primarily a learning exercise for our “younger” members vs. a puzzle for our more “experienced” members. There are NO zebras. We will be exploring some "advanced" concepts from certification exams, such as factors influencing Cardiac Output, and Acid-Base balance.

We would like to see a systematic work-up with ABCs/Review of Systems, as well as ongoing treatment and reassement ala NAEMT and AHA Guidelines. (as well as any other applicable ones you can support with references.)


Where possible, please provide references with your answers to further learning and a culture of Evidence Based practice.


You are paged out to assist a BLS service as ALS back up. You are currently staffing a ground truck due to icing conditions (gotta love winter....)

You arrive to find a 50 y/o M gray/ashen in bed with a Chief Complaint of "feeling cold".



per BLS reporting: (VS/PMH/HPI)
VS : Pt diaphoretic, shivering BP: 180/100 HR: 40 and irregular RR: 24 Sao2: 95 (not getting good reading)

PMH: Recent snowmobile accident, multiple surgeries w/ back and leg incisions. Leg Cast removed w/ surgeon follow up 5 days ago. Per patient, no signs of infection at that time.

HPI: Patient states he has been feeling ill for past two day and progressively worsening. Pt states that he has been unable to get out of bed since last night due to feeling weak. Pt called 911 because he thinks that he has been passing out today while lying in bed.



Your general impression/ initial assessment:
Caucasian

A&Ox4
+radial pulse, irregular
no audible sounds with breathing respirations appear unlabored
Skin cold to touch (thermometer malfunctioning) He is profusely diaphoretic and actively shivering, despite being wrapped in a down blanket and flannel sheets.
  • 0

#2 Speed

Speed

    Advanced Member

  • Members
  • PipPipPip
  • 1100 posts

Posted 02 March 2010 - 02:25 AM

The primary survey is intact and he is going to need transport, so I would load him now with O2 & monitor and get on the way to a facility that has a cath lab and a thoracic and neuro surgeon at the least. On the way start a good assessment for both trauma and medical issues, probably ruling out the need to put him in spinal precautions if you don't absolutely see the need? Start working him up for cardiac and neuro big players. 12 lead, couple of IVs, NRB, an I-stat would be nice to see a PT/PTT, INR if any new software can do that. Rule out DIC which is one of the big three killers in trauma after the resuscitation and surgeries are over (hypothermia?DIC/acidosis). He's been in a wreck so rule out the possibility of a developing bleed (eyes, ears, and nose, and toes, gait- nah I wouldn't road test him prehospital, cranial nerves). He could have a growing sub-dural or ICH (pupils vs. Cushing Syndrome/HTN). Anybody laying down for a long time I would always be aware of some degree of sepsis, but I'm not seeing any yet. HTN, slow bradycardia, irreg hr; you know there are definite cardiac indications here. 95% sao2 but shivering and cold to touch, wow??? He's got to have at least a few floating clots from all those breaks, and lying around with a cast. CVA? Blood sugar, medicine list?
  • 0
Mike Williams CCEMT-P/FP-C

#3 Ectopy

Ectopy

    Advanced Member

  • Members
  • PipPipPip
  • 129 posts

Posted 02 March 2010 - 02:55 AM

I'll take a stab, go easy I'm new.

First a little background on myself so no one is too harsh, I've been in critical care for about a year and am planning on sitting for the board exams within the next few weeks.

Initial Treatment

Since we're a CC unit I'm assuming we have two ALS providers. One provider needs to be getting 2 large PIV's and ensuring the patient is on high flow. The other provider needs to be setting up the monitor and pacer (and if you're really nice some Versed).

I would give 2mg of Versed and initiate pacing until capture. Then of course reassess.

After I get capture, treat any ectopy with lido and continue to monitor as I'm loading the patient into my unit. Although the ongoing TCP will effect your results, getting an initial 12 lead will be tremendously useful due to some of the differentials listed below.

