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Part 1 of 2 Progressive scenario

34 posts in this topic

Posted · Report post

Hey all, this is going to be a fairly long scenario as we follow this patient so I will break it up into 2 scenario's, I do think there are going to be many learning points for our new (and old) members.

This will be 100% accurate to what I was presented with.

You are called to a home in a remote town of 2000 people for a female post seizure. Non-priority call.

You have an acute care clinic in this town which is "closed to ambulances" due to a nursing shortage, but you know the Doc (Family medicine) that is on tonight and feel comfortable taking a patient there if you need a hand stabilizing. The Doc will not assume care of a patient though nor admit anyone.

Closest "Open" ER is 30min away. No surgical unit, no specialties. Just family practice Doc's doing thier best.

City hospital is 2.5hrs away

The home you go to is well kept, with lots of harmless animals. There is a thick smell of cigarette smoke in the air.

You are greeted at the door by a hysterical 300lb man yelling at you "My wife needs help"

You arrive to the livingroom to find a 62y/o F with her head in a bucket vomiting food.

Husband states she is an epileptic & takes dilantin. She has not had a seizure in 12 years, but just had one prior to him calling 911.

She was diagnosed epileptic 12 years ago - post hemmoragic stroke that left her with no deficits (except the epilepy).

This seizure today lasted approx 2 min.

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Posted · Report post

Is she still actively seizing? if not>

How long did the seizure last?

Does she have any after effects from the seizure activity?

What was she doing prior to the seizure beginning?

Any recent illness?

Any meds besides dilantin?

Whens the last time serum levels were checked?

Any other current medical HX?

Vitals?

BP high or normal

Pupils?

Blood glucose?

ETOH?

recreational pharmaceuticals?

12 lead shows?

Once we get these answers, then a phone call to your friend, the Doc in the box might be in order to determine if you really need to take a 2 1/2 hr ride to the city hospital with a neuro dept.

OK : I'll let someone else play now :turned:

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Posted · Report post

Is she still actively seizing? if not>

How long did the seizure last? Approx 2min

Does she have any after effects from the seizure activity? Like the vomiting? Not sure what you're asking

What was she doing prior to the seizure beginning? Smoking, watching TV

Any recent illness? No

Any meds besides dilantin? Amlodipine, Metoprolol, Celebrex, Atorvastatin, Lansoprazole, Ropinirole

Whens the last time serum levels were checked? She can't remember

Any other current medical HX? Nope

Vitals? 142/90 RR20. P102 Sat 94% BGL10.4mmol Temp 36.7

BP high or normal Yes

Pupils? ERL

Blood glucose?

ETOH? No

recreational pharmaceuticals? No

Once we get these answers, then a phone call to your friend, the Doc in the box might be in order to determine if you really need to take a 2 1/2 hr ride to the city hospital with a neuro dept.

OK : I'll let someone else play now :turned:

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Posted (edited) · Report post

Ok I have a few questions, that sugar seems a bit high post seizure, as well as a relatively high heart rate for a pt. on a beta blocker.

12 lead?

Could you describe the seizure activity for me?

What's her mentation now and what's her baseline post stroke. How is her medication compliance? And is she having parkinsonian symptoms or restless leg at baseline?

BAYAMedic

And what was on TV at time of seizure?

Edited by BAYAMedic
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Posted · Report post

What has she ingested or been exposed to in the last 24 hours? Is she the smoker? (I am assuming she is based on her O2 sat)

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Posted · Report post

Does she have any after effects from the seizure activity? Like the vomiting? Not sure what you're asking

Mobey: I was looking for any new stroke type deficits or other physical findings of loss of function , post seizure

Pupils, nystygmus petichia

again: 12 lead shows?

Amlodipine, Metoprolol, Celebrex, Atorvastatin, Lansoprazole, Ropinirole: With these meds , she obviously has other concurrent medical problems.

Bi lateral pulses & BP's

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Posted · Report post

What does she look like in general,

skin,

level of consciousness,

12 years ago, how often would she have seizures, would she get them back to back,

does she look well kept,

Any recent injuries, falls, bumps on the head,

Any change in her daily routine,

Was the seizure sudden or did she know it was coming (aura)

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Posted · Report post

Any recent trauma/ possible head injury? Was she feeling sick/ nauseous before the seizure, or is that new onset? What's her mental status?

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Posted (edited) · Report post

No trauma other than patient complains of pain in her right elbow

Seizure was typical grand maul description

No neuro symptoms

No recent falls etc.

Yes a smoker, 1/2 pack/day x25+ yrs.

General appearance is unwell. Coulor is greyish, vomiting, slight diaphoresis.

ecg.jpg

Sorry for the small pic.... not sure how to expand it.

Ctrl + should help.

Edited by mobey
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Posted · Report post

Sorry Mobey: It's so dark and small as to be unviewable. Yep it's an ECG from a lifepack , other than that ????????

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Posted · Report post

F55EBEBE-CAAA-4215-ACD0-041337659169-529-000000EBEEA28AE6.jpg

B6CCC6C6-7AC2-4E2C-B2C3-D998E9DEF277-529-000000EBCD3B0024.jpg

Sorry for the delay.....

