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#52.... Much More Than Meets The Eye...


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#1 SerendepitySaki

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Posted 20 April 2010 - 01:18 AM

Well Tex (Wes) has nearly twisted my arm off and has talked me in to putting on a case study with him. Definitely an honor. He and I will be dual pilots on this flight. This will hopefully be a learning exercise for all involved including myself.

Thank him for this AWESOME opener, and for those who thought the last one was too easy/cookie cutter... be forewarned... Wes saw my bastard and raised me a sonuvabitch....

This study should have a little something for everybody-novice through seasoned. This patient has a lot going on and more than one problem, so keep digging.

Same rules as case 51.
#1. No question is a dumb question. We are all here to learn and improve our clinical skills.
#2. You can have anything that would be on a VERY, VERY well stocked critical care ambulance.
#3. Please provide references for your answers or be ready to explain your standpoint.

Here we go!
You are working a side job on a 911/CCT truck. At 2200 on a very stormy April night you are dispatched to law enforcement on scene in the rough side of town to a "man down." You arrive on scene to find a group of very inebriated folks in a crawl space under a highway overpass around your patient. You find a 50ish looking year old poorly nourished female. The crawl space has a strong odor of booze, stale urine and emesis.

Quick look finds:
Obtunded. Incoherent & mumbling on stimulation. Pupils PERRL and sluggish.
Respirations deep at 28 breaths/min.
Radial pulse bounding at 68/min
BP 148/104
SPO2 83% room air.
Emesis noticed on patients face and clothes. Audible upper airway gurgling.
Skin is flushed and dry. Uremic frost and periorbital xanthoma noted.
Mildly distended and firm abdomen.
Noticeable spasms/posturing of bilateral forearm and hands. Unusual facial twitching.

Bystanders state that the patient goes to the emergency department at the county hospital every week or two "for a tune up." They call her "Crazy Mary" and say that she can be a little mean, but is happy as long as she has her cigarettes and booze. Before you start vomiting from the stench you take a quick look around the area and see among other things a variety over the counter medication blister packs, beer cans and plastic bottles with the labels removed. You find 6 faded and unreadable patient ID bands on the patient and an unlabeled pill bottle with several different unidentified pills.

Have fun!
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#2 medic675

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Posted 20 April 2010 - 03:08 AM

Lets dive in head first, but in the great words of every medic student.... BSI and SCENE SAFTEY. Any one have a Level a suit?

Anyways, Sats are low, is she maintaining her airway? If not, assist with a bag. Try suctioning, does this improve anything? WHat are her lung sounds? Any witness to explain more. Is the distended abd an unchecked pregnancy...hence the tune up?

So- IV, O2, EKG...I'm thinking 25mg Benadryl for EPS. Trauma...unk events leading up...let go ahead and board and collar...CYA.

this is just a start. go easy. cant wait to hear more.
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Brian Nolan
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#3 TexRNmedic

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Posted 20 April 2010 - 03:23 AM

Well Tex (Wes) has nearly twisted my arm off and has talked me in to putting on a case study with him. Definitely an honor. He and I will be dual pilots on this flight. This will hopefully be a learning exercise for all involved including myself.

Thank him for this AWESOME opener, and for those who thought the last one was too easy/cookie cutter... be forewarned... Wes saw my bastard and raised me a sonuvabitch....


I'm not sure who was doing more arm twisting, you or me. Thanks for getting it posted. I was having a little trouble. I guess I didn't have the authoring privileges for this folder. This study should have enough twists and turns to make just about everyone happy. We have enough prep time in it at least. Should be fun and educational.
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Wes Seale
Houston , TX

#4 Flightgypsy

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Posted 20 April 2010 - 04:25 AM

She sounds like a medical disaster and it will be interesting to see what she ends up having.

There are so many possible diagnoses here and she probably has a complex medical history. Is she jaundiced at all? Couple of thoughts I have to start with are that she is malnourished and an alcoholic (assuming) which makes me think liver problems. Her abdomen is firm and distended possibly ascites from liver failure/cirrhosis and she could be obtunded from hyperammonemia. This could account for the deep, rapid respirations and create a respiratory alkalosis. The uremic frost leads me to think of renal failure which can cause hypocalcemia. Chronic hypocalcemia in a renal patient can be asymptomatic but alkalosis can exacerbate it and could lead to the twitching and muscle spasms that she is having. With kidney and liver problems I would expect all her electrolytes to be out of whack. The periorbital xanthoma makes me suspicious of high triglyceride levels which makes me think of AMI, stroke or untreated diabetes (also consider DKA with Kussmaul's respirations and being obtunded). It would be nice to have an idea of what the pills are in the bottle. So with these thoughts in mind here is my treatment plan.