Enroute

With the irregular pulse, recent history of pretty hefty surgery, here is the list of SOME of the potential differentials (ordered from least to most likely)

Surgically induced A-Fib (increased adrenergic state post op, will try to find data), <---- perhaps too much of a zebra - not necessarily consistent with other symptoms.
Compensated Septic Shock
Clot thrown landing in coronary artery leading to this presentation (12 lead/labs will reveal all haha) I'm expecting

A little bit more about the clot option and why I think this might be the best option with the information given so far:

A clot thrown after recent surgery can of course go anywhere. If it lands in the RCA we're gong to see a lot of these symptom. First, if the clot is indeed in the RCA we're going to have an impaired right ventricle with decreased output, thus the relative systemic hypertension. I wouldnt be surprised to find some pedal edema on this patient. Second, the RCA supplies the sinus node so if the clot was in the RCA I'd suspect the bradycardia as we've seen with this patient.

In effect, this patient is right on the verge of going into some pretty hefty cardiogenic shock when (not if) he goes into complete failure without treatment (if I'm barking up the right tree)

In that case I'd be priming some dopamine due to the RV preload issues.
  • 0
Matthew George - NREMT-P, FP-C, CCP, Instructor

#4 Ectopy

Ectopy

    Advanced Member

  • Members
  • PipPipPip
  • 129 posts

Posted 02 March 2010 - 03:06 AM

How are we ruling out DIC? An I-STAT would be nice to shed some light on any potential acidosis.....
  • 0
Matthew George - NREMT-P, FP-C, CCP, Instructor

#5 SerendepitySaki

SerendepitySaki

    Advanced Member

  • Members
  • PipPipPip
  • 1176 posts

Posted 02 March 2010 - 03:15 AM

Speed/ Matt- you are unable to start an IV.

One provider needs to be getting 2 large PIV's


  • 0
LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#6 SerendepitySaki

SerendepitySaki

    Advanced Member

  • Members
  • PipPipPip
  • 1176 posts

Posted 02 March 2010 - 03:20 AM

you can have any medication or diagnostic modality you wish (within reason) as long as you ask for it. You have an iSTAT. What values would you like? [Speed, I have noted your request, and yes, just like the iPhone, iSTAT has an app for that ;-) ]

How are we ruling out DIC? An I-STAT would be nice to shed some light on any potential acidosis.....


  • 0
LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#7 SerendepitySaki

SerendepitySaki

    Advanced Member

  • Members
  • PipPipPip
  • 1176 posts

Posted 02 March 2010 - 03:52 AM

you can have any medication or diagnostic modality you wish (within reason) as long as you ask for it. You have an iSTAT. What values would you like? [Speed, I have noted your request, and yes, just like the iPhone, iSTAT has an app for that ;-) ]



here ya go guys! you know the bean counters'll almost never spring for these in real life, so virtually enjoy it here....

http://www.abbottpoi...ge_Brochure.pdf
  • 0
LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#8 SerendepitySaki

SerendepitySaki

    Advanced Member

  • Members
  • PipPipPip
  • 1176 posts

Posted 02 March 2010 - 03:58 AM

go easy I'm new.



likewise. so are we. (at least to case studies on this forum!) it's all about the learning and you'll probably teach us a thing or three before it's all over....
  • 0
LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#9 Ectopy

Ectopy

    Advanced Member

  • Members
  • PipPipPip
  • 129 posts

Posted 02 March 2010 - 05:07 AM

Ok well if I cant start an IV im going to go IO and then start a central line if my team has that ability (my team does not). I'm very suspicious that this gentleman is about to crash out on me, so I want something large bore to prop up RV preload (once again if I'm barking up the right tree). If he's septic, I also want to stay ahead of the fluid resuscitation curve.

