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


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#21 medic675

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Posted 21 April 2010 - 02:37 AM

Can we auscultate the heart and percuss the abdomen? What can we hear or not hear?
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Brian Nolan
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#22 SerendepitySaki

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Posted 21 April 2010 - 02:43 AM

ding ding! the man wins a prize! show the audience what he's won Vanna!
congratulations sir! you've won this LOVELY previously unhinted at physical assessment clue, to be presented in the very near future, solely on the basis of how you worded your post! well done sir!

and good big picture logistics lesson with the flying comment speed! thanks! that's really something we need to stress with every case.....

too bad all the birds are down, diverted, yadda yadda...she's yours and yours alone... after all, you gotta have time to dig up the remaining three or four dxs that no one has touched on yet....

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

#23 SerendepitySaki

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Posted 21 April 2010 - 03:00 AM

caCHING! rack up another clue leading to a specific as unyet undiscussed problem with this lady....GOOD Physical assessment skills! eyes and ears baby! (and nose Speed!)

I'm going to mention this now, even tho the timing is BS, compared to how it would go down in the field... i don't want this clue lost in the detailed summary post coming up...

abdomen as expected w/ chronic etOHer... specifics to follow...along w/ lungs, etc as promised.

as for auscultation...

when you took her radial pulse, it was hard to be sure, kinda diminished, but you briefly switched to brachial and thought you felt a "double tap"...
when you auscultate apically, even though you are hurrying and it is loud and distracting on scene, you can't be sure, but you think you occasionally hear an "extra" double beat...



Can we auscultate the heart and percuss the abdomen? What can we hear or not hear?


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

#24 TexRNmedic

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Posted 21 April 2010 - 11:54 AM

While I read through everything you guys have asked for in round #2 and put it all together, lets take a look at what you have already picked up on. Who needs labs at this point when you have such great assessment skills? Airway compromise, renal problems, hyperlipidemia, hypocalcemia, cardiovascular dz and maybe a little hepatic issue or two. Start thinking how this will impact your treatment plan. Airway management, IVFs, drugs. Think about the multi-systemic effects of hypocalcemia. See you guys soon with round 2 update.
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Wes Seale
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#25 jjones1418

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Posted 21 April 2010 - 06:15 PM

Being a well-stocked Critical Care Unit (lol) I'm going use something like Fentanyl, Propofol and Roc to intubate if I need to. Keep her down with Ativan on top of the Propofol if it doesn't do it alone. In my experiences, propofol isn't the best agent for transport sedation.

Those seem to be the most gentle induction / paralytic agents, especially with this electrolyte wreck that she is. I'm staying away from Etomidate and Succinylcholine.
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Jason Jones, EMT-P

#26 SerendepitySaki

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Posted 21 April 2010 - 06:30 PM

excellently well done sir! would you like to do "our" job for us [Tex & I] and explain your thinking on your last sentence.... not sure everyone is tracking...

Being a well-stocked Critical Care Unit (lol) I'm going use something like Fentanyl, Propofol and Roc to intubate if I need to. Keep her down with Ativan on top of the Propofol if it doesn't do it alone. In my experiences, propofol isn't the best agent for transport sedation.

Those seem to be the most gentle induction / paralytic agents, especially with this electrolyte wreck that she is. I'm staying away from Etomidate and Succinylcholine.


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

#27 onearmwonder

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Posted 21 April 2010 - 06:51 PM

So about the double tapping pulses and heart sounds, does a Bisferiens pulse ring a bell? Bisferiens pulse is a difficult pattern to recognize and is best palpated over the carotid artery. It is characterized by two systolic peaks and is seen in aortic regurgitation with or without aortic stenosis, and in some patients with hypertrophic cardiomyopathy. Am I on the right track? Reference from http://physicalexami...g/?q=node/33...

Matt
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#28 SerendepitySaki

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Posted 21 April 2010 - 07:01 PM

yep. one BAZILLION bonus points~! and thanks for providing the ref!

everyone please hold that thought and work up your diff dx for bisferiens pulse off line for now.
just "back pocket" the info....
i gave the clue slightly out of sequence so that it didn't get lost in the barrage of info Tex and I are about to put out....

and yes, there are at LEAST three more things waiting to bite y'all in the ass.... (no, you haven't necessarily received the info yet)

GREAT job by all to date....!!!!! get your friends and students to play!

So about the double tapping pulses and heart sounds, does a Bisferiens pulse ring a bell? Bisferiens pulse is a difficult pattern to recognize and is best palpated over the carotid artery. It is characterized by two systolic peaks and is seen in aortic regurgitation with or without aortic stenosis, and in some patients with hypertrophic cardiomyopathy. Am I on the right track? Reference from http://physicalexami...g/?q=node/33...