1) Suction and intubate to protect her airway. I would not rule out RSI but would consider nasal intubation without drugs as a first line.
2) IVs if not already

Load and go and then (after getting as much information as possible from bystanders):

3) Full secondary assessment findings? ( lung sounds, pupils etc?)
4) I-stat- ABG and chem panel with glucose included (and hopefully magnesium as well)
5) 12 lead EKG

Can we get any further information from the bystanders. If there is no history of trauma or a fall I wouldn't necessarily c-spine her but don't think you would be faulted for doing so.

Flying totally blind here but just a place to start.
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#5 Flightgypsy

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Posted 20 April 2010 - 10:00 AM

I forgot to ask if she has a positive Chvostek or Trousseau's sign?
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#6 SerendepitySaki

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Posted 20 April 2010 - 11:43 AM

yes and yes. Thank you for asking. Way to hit some high points right outta the gate...!!!! note use of word "some"...B) hopefully, more will suggest itself on secondary/tertiary.....

all good stuff from everyone.... y'all are HUNGRY! this has only been up a few hours!

Medic Brian...GREAT Start...good basics and ABCs!...if you would not mind expanding on your benadryl and EPS thoughts....

Tex and I will give folks a little longer to reply and then provide a summary of secondary assessment data, completed interventions, incomplete interventions and pt responses to the same.

as "always", plan on a long transport time...:rolleyes:


I forgot to ask if she has a positive Chvostek or Trousseau's sign?


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

#7 STPEMTP

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Posted 20 April 2010 - 12:54 PM

Wow...... this is looking like quite the train wreck........

Initial airway appears to have been covered already in previous post (suction and bagging). If no improvement in oxygenation with BLS, intubate and attempt deep suctioning. Hopefully able to intubate without RSI (but highly unlikely we will get that lucky) :P

Spasming of arms, is this hand flapping? (asterixes?)

Let's get a couple of IV's, big bores would be nice. TKO at this time
EKG/ 12-Lead
Blood glucose

Further info requested:
any edema?
any cyanosis? (hands/feet)
Ascities?
Any goiter? (hyperthyroid cause for protruding eyes)
Any jaundice?
temp? (r/o hypothermia cause)
Istat 8+
Any dialysis shunt noted?
Was this a sudden onset of altered mental status, or over a couple of days?
When was the last time she was in for a "tune up"?
Bring the pills, maybe pharmacy can identify them at destination. If adequate people available, look at drug reference pictures (mosby nursing drug handbook) and see if you can identify any of the pills.
Lots of possible causes here......

Current differential diagnose:
1. Hepatic encephalopathy
2. Uremic encephalopathy
3. Intercranial event (bleed, edema, mass)

How far to county hospital that she goes to for weekly tune up?


Great case!!!
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#8 onearmwonder

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Posted 20 April 2010 - 04:27 PM

Wooo Hooo lets get it on! This will be my first official participation.

You sure she's not from OKC, OK? Ha ha...

Let's start off with the basics:

GCS: ?, pupils are PERRL, but at what? What is her normal mental status per bystanders?

Airway: Suction any blood, vomit, teeth, swallowing?, is it kinked?, etc... Does this help with O2 SAT/LOC?

Breathing: We have 28/min, shallow?, deep?, = rise and fall of chest?,
injuries/scars to chest?, lung sounds?, O2 sat is 83%, apply NRB mask,
or allow her to breath via BVM w/ good seal that has a "duckbill valve"
w/ 100% O2. No PPV, just let her breath normally so to not
give gastric destention. Oh and jaw thrust. Does this help?

Circulation: We have radial pulses bounding at 68bpm. Why not higher with O2 SATS @ 83%? Beta Blockers onboard?
Skin flushed and dry. Possible anti cholinergic OD? Possible SSRI OD due to the tremmors and flushed dry skin?
Possible beta blockers blunt increased HR? Mucosa? Pedal pulses?

Disability: Any trauma to head, neck or back? CSM? Blood glucose? Bleeding anywhere? Maybe give .o4mg/kg Narcan
IM/IV prior to intubation?

So we need at least 1 good IV 18g/16g. ECG monitor. 12 lead. C-collar and LSB. Another set of vitals w/ looking for Chevosteks/Trousseaus signs(carpal spams) during BP due to facial twitching. Would be nice to have I-stat for electrolytes especially mag due to possible chronic ETOH. And when you have low mag you can have low calcium. Distended ABD can be like said before liver failure, ascites, causing hepatic encephelopothy(sp) due to high ammonia, uremic encephalopothy same.