If I'm unable to start an IV that tells me one of two things. Either I suck at IV's (story of my early career) or that this guy is really obese or has blown veins from "other" causes (amateur pharmacology, dialysis, etc). I'd be very interested to see if he has a medication list or further medical history besides his recent surgery. While I think that the recent surgery is most likely the cause of what we're seeing, any underlying issues will of course change how we approach things.

From the iSTAT:

cTnl/Troponin - Still think this might be an infarction (probably inferior/right) caused by clot.
Blood Gasses/'Lytes - See if this gent is acidotic post-op also good look at respiratory adequacy on a chem level.

Still, a 12 lead will give me a much faster look at whats going on while we are getting access/pacing/loading before I'm able to run any portable labs.

I'm still watching out for signs that this might be a septic event (still suspicious of this due to the two day onset of symptoms), neuro event, or a slow bleed (symptoms not as consistent with this).

On a purely unscientific note, I can't tell you how many patients I've had that said they felt "cold" and we're in profound compensated shock that turned into profound decompensated shock. Usually the tipping point is approaching when they ask the crew for water 'cause they're so thirsty. Purely unscientific observation.

Interesting case!
  • 0
Matthew George - NREMT-P, FP-C, CCP, Instructor

#10 Trouble

Trouble

    Member

  • Members
  • PipPip
  • 10 posts

Posted 02 March 2010 - 05:36 AM

Good to see some one pick up the gaunlet for case studies. I also have been on the sidelines watching "the show. " Kinda of new at this. However, here is my 2 cents.The pt. had a back and leg injury which required a cast. So with the injury, I am concerned about the probability of a DVT - thrombosis or fat embolism developing and causing a PE. It would fit the following symptoms - irregular pulse- pulse paradoxus, diminished to absent breathe sound on auscultation. And it would fit the hypertension. It would be nice to known if the pt. was previously taking any anticoagulants and was he compliant taking them? I would also like to place him on a EKG monitor to what rhythm he is in and perform a 12- lead ekg in hopes of getting positive findings of a PE. However, I don't know how effective it will be with the pt shivering violently.

The only symptoms which confuses me is pt c/o " Feeling cold", shivering and is also diaphoretic. Is this right? or a typo error.:unsure:

puzzled
  • 0

#11 Ectopy

Ectopy

    Advanced Member

  • Members
  • PipPipPip
  • 129 posts

Posted 02 March 2010 - 05:54 AM

Good to see some one pick up the gaunlet for case studies. I also have been on the sidelines watching "the show. " Kinda of new at this. However, here is my 2 cents.The pt. had a back and leg injury which required a cast. So with the injury, I am concerned about the probability of a DVT - thrombosis or fat embolism developing and causing a PE. It would fit the following symptoms - irregular pulse- pulse paradoxus, diminished to absent breathe sound on auscultation. And it would fit the hypertension. It would be nice to known if the pt. was previously taking any anticoagulants and was he compliant taking them? I would also like to place him on a EKG monitor to what rhythm he is in and perform a 12- lead ekg in hopes of getting positive findings of a PE. However, I don't know how effective it will be with the pt shivering violently.

The only symptoms which confuses me is pt c/o " Feeling cold", shivering and is also diaphoretic. Is this right? or a typo error.:unsure:

puzzled


First, a fever can definately be associated with a PE (43% above 38.7C per Medscape) which could explain the shivering. Also, the patient is diaphoretic and tachypneic which are S+S of PE. HOWEVER reasons I don't think it's a PE based on the limited information we have so far: (I'm going to eat my words on this one)

1) Although respiratory symptoms do not have to accompany a PE, they often do and none are present in this presentation
2) Tachycardia usually goes hand in hand with PE, we have profound bradycardia. New onset afib is the most common arrhythmia associated with PE but it usually a fast conducting fib tach rhythm. This is the biggest sign to me.
3) Excluding respiratory distress, other signs and symptoms usually associated with a PE (w/o resp distress) aren't there like chest pain, abdominal pain, tingling etc.