Matt


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

#29 SerendepitySaki

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Posted 21 April 2010 - 07:05 PM

PS: make sure y'all KNOW what may ACTUALLY be causing the double beat.....
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#30 RoadieRN

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Posted 21 April 2010 - 07:37 PM

Does the patient have some form of a cardiac related itis? Or does the patient have some kind of an aneursym causing the funkiness?
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Nick Crusius RN, BSN

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#31 TexRNmedic

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Posted 21 April 2010 - 09:31 PM

Just have to wait and see Roadie! I should have next update posted later tonight. Everone is doing a great job figuring this one out. The fun part is still to come-treatment of all this mess!
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Wes Seale
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#32 TexRNmedic

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Posted 21 April 2010 - 10:04 PM

Round #2
Shortly after arrival on scene, you hear the comm-spec page out the entire service with a safety notice. “The National Weather Service has issued a flood warning that encompasses our service area. Expect heavy rain and widespread street flooding.” The two LEOS hear this and state that the scene looks safe and that they are leaving before getting stuck under the interstate overpass.

You hesitantly expose the patient for further assessment and treatment. Once your nose stops burning and eyes stop watering from the general “aroma,” you see no obvious jaundice, but it is hard to tell under the dirt. No significant surgical scars on anterior or posterior thorax.

Neuro: Occasional incoherent mumbling on stimulation. Will open eyes and withdraw to deep painful stimulus x4 extremities (should be enough to figure out a GCS). Pupils PERRL @ 3mm/ sluggish. Noticeable muscle twitching aggravated by stimulation of the 7th cranial nerve. Mild bilateral asterixis. General muscular weakness.

Pulm: RR 28 and deep. On inspection of oropharynx noticeable emesis and poor dentition (rotting, broken and missing teeth). Mucous membranes pale. Significant tracheobronchial gurgling that doesn't completely clear with oropharyngeal suctioning and inspiratory/expiratory rhonchi increased in right middle and lower lobe. Thanks to RoadieRN your ETCO2=48. Pleth O2 increases to 94% with BLS airway maneuvers, suction and NRB. Virtually no gag with suctioning.

Card: Cap refill=3 seconds. Bilateral radial pulses easily palpated and regular. DP pulses slightly diminished. Noticeable double bump in central pulses. + hepatojugular reflex. Scabbed up AV fistula to left forearm. + Thrill and bruit. Mild BLE edema. Harsh systolic murmur noted. Hard to tell, but maybe a double apical beat.

GI/GU: Mild distention of abdomen. Palpable solid organ in RUQ. +transabdominal fluid wave on palpation. BS hypoactive. No bladder distention.

Musculoskeletal: No obvious trauma. Long bones, C&T spine and pelvis stable and in normal anatomical position. Generalized weakness.

Repeat V/S HR 66, RR 28, 134/92, SaO2 94%, oral temp WNL.

TX: BLS airway maneuvers, suctioning and NRB at 15LPM. Your partner begs you to wait until you are in the more controlled environment in the back of the rig before attempting ET intubation or NGT placement. C-collar and BB, well padded under pressure points to prevent breakdown. 18 gauge IV SL established to R AC x1. Capillary and venous blood glucose samples read high (>500). Unfortunately your ISTAT is back in the rig. We will have to wait until we are loaded before running labs. You get a quick ECG.

Posted Image

Before dragging this gal out of the crawl space and back to the ambulance you try one more time to get some history from the bystanders. You specifically ask them what property is hers and from what containers has she been drinking. They say she doesn’t have much other than the bedding and they hand you one of the bottles she has been working on since this morning. They say the last time she was awake was during the afternoon rush hour. You look in the bottle and find a relatively odorless green liquid.

Now what? Intubation drugs? IV fluids? Other meds? Once your are loaded we can drop an ETT, NGT and get some labs.

Care to list some differential diagnoses or any clues you see hidden above?
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Wes Seale
Houston , TX

#33 RoadieRN

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Posted 21 April 2010 - 11:42 PM

Two words for you... Pandora's box.
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Nick Crusius RN, BSN

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

#34 SerendepitySaki

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Posted 21 April 2010 - 11:46 PM

thousand mile journey begin with first step grasshopper. break it down into manageable chunks... you started off GREAT... I particularly liked your first post on the thread... keep that good stuff coming...!!!!!!

Two words for you... Pandora's box.