Does helping breathing and basic airway help with SATS and LOC? Is she actually seizing. If so lets try to stop them by giving 2mg Ativan IV or 2-4mg IM. Don't want to RSI a seizing pt. if we don't have to. If not we need to RSI using Succs @ 1.5mg/kg, Etomidate @ .3mg/kg. After hopefully successful intubation and another set of appropriate vitals medicate with 5mg of versed IV and 1-2mcg/kg Fentanyl IV as needed depending on ETA to hospital. After intubation do SATS go above 95%? Oh and insert 18fr OG tube please.

Yeah so like stated in other posts, was this acute or gradual? Bring and look up pills using epocrates or give to hospital pharmacy.

Diff Dx: CVA-Ischemic due to thrombus,emboli, or hemmoragic
ETOH OD/Anticholinergic OD/SSRI OD
Hepatic/Uremic Encephalopothy
Sepsis
Hypo Mag/Hypo Calc

OD thoughts and electrolyte abnormalities are derived from Goldfrank's Manual of Toxicologic Emergencies.

Who's next?

Good start peoples!
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#9 TexRNmedic

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Posted 20 April 2010 - 04:48 PM

If there is no history of trauma or a fall I wouldn't necessarily c-spine her but don't think you would be faulted for doing so.


Looks like Sean beat me to a response this morning. Y'all are doing a great job picking up on the clues. We are going to wait a bit longer so that any stragglers can chime in before the next round of info. There are a few clues still there y'all haven't mentioned yet. I'm pretty sure I remember a thread elsewhere on FW discussing the need to C-spine immobilize and backboard patients. While we are waiting anyone want to talk about the risk/ benefits of BB this gal? Remember very thin and poorly nourished (and you know you are going to have a tough extrication and long transport ;) ).
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Wes Seale
Houston , TX

#10 TexRNmedic

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Posted 20 April 2010 - 05:20 PM

Wow...... this is looking like quite the train wreck........

Yes she does! Thats because she is one.

Any goiter? (hyperthyroid cause for protruding eyes)


No exophthalmos. But she still is pretty darn ugly!

For those that are new to FW and are hiding in the shadows reading, here are some clues to some of the possible assessment findings that others have brought up: (and yes I'm using a little Wikipedia- it does have some decent basic info)

Chvostek and Trousseau sign

Here is a video showing a + Chvostek sign and one for Trousseau's.
Uremic frost

Periorbital xanthoma


Asterixis and an asterixis video.

Pretty subtle clues, but can really help narrow down a dx (or in this case 1 of multiple dx).
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Wes Seale
Houston , TX

#11 RoadieRN

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Posted 20 April 2010 - 06:45 PM

Sounds like what we get in the ED frequently that we fix and send to the MICU so they can do it again. Gotta love job security.

Like what has been stated so far... A thought that comes to mind with her VS is I'd be surprised if she ingested a Beta blocker. Reason being, she is hypertensive. Perhaps she has a head bleed and slowly making her way towards to trying to herniate. Just a thought. Did she maybe ingest TCA or SSRIs? Does my iPhone or iTouch have the app for looking up pills according to the numbers on the pill? If so, look up and see what we have in our mystery pill bottles? If I have a long transport time maybe we can look it up.

Definitely would want to know a FSBS. Rules out a lot of the potential differential dx. If we had an I-Stat, gravy. Otherwise, I'd tried a touch of Narcan 0.4mg and see if there is any response. Sounds like her resp effort is ok for now. 15L NRB. What response do I get? If I have an ETCO2, place one on her to help look at her ETCO2 trends. If she is maintaining her airway at this time, then leave her be for now. While I'm OP suctioning, assess what else I see is coming her mouth and check her gag. What does her EKG look like? Any flat or peaked T-waves? Long Q-Ts?

As far as C-spine and BB with this patient, definitely seems like the right modality. I'd want to put towels under her neck and back to help provide better C-spine alignment. Using a KED board with pad and c-collar would provide enough support to get her on the BB and not cause more harm than good.

Just the start of things to come...
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Nick Crusius RN, BSN

Keep the rubber(or skid, if it applies) side down!

#12 jjones1418

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Posted 20 April 2010 - 07:20 PM

I agree mostly with what's been said so far. I'm not sure I'm leaning toward EPS at the moment. We would definitely want to get that airway under control.