From my experience patients that become acute rather quickly from a PE tend to not have a "few day" history of feeling sick. This gentleman hasn't been feeling well for two days, and has (it seems) decompensated rather quickly. To me this presents more like a heart failure scenario, but we shall see!

I'm not at all disagreeing with you, it's a definite possibility just for the sake of argument and collective education I'll play the thrombus route, but instead of pulmonary, cardiac! :-)

All the best,
Matt
  • 0
Matthew George - NREMT-P, FP-C, CCP, Instructor

#12 Ectopy

Ectopy

    Advanced Member

  • Members
  • PipPipPip
  • 129 posts

Posted 02 March 2010 - 06:12 AM

Also, the reason I'm being so persistent with the RCA embolus is the hypertension plus the bradycardia
  • 0
Matthew George - NREMT-P, FP-C, CCP, Instructor

#13 TexRNmedic

TexRNmedic

    Advanced Member

  • Members
  • PipPipPip
  • 257 posts

Posted 02 March 2010 - 06:33 AM

Hello everyone.



Welcome back to the case presentations! SerendepitySaki and myself will be the moderators for this case.


Goals of this case: It is primarily a learning exercise for our “younger” members vs. a puzzle for our more “experienced” members. There are NO zebras. We will be exploring some "advanced" concepts from certification exams, such as factors influencing Cardiac Output, and Acid-Base balance.

We would like to see a systematic work-up with ABCs/Review of Systems, as well as ongoing treatment and reassement ala NAEMT and AHA Guidelines. (as well as any other applicable ones you can support with references.)


Where possible, please provide references with your answers to further learning and a culture of Evidence Based practice.


You are paged out to assist a BLS service as ALS back up. You are currently staffing a ground truck due to icing conditions (gotta love winter....)

You arrive to find a 50 y/o M gray/ashen in bed with a Chief Complaint of "feeling cold".



per BLS reporting: (VS/PMH/HPI)
VS : Pt diaphoretic, shivering BP: 180/100 HR: 40 and irregular RR: 24 Sao2: 95 (not getting good reading)

PMH: Recent snowmobile accident, multiple surgeries w/ back and leg incisions. Leg Cast removed w/ surgeon follow up 5 days ago. Per patient, no signs of infection at that time.

HPI: Patient states he has been feeling ill for past two day and progressively worsening. Pt states that he has been unable to get out of bed since last night due to feeling weak. Pt called 911 because he thinks that he has been passing out today while lying in bed.



Your general impression/ initial assessment:
Caucasian

A&Ox4
+radial pulse, irregular
no audible sounds with breathing respirations appear unlabored
Skin cold to touch (thermometer malfunctioning) He is profusely diaphoretic and actively shivering, despite being wrapped in a down blanket and flannel sheets.



Hey folks. Thanks for getting the case studies kicked back off.

The patient looks like crap, feels like crap and is probably getting ready to crap out on us. One way or another this fella is shocky. I'm going to load this guy pretty quick and be thinking about what is the right facility for this guy. Neurosurgery/thoracic surgery/cath lab etc and how long will it take to get there. He is A&Ox4. Does he have any neuro deficits/unusual findings? How long ago was the accident?

Before this fella becomes unconscious, I'd like to know any other past medical history, allergies and grab his bag o' meds on the way out the door.

First impression, this guy looks like an MI/cardiovascular insult/shock. The odds of a peripheral venous thrombus traveling through pulmonary circulation and into the coronary arteries is probably very very low and this guy doesn't quite look like a PE. Maybe a coronary artery thrombus secondary to afib. The hypertension is probably compensatory related to low cardiac ouput.