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

#35 RoadieRN

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Posted 22 April 2010 - 12:30 AM

Prior to seeing the magic green juice, ethylene glycol ingestion was near the top of my differential dx. After reading further into the scenario, that is still my number one dx at this time. I read up on it on emedicine (see links below) and it certainly fits the picture. Pt has deep, Kussmall like respirations. This likely is a sign of significant acidosis. Her BS is also greater than 500 further adding to the Kussmall/EG ingestion picture. As far as treatment goes, let's start from the top. The pt has minimal gag. Get her loaded into the back to the back of the truck and maybe move out of the way of Noah's Ark to a better location to start RSI with this patient. 15L NRB while I'm prepping my drugs. I'd give the pt Zofran 4 mg IV to help prevent further emesis and also make the likelihood of further aspiration less. If we are running dual ALS providers, have my partner start a 2nd line to ward off evil spirits. As far as my RSI drugs go, I'd avoid Succ d/t the fact of the hyper K that can result from administration 48-72 hours later. I'd go with Rocc 1mg/kg. As far as the use of Etomidate, I don't think it is an absolute contraindication in patient such as this. My dose would be 0.3mg/kg. If I have a Glidescope, then I get that set up with my DL ready to go, just in case. I have a feeling we are gonna find all sorts of interesting things in her oropharynx when we go for the intubation. Using the Glide will give me and my partner a chance to both see the same thing in case this is a difficult intubation. While all this is going on, I'm gonna open up her fluids and give a 250-500ml fluid bolus to help enhance teh renal clearance and mobilize any accumalation of calcium oxalates. Now granted she receives HD already, so enhancing renal clearance is kinda a moot point. Nonetheless, the volume likely won't hurt her. If intubation is successful, I'm gonna start her at a high rate(16-20, mininium) and use my ETCO2 to help titrate my rate according to her. If my I-Stat does ABGs, then I will want to check it out to help guide my vent management. I suspect she is gonna be quite acidotic. Once we are en route, I'm want to consult the local Poison Center and talk to a toxicologist about what I'm seeing and my suspicions. My thought is an amp of Calcium Gluconate would do this patient well. In addition, I'd want to pick their brain about possibly starting a 3 amps of HCO3 in 1L D5W gtt. She is going to need to be corrected and this is going to help her. Her EKG is nasty. I am not an EKG genius by any means, but Google does me well. (See 3rd link). It looks like she has some hyperkalemia according to her EKG. Treating her K is likely the right way to go. Giving her volume like you would with a DKA patient followed by an Insulin gtt may not work very well. Something in the back of the head says insulin doesn't do well severe acidosis. Maybe the voices again. Not sure. Anyway, check her lytes in the back of the truck and see how high her K is and treat accordingly. Her anion gap is going to be insane.

http://emedicine.med...814701-overview

http://emedicine.med...yDepartmentCare

http://www.google.co...ved=0CBwQ9QEwBQ

My kids need dinner. I'll check in later to see where we are.
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Nick Crusius RN, BSN

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

#36 SerendepitySaki

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Posted 22 April 2010 - 12:43 AM

GREAT BALLS OF FIRE! we'll give the other kids a chance to play... (not to mention it's Tex's BirthDay and I've got a final and a hot date tomorrow night) get up with you ASAP....possibly Fridayish..... she's still got a bit going on that no one has touched on... anyone got anything to add, delete, modify?

Prior to seeing the magic green juice, ethylene glycol ingestion was near the top of my differential dx. After reading further into the scenario, that is still my number one dx at this time. I read up on it on emedicine (see links below) and it certainly fits the picture. Pt has deep, Kussmall like respirations. This likely is a sign of significant acidosis. Her BS is also greater than 500 further adding to the Kussmall/EG ingestion picture. As far as treatment goes, let's start from the top. The pt has minimal gag. Get her loaded into the back to the back of the truck and maybe move out of the way of Noah's Ark to a better location to start RSI with this patient. 15L NRB while I'm prepping my drugs. I'd give the pt Zofran 4 mg IV to help prevent further emesis and also make the likelihood of further aspiration less. If we are running dual ALS providers, have my partner start a 2nd line to ward off evil spirits. As far as my RSI drugs go, I'd avoid Succ d/t the fact of the hyper K that can result from administration 48-72 hours later. I'd go with Rocc 1mg/kg. As far as the use of Etomidate, I don't think it is an absolute contraindication in patient such as this. My dose would be 0.3mg/kg. If I have a Glidescope, then I get that set up with my DL ready to go, just in case. I have a feeling we are gonna find all sorts of interesting things in her oropharynx when we go for the intubation. Using the Glide will give me and my partner a chance to both see the same thing in case this is a difficult intubation. While all this is going on, I'm gonna open up her fluids and give a 250-500ml fluid bolus to help enhance teh renal clearance and mobilize any accumalation of calcium oxalates. Now granted she receives HD already, so enhancing renal clearance is kinda a moot point. Nonetheless, the volume likely won't hurt her. If intubation is successful, I'm gonna start her at a high rate(16-20, mininium) and use my ETCO2 to help titrate my rate according to her. If my I-Stat does ABGs, then I will want to check it out to help guide my vent management. I suspect she is gonna be quite acidotic. Once we are en route, I'm want to consult the local Poison Center and talk to a toxicologist about what I'm seeing and my suspicions. My thought is an amp of Calcium Gluconate would do this patient well. In addition, I'd want to pick their brain about possibly starting a 3 amps of HCO3 in 1L D5W gtt. She is going to need to be corrected and this is going to help her. Her EKG is nasty. I am not an EKG genius by any means, but Google does me well. (See 3rd link). It looks like she has some hyperkalemia according to her EKG. Treating her K is likely the right way to go. Giving her volume like you would with a DKA patient followed by an Insulin gtt may not work very well. Something in the back of the head says insulin doesn't do well severe acidosis. Maybe the voices again. Not sure. Anyway, check her lytes in the back of the truck and see how high her K is and treat accordingly. Her anion gap is going to be insane.

