Out Running...

26 posts in this topic

Posted (edited) · Report post

So this is a case from our medical director he gave to us during our annual conference on clinical updates and where we are going clinically, what we do well and where we need to improve...

[b]Background[/b]
Called to a 40yo male who collapsed while running. He has no prior medical history, taking no medications and is not allergic to anything he knows of. Prior to collapsing he complain of feeling very unwell with sudden onset 10/10 abdo pain (diffuse and states "pain is all over") and explosive diarrhoea.

[b]Vitals[/b]
RR: 35/min with a shallow tidal volume
HR: 160/min with weak radial pulse
BP: 90/70
Cap Refill: 4 seconds
GCS: 13 (E3, V4, M6) - appears mildly confused and responding to voice
12-lead ECG: attached

[attachment=456:19-12-2012 8-43-57 a.m..jpg]

I'm not going to give you any other info now. When we went through this scenario we were given the above info and we had to ask for other information that we thought would be relevant and then make a treatment decision. So if you want more info ask for it and if I don't know it I'll make it up consistent with the actual diagnosis. Edited by HarryM
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Posted · Report post

Pericarditis with rapid colonic response?
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Posted · Report post

I've heard about your pericarditis fantasy Arcitckat...but that's not it.
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Posted · Report post

DAMMIT!!!!!!!!!!!!!
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Posted · Report post

Ill make up a pericarditis scenario for you next time.

What are the physical findings? Specifically abdo. Distention, tenderness, rigidity, guarding? Any recent trauma or illness?

Any weakness, numbness, tingling in extremities?
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Posted · Report post

No abnormal abdo findings. Pain does not change on palpation or percussion. Pain cannot be pinpointed at all and is across abdo. Mixture of cramping and sharp intermittent pain. Nil distension, rigidity or guarding. No recent trauma or illness. No weakness, numbess or tingling in extremities.
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Posted · Report post

Lung sounds? Skin condition/ color/ temp? You say he "collapsed," did he fall down, get dizzy, pass out? Did anyone witness his collapse and can describe it, specifically if there was any seizure like activity? What color is the diarrhea? Any nausea?
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Posted · Report post

ECG looks like SVT with rate about 160 and some non-specific ST depression

His pain makes me wonder if he has an aortic anyersim

With his physiological signs he is just enough this side of status 2 for me to call him that (unstable)

For now, simple ABCs and take him to the hospital

What was Tony Smith thinking?! :D
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Posted · Report post

Lung sounds are clear. Skin is flushed systemically and warm to touch with a temp of 37. He was witnessed to be running before slowing down for about 5 seconds before collapsing to the ground remaining conscious throughout. Pt states he had sudden onset abdo pain and felt need to pass bowel movement, he slowed down and became so dizzy he fell to the ground but remembers all events and was not KO'd or lost consciousness at any point. On the ground he lost bowel control.

Kiwi - not an aortic aneurism.
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Posted · Report post

Bloody hell I am fresh out of ideas then, ring up ICP and let them figure it out ...
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Posted · Report post

I would say gastroenteritis. He was just jogging so that could explain his RR and HR findings...especially if he is new to jogging.

I want to ask what supplements is he taking. What does his diet consist of? How often does he rehydrate?

You said he had explosive diarrhea, how much was there? That could explain the low BP since he is losing fluid.

Did pain subside after BM?
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Posted (edited) · Report post

Nil supplements. No abnormal diet (healthy eater and stays away from saturated fats). He has had 2L of water today which is his usual intake and he jogs 10km 3x per week. BM was moderate, standard size BM apart from it's wateriness and uncontrollability and only 1. Pain did not subside after it and patient still feels like he needs to make another BM but is able to hold it in.

It's not gastro

[b]While all the questioning occurs: [/b]
BP drops of 75/55, HR drops to 100/min and RR increases to 40. Edited by HarryM
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Posted (edited) · Report post

Sounds like he is going into shock. Spontaneous GI bleed? Internal Bleeding? Any Recent surgery?

Is he Anemic? Is he African American (Sickle Cell)? Toxic Shock?

Though the symptoms don't match up a muscle strain can cause diarrhea if the diarrhea was bad enough could possibly cause the other signs and symptoms. Doesn't explain the dizziness though.

Heat stroke?

I'm guessing here now Edited by MikeEMT
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Posted · Report post

[size=5]Very wild guess, Food poisoning![/size]
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Posted · Report post

I don't like that his HR dropped with the blood pressure, to me shows that he is not compensating as well anymore, could go very quickly into decompensated shock. I'd grab an extra person and begin transporting emergent to the nearest surgical center (provided it's not to far away). Large bore IV, fluid challenge to achieve radial pulses/ SBP ~90, getting ready to use pressor agents. Also be prepared for him to code. I'm thinking that he either ruptured an aneurysm, or has a major bleed of an abdominal organ. Is his abdomen still soft? No palpable masses? Would love to have an ultrasound... Again, what color was the BM? Any metalicy smell?
If I carried fentanly I think I may consider that as well, to see if we can get the pain better under control to pinpoint its origin.
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Posted · Report post

[quote name='MikeEMT' timestamp='1355918003' post='291813']
Sounds like he is going into shock. Spontaneous GI bleed? Internal Bleeding? Any Recent surgery?