1st line treatment: O2. 12 lead ECG. Vascular access (I read peripheral IV attempt unsuccessful). I'll take a quick look at an EJ while my partner gets the IO handy(assessing for JVD at the same time). If I have the ability, I'd love to have an ABG, H&H, Plt and basic chemistry. Don't know of any prehospital LFT capability-yet. My best guess is this guy is infarcting somewhere downstream of his LAD (anterior MI). RV infarcts are usually hypotensive and not the case here. ECG may show a high grade AVB, thus accounting for the bradycardia. Guess I'll have to wait for the next post to see what the 12-lead shows. Need a little more info before I decide on inotropes, IV fluid, nitrates, diuretics etc. Guess I need to stop looking in my crystal ball and get back to the patient.

A-I want to take a quick look at this guy's airway and think about how I will manage it if/when he crumps. (ETT, King) I want to have a plan and have my partner be on the same page with me.
B-Unlabored respirations at 24 with a 95% sat. Not to bad. What are the auscultated lung sounds. "no audible sounds with breathing". Is this 6 feet away or with a stethoscope? Percuss his chest. Depending on what my ears tell me, I might change up my treatment.
C-Radial pulses present. Bradycardic. Skin cool, dusky and sweaty. BP in both arms. Pedal pulses. Edema assessment. A good auscultation of the heart and abdomen. How has this guys intake and output been. Has his urine looked "funny" or an unusual color. Any change in stool (melena, hematochezia, BRBPR, clay). Any nausea, vommiting or pain of any kind (I'll figure out if the pain is relevant or not). Any unusual abdominal tenderness or findings on palpation? Mucous membranes-color and moisture?

Depending on what my detailed assessment comes up with I'll have a few things in the arsenal to have ready. (TCP, Inotropes, nitrates, diuretics, IV fluids, NIPPV etc.) Lets start heading to the ER.

Dif diag-
1. Some sort of cardiovascular shock/MI/aortic aneurysm
2. Rhabdomyolysis (maybe with a little ARF)
3. Sepsis
4. Head bleed
5. Combo of more than 1 of these

Thanks again for investing your time and presenting us with case studies.
  • 0
Wes Seale
Houston , TX

#14 Ectopy

Ectopy

    Advanced Member

  • Members
  • PipPipPip
  • 129 posts

Posted 02 March 2010 - 06:45 AM

Hey folks. Thanks for getting the case studies kicked back off.

The patient looks like crap, feels like crap and is probably getting ready to crap out on us. One way or another this fella is shocky. I'm going to load this guy pretty quick and be thinking about what is the right facility for this guy. Neurosurgery/thoracic surgery/cath lab etc and how long will it take to get there. He is A&Ox4. Does he have any neuro deficits/unusual findings? How long ago was the accident?

Before this fella becomes unconscious, I'd like to know any other past medical history, allergies and grab his bag o' meds on the way out the door.

First impression, this guy looks like an MI/cardiovascular insult/shock. The odds of a peripheral venous thrombus traveling through pulmonary circulation and into the coronary arteries is probably very very low and this guy doesn't quite look like a PE. Maybe a coronary artery thrombus secondary to afib. The hypertension is probably compensatory related to low cardiac ouput.

1st line treatment: O2. 12 lead ECG. Vascular access (I read peripheral IV attempt unsuccessful). I'll take a quick look at an EJ while my partner gets the IO handy(assessing for JVD at the same time). If I have the ability, I'd love to have an ABG, H&H, Plt and basic chemistry. Don't know of any prehospital LFT capability-yet. My best guess is this guy is infarcting somewhere downstream of his LAD (anterior MI). RV infarcts are usually hypotensive and not the case here. ECG may show a high grade AVB, thus accounting for the bradycardia. Guess I'll have to wait for the next post to see what the 12-lead shows. Need a little more info before I decide on inotropes, IV fluid, nitrates, diuretics etc. Guess I need to stop looking in my crystal ball and get back to the patient.