Just not tech savy

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Posted · Report post

Pericarditis as a result of Cardiosepsis causing the hyperglycemia and a febrile seizure...the temp is tympanic I assume? How is it or is it calibrated? I usually end up adding 2 degrees to a tympanic temp to get an equivalent core temp.

One day someone will actually post a pericarditis case...I know it.

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Posted (edited) · Report post

Hello,

I would get her on the stretcher, monitor, get a line and put her on some o2.

I think the EKG is worrying. I would lean away from Pericarditis because their hasn't been a preceding illness (i.e. flu, ect). Also, it my understand that any ischemic changes rules out Pericarditis.

She had risk factors for CAD:

- Smoked 1/2 pack x 25 years

- Dyslipemia (taking Atrovastin)

- Lack of physical activity (watches TV)

- Hyperglycemia

- Age

She has the look and the symptoms: gray, unwell, and pain in her right elbow

The EKG shows Q-waves (I think), ST elevation in V1,2,3,4,5 and V6. ST depressions in II and III Plus, spike T-waves in a few locations

Also, the wide QRS morphology with spike 'T' waves could be caused by electrolytes which can minic an AMI, especially hyperkalemia / hypokalemiia.

Hyperkalemia can produce very odd looking EKG. Maybe, she has some renal inefficiency that has progressed?

Enough rambling.

I would:

1. Do a 12/15 lead EKG

2. Get bilateral BP's (as noted above)

3. Give her an antiemetic like Zofran IV or SL

4. Give small doses of Fentanyly for the arm pain (25mcg PRN)

5. Give NS 500

6. Watch her LOC for any changes

7. Give the N+V time to settle then give ASA PO

8. Transport to the local ED for some more assessments and labs (mainly lytes and BUN/Cr/Tn-I).

A stop here is a good idea before a long transfer.

I would like to know:

1. How long has she been feeling unwell?

2. Temp?

3. Why is she on Ropinirole? I looked it up and it is for Parkinson Disease and Restless Leg Syndrome.

4. Any rash?

5. Stiff neck? Still back or legs?

6. Splinter hemorrhages in the hands and feet?

7. Decreased voiding?

Cheers

I

Edited by DartmouthDave
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Posted · Report post

Also, the wide QRS morphology with spike 'T' waves could be caused by electrolytes which can minic an AMI, especially hyperkalemia / hypokalemiia.

Hyperkalemia can produce very odd looking EKG. Maybe, she has some renal inefficiency that has progressed?

Enough rambling.

I would:

1. Do a 12/15 lead EKG 15 not available (i didn't do one... so you don't get one hahaha)

2. Get bilateral BP's (as noted above) They are equal

3. Give her an antiemetic like Zofran IV or SL 8mg PO in.

4. Give small doses of Fentanyly for the arm pain (25mcg PRN) We have a problem huston.... You cant get a IV!

5. Give NS 500 Done

6. Watch her LOC for any changes Getting lethargic, but easily roused. More fatigue then lethargy

7. Give the N+V time to settle then give ASA PO 160mg down the hatch

8. Transport to the local ED for some more assessments and labs (mainly lytes and BUN/Cr/Tn-I).

A stop here is a good idea before a long transfer.

I would like to know:

1. How long has she been feeling unwell? Just since the seizure

2. Temp? Normal

3. Why is she on Ropinirole? I looked it up and it is for Parkinson Disease and Restless Leg Syndrome. RLS

4. Any rash? Nope

5. Stiff neck? Still back or legs? Nope

6. Splinter hemorrhages in the hands and feet? Nope

7. Decreased voiding? Nope

Cheers

Anyone want to bypass local doc-in-a box?

Also: you have the option to transmit this to cardiologist and activate a thrombolytic protocol. You carry TNK. However, the cardiologists in this program are very busy working the cath lab while on call, and don't like to be bugged unless you are pretty sure.

the temp is tympanic I assume? How is it or is it calibrated?

Once a week I drop it on the ambulance floor and kick it against the wall.... If it still works, I consider it calibrated.

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Posted · Report post

Kind of hard to give a thrombolytic until you get Venous access isn't it? If you can't get a peripheral line, then maybe an EJ, then it's time for IO, She's not going to be happy, but what can you do

Yes: I would bypass the doc in the box unless she has a sprained wrist. this lady is way beyond the capabilities of the local clinic.

If you have 12 lead capability , you also have 15 lead. just sayin!

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Posted · Report post

I would consider the 12 lead suspicious for at least a lateral wall MI. I would definitely bypass the local facility, if they are anything like the ones here all they'd do is yell at me for brining a pt who needs further care there and transfer her out. I agree with island EMT, time to go for an EJ in this lady and start considering an IO. I would transmit this EKG to the receiving facility, to me it's suspicious enough to "bother" them and see if they want us to begin TNK.

BTW how did she get the 500cc of NS if we don't have a line?

New set of vitals please

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Posted · Report post

Hello,

I wonder about and IO and TNK? I am sure it is fine but I have never thought about it, until now.