Is he Anemic? Is he African American (Sickle Cell)? Toxic Shock?

Though the symptoms don't match up a muscle strain can cause diarrhea if the diarrhea was bad enough could possibly cause the other signs and symptoms. Doesn't explain the dizziness though.

Heat stroke?

I'm guessing here now
[/quote]

It's none of these but you are on the right track with the S word. Dizziness most likely caused by sudden hypotension.

[quote name='fakingpatience' timestamp='1355935560' post='291819']
I don't like that his HR dropped with the blood pressure, to me shows that he is not compensating as well anymore, could go very quickly into decompensated shock.
[/quote]

Spot on with this....although consider what type of shock he could be in. His abdo is still soft with no masses. His BM was watery and runny but not an abnormal colour or smell. The patient vomits while you are there. No blood in the vomit. It looks normal.

[quote name='emtdennis' timestamp='1355931897' post='291817']
[size=5]Very wild guess, Food poisoning![/size]
[/quote]

Nope
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Posted · Report post

[b]Treatments so Far:[/b]
- Large bore IV: you get a 16G in an ACF when you first arrive but since his BP has dropped you can't get a second line
- Fluid loading: after 1L you achieve a minor rise in BP to 80/60 but nil other vitals improve and patient condition doesn't improve
- Fentanyl: to achieve any form of pain relief you'd need a minimum bolus dose of 50mcg - do you want to risk it?
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Posted · Report post

JVD? Difficulty breathing? Chest pain? Breath sounds?

He's in shock. No signs of bleeds, the diarrhea wasn't enough to cause hypovolemia. No signs of neuro involvement, leaves mechanical. PE would be my guess with the increasing RR.
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Posted · Report post

Nil JVD, SOB or chest pain. Lungs clear on auscultation. No stridor from upper airway. His RR is now slowing down. It's not PE.
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Posted · Report post

Ruptured spleen? some sort of anphylaxis (any other signs for that?)

To sum it up, he may be having some sort of inflammation, he's running right towards schock, massive, diffuse abdominal pain, diarrhoea. How is he neurologically? Especially leg movement, reflexes. He didn't actually lose control over bowel movement, simply couldn't hold it anymore? Consider spinal cord damage... although infarction or inflammation in that area seems fairly far fetched. Endocrinological changes, wouldn't really explain abdominal pain.

How does he react to norepi or whatever you've got.

I've actually had a patient with massive gall stones presenting with those kind of symptoms... What does the stool look like? Prior to giving him catecholamines, I'd risk pain management, how does he react?
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Posted · Report post

Well it's not an "S" word, but I'm going to take the safe route and treat him like a ruptured AAA. Hold off the fluids, and start Dopamine. I like Ketamine for this guy for pain, and will also use it to intubate if his GCS drops off. Depending on where we are, we better start thinking about air transfer. Was this bloody diarrhea? Oh ya.... don't palpate the abdomen! I would like to know if it is ridged though?
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Posted · Report post

Is his skin still flushed and warm? You said his RR decreased, is that because he is getting tired of breathing/ lethargic, or is relaxing? What is the pulse ox?

Here is my thinking "aloud"
Types of shock:
Hypovolemic: Possibly, but where is he bleeding into? Skin should be pale/ cool/ clammy
Neurogenic: Doesn't quite fit with his initially elevated HR, but possible. Unlikely traumatic, but possibly a bleed?
Cardiogenic: 12 lead is clear, but could possibly be NSTEMI or other. Don't really think pericardial tamponade, no hx or s/s/for that. No s/s of CHF
Anaphylactic: Could possibly be a severe reactions, without respiratory compromise, however what is he reacting to? Fits with the sudden onset, tachycardia, hypotension, sudden diarrhea + vomiting
Septic shock: Doesn't' fit the sudden onset. He is slightly febrile though

I'd be tempted to give him epi at this point. Would help with the refractory hypotension, and if cause is anaphylactic could assist there also.
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Posted · Report post

[quote name='HarryM' timestamp='1355909657' post='291807']
Lung sounds are clear.
.
[/quote] Doubt it is allergic reaction with this finding
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Posted (edited) · Report post

His RR decreased because he is getting lethargic. His skin remains flushed and warm to touch even with drop in BP. There is absolutely nothing abnormal with stools or emesis. Abdo pain is not worsened with palpation or percussion and as above there is no rigidity, guarding, distension etc.

Fake patience (especially) and fab you are both on the right track with your posts. What treatments would you now give?

Do you want me to reveal? Edited by HarryM
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Posted (edited) · Report post

Please do so, it's been a great scenario so far. To be honest what I would do is keep on guessing and rush to hospital, intubate at some stage and rush again.

Anaphylaxis?

Edit: Anterior wall infarction? Paralytic ileus with massive toxine spread? Probably deteriorating too quickly... Edited by fab
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