A-I want to take a quick look at this guy's airway and think about how I will manage it if/when he crumps. (ETT, King) I want to have a plan and have my partner be on the same page with me.
B-Unlabored respirations at 24 with a 95% sat. Not to bad. What are the auscultated lung sounds. "no audible sounds with breathing". Is this 6 feet away or with a stethoscope? Percuss his chest. Depending on what my ears tell me, I might change up my treatment.
C-Radial pulses present. Bradycardic. Skin cool, dusky and sweaty. BP in both arms. Pedal pulses. Edema assessment. A good auscultation of the heart and abdomen. How has this guys intake and output been. Has his urine looked "funny" or an unusual color. Any change in stool (melena, hematochezia, BRBPR, clay). Any nausea, vommiting or pain of any kind (I'll figure out if the pain is relevant or not). Any unusual abdominal tenderness or findings on palpation? Mucous membranes-color and moisture?

Depending on what my detailed assessment comes up with I'll have a few things in the arsenal to have ready. (TCP, Inotropes, nitrates, diuretics, IV fluids, NIPPV etc.) Lets start heading to the ER.

Dif diag-
1. Some sort of cardiovascular shock/MI/aortic aneurysm
2. Rhabdomyolysis (maybe with a little ARF)
3. Sepsis
4. Head bleed
5. Combo of more than 1 of these

Thanks again for investing your time and presenting us with case studies.



Isn't that the truth! We need a 12 lead. Very good point about the thrombus going through the pulmonary circulation and into the coronary arteries. I guess I'm still used to will's zebras.....
  • 0
Matthew George - NREMT-P, FP-C, CCP, Instructor

#15 Ectopy

Ectopy

    Advanced Member

  • Members
  • PipPipPip
  • 129 posts

Posted 02 March 2010 - 06:51 AM

Also Wes, where are you going with this guys input/output and urine in regards to this case? Not being snippy, just something I hadn't thought of and thus want to learn about.
  • 0
Matthew George - NREMT-P, FP-C, CCP, Instructor

#16 TexRNmedic

TexRNmedic

    Advanced Member

  • Members
  • PipPipPip
  • 257 posts

Posted 02 March 2010 - 07:16 AM

I'll take a stab, go easy I'm new.

First a little background on myself so no one is too harsh, I've been in critical care for about a year and am planning on sitting for the board exams within the next few weeks.

Initial Treatment

Since we're a CC unit I'm assuming we have two ALS providers. One provider needs to be getting 2 large PIV's and ensuring the patient is on high flow. The other provider needs to be setting up the monitor and pacer (and if you're really nice some Versed).

I would give 2mg of Versed and initiate pacing until capture. Then of course reassess.

After I get capture, treat any ectopy with lido and continue to monitor as I'm loading the patient into my unit. Although the ongoing TCP will effect your results, getting an initial 12 lead will be tremendously useful due to some of the differentials listed below.

Enroute

With the irregular pulse, recent history of pretty hefty surgery, here is the list of SOME of the potential differentials (ordered from least to most likely)

Surgically induced A-Fib (increased adrenergic state post op, will try to find data), <---- perhaps too much of a zebra - not necessarily consistent with other symptoms.
Compensated Septic Shock
Clot thrown landing in coronary artery leading to this presentation (12 lead/labs will reveal all haha) I'm expecting

A little bit more about the clot option and why I think this might be the best option with the information given so far:

A clot thrown after recent surgery can of course go anywhere. If it lands in the RCA we're gong to see a lot of these symptom. First, if the clot is indeed in the RCA we're going to have an impaired right ventricle with decreased output, thus the relative systemic hypertension. I wouldnt be surprised to find some pedal edema on this patient. Second, the RCA supplies the sinus node so if the clot was in the RCA I'd suspect the bradycardia as we've seen with this patient.

In effect, this patient is right on the verge of going into some pretty hefty cardiogenic shock when (not if) he goes into complete failure without treatment (if I'm barking up the right tree)

In that case I'd be priming some dopamine due to the RV preload issues.