So, we have a medical clinic and an ED 30 minutes away?

Cheers

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Posted · Report post

I think the EKG is worrying. I would lean away from Pericarditis because their hasn't been a preceding illness (i.e. flu, ect). Also, it my understand that any ischemic changes rules out Pericarditis.

It's a running joke. I guess pericarditis for everything.

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Posted · Report post

Hey Moby,

You better make the next scenario a paracarditis! =)

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Posted · Report post

BTW how did she get the 500cc of NS if we don't have a line?

New set of vitals please

Great catch!

Typing without thinking...

OK, so we transmit to the city hospital & the Cardiologist Gives the consent for SQ lovenox, but says no to the IO.

Plavix 300mg PO.

He states he suspects large MI and orders to bypass to the cath lab.

New vitals: 148/88 HR 87. Resp rate 18, Spo2 97

An hour passes, we are now about 1hr from the cath lab. The patient is quite diaphoretic and c/o new midsternal crushing chest pain 7/10. She begins to vomit again.

BP 146/70 HR98

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Posted · Report post

Repeat 12 lead, repeat d-stick. What is her mental status now?

I'm not sure about the PO zofran you gave earlier, I know with IV zofran you could repeat a dose at this point, so since we don't have a line I'd do 0.4mg IM.

Cautiously begin giving the pt nitro SL 1 pill q5mins as so long as pressure holds. Consider a narcotic pain medication IM.

I'd also have the IO kit sitting out next to pt, incase she deteriorates and I need venous access. Oh, and I'd put the "oh sh*t" pads on her, just in case.

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Posted · Report post

OK, so we transmit to the city hospital & the Cardiologist Gives the consent for SQ lovenox, but says no to the IO.

Plavix 300mg PO.

He states he suspects large MI and orders to bypass to the cath lab.

New vitals: 148/88 HR 87. Resp rate 18, Spo2 97

An hour passes, we are now about 1hr from the cath lab. The patient is quite diaphoretic and c/o new midsternal crushing chest pain 7/10. She begins to vomit again.

BP 146/70 HR98

At this point you have a pt that is heading down the path of no return and it's not going to get better soon. She is starting to circle the drain and you have no IV access.

It's time to think a little outside the box here. Did you look at her feet & lower legs?? There are several good veins there that can usually be found even when you've had no luck on the hands & arms.

Me : Would have gone to the EJ as a direct route , but it's all how comfortable you are with finding the landmarks.

You really need to be careful with the nitro, looks to be rt sided from what little we've gotten from the ECG strip.

Like Patience said pads on and be ready.

Diesel bolus might be her only option at this point on your journey

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Posted · Report post

You've got time, why hasn't anyone asked for a right side 12 lead?

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Posted · Report post

At first glance this would appear to be an MI or otherwise cardiac related...but...some other things there too.

She has had a prior hemmorhagic CVA...while it was 12 years ago this is still something to be thinking about. Add in that this was her first seizure in 12 years and her disorder was caused by the CVA in the first place...worth keeping in mind. If she is getting less responsive/lethargic and continueing to do so, very concerning. Repeat neuro exams, especially with a 2.5 hour transport are mandatory. The 12lead looks both like an acute MI, and a little like one that's been ongoing for awhile.

With the recent seizure and her history I'd be a little leery about the plavix and lovenox. Not saying I wouldn't, but a conversation with the cardiologist would be in order with my concerns expressly laid out. The tnk is definetly out.

Far as the access issue...if you can't find a peripheral vein then she get's an IO. Right away. You can try lidocaine (which is less than effective that I've seen) along with some IM fentanyl and versed, but she still get's it early. The other option, which will depend on how well you know the local doctor and what his capabilities are, is that it might be worth calling and asking if he'd be willing to start either an IJ or subclavian before you continue towards the city. If it's something he's good at it won't add much time, and with this being a high risk patient for both cardiac and neuro issues (or something else), a long transport, and the potential use of anticoagulants and/or thrombolytics, it'd be worth having.

Continue with repeat 12 leads (or 18 but since you said that's out...), repeat neuro exams and aggresively treat the nausea with your anti-emetic of choice. If the lethargy continues to progress or the vommitting becomes severe...carefully intubate.

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Posted · Report post

At this point you have a pt that is heading down the path of no return and it's not going to get better soon. She is starting to circle the drain and you have no IV access.

It's time to think a little outside the box here. Did you look at her feet & lower legs?? There are several good veins there that can usually be found even when you've had no luck on the hands & arms.

Me : Would have gone to the EJ as a direct route , but it's all how comfortable you are with finding the landmarks.

You really need to be careful with the nitro, looks to be rt sided from what little we've gotten from the ECG strip.

Like Patience said pads on and be ready.

Diesel bolus might be her only option at this point on your journey

Nitro is supplied at 0.4mg spray.

Oh yes.... the feel/legs/upper arms etc were all tried. 9 times in fact! There is no chance at IV unless you go EJ.

I would love to post a 15/18 lead for ya'll, but I just didn't do one. I am not posting a fake scenario so I don't wanna make crap up.

So before I wrap this up, are we spraying the nitro without a line?

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