http://emedicine.med...814701-overview

http://emedicine.med...yDepartmentCare

http://www.google.co...ved=0CBwQ9QEwBQ

My kids need dinner. I'll check in later to see where we are.


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

#37 Flightgypsy

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Posted 22 April 2010 - 02:57 AM

The assessment findings seem to solidify our diagnoses of liver and kidney failure with ascites and hypocalcemia.

I concur with Roadie on the ethylene glycol poisoning! :D I agree that we should intubate with as few drugs as necessary and we should be able to get away with that as she has minimal gag reflex. I do love the glidescope as well!

I'd go ahead and give her the Calcium and possibly some bicarbonate as we can't give her lots of fluids to help with the acidosis either.

I am thinking the EKG confirms our hypocalcemia along with all the other clues we have received and some calcium will also help protect the heart with the hyperkalemia.

I am adding severe anemia and either aortic stenosis or regurgitation (leaning toward stenosis) to our list of diagnoses. Do we have a H/H on our I-stat? The Pulsus bisferiens can be seen with anemia as well. (Thanks for the info on that one!).

Not sure I would use D5W on this patient though.

Oh and is there a possibility this was a suicide attempt?
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#38 Flightgypsy

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Posted 22 April 2010 - 03:03 AM

Oh and Happy Birthday Tex!! :lol:
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#39 TexRNmedic

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Posted 22 April 2010 - 03:37 AM

I have a few questions for you. Get you to share the wealth of knowledge a bit.

[quote name='RoadieRN' date='21 April 2010 - 07:30 PM' timestamp='1271896255' post='22072']
I'd give the pt Zofran 4 mg IV to help prevent further emesis and also make the likelihood of further aspiration less. [/quote]
Good thought. We throw this drug around pretty often in hospital, but it actually does have some, however small, risks. Long QT and hepatorenal metabolism/excretion. What is the purpose of RSI? We are managing the airway with BLS and suction very successfully so far.

[quote]I'd avoid Succ d/t the fact of the hyper K that can result from administration 48-72 hours later. [/quote]
Take another look at onset of hyperkalemia p/ succinylcholine administration. This is a depolarizing NMB. Even though she doesn't have it, take a look at sux use in duchenne muscular dystrophy.

[quote]I'd go with Rocc 1mg/kg.[/quote]
What is the typical onset and duration of Zemuron? Will this patient's dz change how this med works or how long it sticks around? Think about failed airway management, hypocalcemia effects on airway, etc.

[quote]I'm gonna open up her fluids and give a 250-500ml fluid bolus to help enhance teh renal clearance and mobilize any accumulation of calcium oxalates. Now granted she receives HD already, so enhancing renal clearance is kinda a moot point. Nonetheless, the volume likely won't hurt her.[/quote] We don't know how much renal function she really has. Her chronic renal failure may be secondary to a tox ingestion in the past. IVF may not be a bad idea. Look at the cardiovascular dz clues too.

[quote]My thought is an amp of Calcium Gluconate would do this patient well. In addition, I'd want to pick their brain about possibly starting a 3 amps of HCO3 in 1L D5W gtt.[/quote] What will be your endpoint for Ca administration? How will you now it is helping or hurting? Any particular reason for 50 vs 100 vs 150meq of bicarb? Same thing for the D5W vs NS? Why or why not LR.

[quote]Treating her K is likely the right way to go. Giving her volume like you would with a DKA patient followed by an Insulin gtt may not work very well. [/quote] How does insulin effect serum K level?

[quote]Something in the back of the head says insulin doesn't do well severe acidosis.[/quote] Then why do we treat DKA with an insulin gtt?

[quote]Maybe the voices again. Not sure. Anyway, check her lytes in the back of the truck and see how high her K is and treat accordingly. Her anion gap is going to be insane. [/quote] You know it is and sounds like a great plan! Great thought process here. And look how much you figured out without the benefit of labs.
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Wes Seale
Houston , TX

#40 medic675

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Posted 22 April 2010 - 03:38 AM

Can I request the SS Minnow A.S.A.P since all the birds are grounded.
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Brian Nolan
Paramedic-firefighter