Matt- You are kind of half right regarding RV infarct. You will see RV involvement in approx 30% of RCA MIs (can find this in the Critical Care Nursing Cert by Ahrens Et al). As the RCA supplies the SA node in the vast majority of the population, you will also see bradycardia as the rate is set by other cells (usually sub-junctional). When the RV fails it causes a back up into the venous circulation (resulting in peripheral edema). The poor RV output causes a low LV preload, low LV end diastolic volume and LV end diastolic pressure. In turn poor cardiac output and hypotension (similar to that seen in dehydration or other low preload states). These folks need preload, therefore titrated IVF. Actually shooting for a very high central venous pressure. This will help more than an inotrope. Dopamine has the potential to increase myocardial O2 demand and worsen the MI and should be used cautiously. Hope this helps. If you already knew it, then it was a good refresher for me.
-Regards
  • 0
Wes Seale
Houston , TX

#17 TexRNmedic

TexRNmedic

    Advanced Member

  • Members
  • PipPipPip
  • 257 posts

Posted 02 March 2010 - 07:39 AM

Also Wes, where are you going with this guys input/output and urine in regards to this case? Not being snippy, just something I hadn't thought of and thus want to learn about.


Matt,intake and output is the ICU nurse in me. I'm working on my first two items on my DD list. I'm trying to figure out what, if any, renal involvement is going on. Low cardiac output states will cause poor urine output. Renin-angiotensin cascade kind of stuff. If low urine output, is he dehydrated on top of everything. Then I'm working on a rhabdo/acute renal failure angle. This guy has been pretty beat up (lots of muscle injury, plus he has been immobile for some length of time). The rhabdo process creates lots of trash (protein mostly) that the kidneys have a hard time handling. Lots of anaerobic metabolism, leading to metabolic acidosis. If you had the labs available you would expect to see elevated LFTs (hence the reason I'd like to see them on this guy), elevated lactate, an elevated anion gap and a low SVO2. This train of thought is helping me decide on how I am going to treat. Does he need IV fluids or diuretics? Do I need to lower his BP/SVR or is the high BP compensatory? If I am going to lower the BP, how (beta blockade vs nitrates). Bicarb? I'm look at his bowel habits as well as looking at his skin/mucous membranes (petechiae) looking for signs of bleeding/DIC. Really low on my list of probabilities considering his cast came of 5 days ago( meaning his injury was a least a couple of weeks ago). Make sense?
  • 0
Wes Seale
Houston , TX

#18 TexRNmedic

TexRNmedic

    Advanced Member

  • Members
  • PipPipPip
  • 257 posts

Posted 02 March 2010 - 08:16 AM

Matt,intake and output is the ICU nurse in me. I'm working on my first two items on my DD list. I'm trying to figure out what, if any, renal involvement is going on. Low cardiac output states will cause poor urine output. Renin-angiotensin cascade kind of stuff. If low urine output, is he dehydrated on top of everything. Then I'm working on a rhabdo/acute renal failure angle. This guy has been pretty beat up (lots of muscle injury, plus he has been immobile for some length of time). The rhabdo process creates lots of trash (protein mostly) that the kidneys have a hard time handling. Lots of anaerobic metabolism, leading to metabolic acidosis. If you had the labs available you would expect to see elevated LFTs (hence the reason I'd like to see them on this guy), elevated lactate, an elevated anion gap and a low SVO2. This train of thought is helping me decide on how I am going to treat. Does he need IV fluids or diuretics? Do I need to lower his BP/SVR or is the high BP compensatory? If I am going to lower the BP, how (beta blockade vs nitrates). Bicarb? I'm look at his bowel habits as well as looking at his skin/mucous membranes (petechiae) looking for signs of bleeding/DIC. Really low on my list of probabilities considering his cast came of 5 days ago( meaning his injury was a least a couple of weeks ago). Make sense?