1) C-Spine Immobilization and Suction, NPA, NRB. Could BVM if SpO2 doesn't improve. Probably going to puke on you again.
2) ECG
3) IV Access
4) Blood Glucose

Seems like the same starter points that everyone else is after. Gonna hold off on narcan at the moment. RR of 28 and deep. Pupils are equal and reactive. I'd also like to see if I recognize any of the medications. Maybe we're lucky and it's brand name stuff with the name on the pills. (haha)

Probably just going to intubate her as well. Doesn't seem as if she's protecting her airway. This is assuming her blood glucose is WNL or fixed by us if it's not. (Thaimine / D50)
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Jason Jones, EMT-P

#13 medic675

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Posted 20 April 2010 - 07:31 PM

So for the EPS and Benedaryl, I am think ing she may be mixed some drugs the wrong way, Three times I got burned cause someone told me my patient was seizing and it turned out to dystonic reactions to to much meds. easy fix. Bystander stated "Crazy Mary" gets tuned up...Does she get haldol at the hospital and she got to much? Is the shaking over her arms caused by low CO2 with her deep resps at 28? Now im going to go read the wiki links to understand the signs you alll are talking about. Saki- whats a good book or site to learn labs?
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Brian Nolan
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#14 Flightgypsy

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Posted 20 April 2010 - 09:46 PM

Just want to add sepsis in there as a possible diagnosis with the bounding pulses and flushed, dry skin. I would be a little cautious about giving fluids at this stage though with possible kidney failure and her BP is ok as well. The 2 large bore IV's at TKO would be the way to go though with so many unknown's going on.

I don't think I would BB her unless I had a really strong suspicion of trauma. She would be at really high risk of developing pressure sores very quickly and they could be fatal for her in her extremely malnourished state. If you did BB her you would want to pad it well. I like to put a c-collar on an intubated pt anyway for tube protection so you could compromise. And she is pretty obtunded and not moving much anyway. If she starts waking up with treatment then I would re-evaluate. (out of control agitation=sedation).

Definitely put down an OGT! (Forgot to mention that one).

Good thoughts all.
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#15 onearmwonder

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Posted 20 April 2010 - 11:11 PM

So she has a problem with her thyroid, kidneys, and liver. All the clues are there, but it's hard for me to expalin and understand how they relate to each other. Low mag/calcium can be due to liver due to chronic ETOH abuse. Also the Astrixis could help confirm the arm flapping due to hepatic failure with a build up of ammonia also causing the altered LOC. Hyperphosphatemia is associated with low calicum possibly causing the tetany of the face and arms due to renal failure. The proptosis could be due to the possible thyroid dysfunction. My best guess...

Matt
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#16 SerendepitySaki

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Posted 20 April 2010 - 11:45 PM

Matt, add in SEVERAL more biggees that are there, ( but not yet obvious, based on what we've given so far)... just a little something to look forward to... B) PS: just to give you something to think about... rvw your initial airway mgt paragraph, the pt presentation, and other folks posts... you "might" want to change something.... classic teaching point...and i'm not talking about "style" points....

Brian, you bring up some good points... check your Private Messages.;) and there's a zillion refs out there....
for starters, I have this one handy, it's rock solid, a little "nursey" , but in a good way....
http://www.amazon.co...71806494&sr=8-1
i have the 2003 edition...can't vouch for the newer ones, but you could probably pick up a used one cheap...
Matt (Durango) mentioned this one earlier:
Goldfrank's Manual of Toxicologic Emergencies
http://www.amazon.co...71806682&sr=1-1


Gypsy, GREAT point on the backboard padding! one of my pet peeves....

Jason, Nick... definitely some good stuff in your posts... GREAT point on the Blood Glucose level! Excellent Differential Dx! Nick, really excellent thoughts on the drugs....good big picture, down the road type thinking!

like Tex said...we'll give some other folks a chance to play and get round two up by the end of the week with some of the stuff you've asked for and see where you want to go from there.... answers to questions to date, FSBG and EKG will be in round two.
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#17 medic675

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Posted 21 April 2010 - 01:16 AM

Any chance we can get labs....specifically CPK and WBC?
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Brian Nolan
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#18 medic675

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Posted 21 April 2010 - 01:23 AM

Can we get her temp, also?
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Brian Nolan
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#19 SerendepitySaki

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Posted 21 April 2010 - 01:38 AM

detailed labs to follow after consolidated update #2. prob "big" update #3 or 4
temp unremarkable for environmental conditions, etc.... (GOOD diff dx phys assmnt question!)

Can we get her temp, also?


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

#20 Speed

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Posted 21 April 2010 - 02:10 AM

I would at least make an attempt to get some hx from those around. I'd board her just from the risk that there may have been an assault, too many risk factors on this scene w/ this presentation. I'd think about flying her unless I could absolutely r/o CVA in the next 10 min. And what everybody else said. First thing that comes to mind is metabolic, then neuro, everyone under that bridge is septic, renal, tox.... Call the hospital on the wrist band. Strip her all the way down, ID, bracelets. Look the skin over real good. Get a good whiff....ha, ha
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Mike Williams CCEMT-P/FP-C