-Matt. Two more things about what I just posted, then I am going to bed. You may or may not see a low SVO2 in rhabdo. If you were to pull a venous blood sample from the right atrium on a normal person at rest and ran an ABG off of it you would expect to see roughly 25% of the oxygen had been consumed on its trip through the body. If cardiac output is low or O2 demand is high (high metabolic states like sepsis) you would expect more oxygen to be consumed of what was being delivered and thus a lower SVO2. This dude probably has both and therefore a low SVO2. Second, rhabdo urine has a very unique color and clarity. I'm not really sure how to describe it other than reddish, purple kind of color. Unless this guy just had a big meal of beets, if he had red urine I would quickly be clued in that something wasn't right. Good night Flightweb. Looking forward to everyones $0.02 and the rest of the story.
  • 0
Wes Seale
Houston , TX

#19 JLP

JLP

    Advanced Member

  • Members
  • PipPipPip
  • 493 posts

Posted 02 March 2010 - 03:54 PM

-Matt. Two more things about what I just posted, then I am going to bed. You may or may not see a low SVO2 in rhabdo. If you were to pull a venous blood sample from the right atrium on a normal person at rest and ran an ABG off of it you would expect to see roughly 25% of the oxygen had been consumed on its trip through the body. If cardiac output is low or O2 demand is high (high metabolic states like sepsis) you would expect more oxygen to be consumed of what was being delivered and thus a lower SVO2. This dude probably has both and therefore a low SVO2. Second, rhabdo urine has a very unique color and clarity. I'm not really sure how to describe it other than reddish, purple kind of color. Unless this guy just had a big meal of beets, if he had red urine I would quickly be clued in that something wasn't right. Good night Flightweb. Looking forward to everyones $0.02 and the rest of the story.


This patient back surgery for a snowmobile accident - spinal cord injuries are the norm in such accidents and may be occult or may result after a latent period from edema after the fact. The combination of profuse sweating, peripheral shutdown (poor sat reading despite high BP suggests massive vasoconstriction) and hypertension suggests possible sympathetic overload secondary to autonomic dysreflexia, with the bradycardia perhaps due to an intact vagal trying to compensate for the hypertension by reducing heart rate and AV nodal conduction. Combine that with preceding weakness and I am wondering if it is late-onset spinal cord injury due to a migrated clot or edema. An alternative is a renal thrombus, with the kidney responding to loss of blood flow with a massive release of angiotension and again, a sympathetic response, with the parasympathetic system trying to moderate the response with bradycardia.

I'd drop an IO in, and start with a small bolus. If HR and BP move towards normal values even a little, I'd suspect an exagerrated shock response and give more fluid. Check for urine output: there should be some renal reponse to fluid unles the kidneys are entirely shut down. As Tex RN said, I'd be looking for possible rhabdo as well.

What meds is the patient on? any alpha-adrenergic agents, anti-depressants? is it possible there was a goof-up, and the patient was given Demerol or Talwin for post-op pain while already taking an SSRI (serotonin syndrome - pretty far out but who know?)?
  • 0

#20 SerendepitySaki

SerendepitySaki

    Advanced Member

  • Members
  • PipPipPip
  • 1176 posts

Posted 02 March 2010 - 05:24 PM

We're going to put our heads together tonight, edit a smooth, consolidated reply to the posts to date and get it out ASAP... I will check again @1700ish... anything posted by then will be included in our consolidated reply ...

remember basic rules of engagement.... no zebras... at least WE'RE not emphasizing any... you can have just about anything you want, as long as you ask for it.... please try and ref your posts where applicable...(if someone questions you, it's applicable, if you're "new", it's applicable...no, I don't think we expect you to ref ACLS guidelines, unless it's to point a questioning colleague in the correct direction...)

we will be posting more scene size up and basic assessment info in the next go round....

"new" guys come out and play! most of the stuff we plan to discuss here can be found in NAEMT, AHA, ACE-SAT, etc....
  • 0
LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup