ERDoc

It is the frequent fliers that scare me the most, especially the drunk ones. They always get put in a corner and forgotten about. I don't want to be the one on duty the day that they actually have something and it gets missed because everyone thinks they are just drunk again and end up in the corner.

Another technique that I find works (very similar to Rids) is to tell someone that if they don't wake up and start talking that I will have to assume the worst and put a tube down their throat to make sure they keep breathing and a tube in their penis. A colleage of mine likes to ask the nurse, in front of the "unconscious" patient, to get 5cc of that new drug Nakel (NaCl). He makes a point to say, "It's a good thing for him he really is unconsious, because if he wasn't this new drug could kill him." I have never tried it, but he claims a 100% success rate.

A little nailbed or knuckle pressure is a very noxious stimulus with little chance of causing any real harm and family members may not notice it if they are crowding around.

Hæmorrhagic shock is hopovolemic shock. As ERDoc said, there are multiple ways to create a hypovolemic state of shock, but hæmorrhagic is one way. And yes, non-arterial bleeding can cause hypovolemia. Such is commonly the case in internal bleeding. Whether venous or arterial, internal or external, it will always be "major."

On that note, scalp wounds can be very bad also. They can look minor, but the scalp is so vascularized that they bleed like stink. The pt can bleed out and you will never know because it is pooling in the sheets behind them. I have seen several cases of pts dropping their pressures because of a scalp wound that was not cared for properly.

Sorry I didn't conclude this case. chbare, you are very close. The seizures are from INH toxicity, not necessarily an OD. Can you tell me how the INH causes seizures?

Not to get off the topic, but what about this patient made you think he was hypoglycemic?

Hemorrhage can cause hypovolemic shock. Anything that causes you to have less volume in you blood vessels can cause hypovolemic shock (ie dehydration, third spacing, etc).

With all of the evidence that has been published, about the only thing that has really panned out is that large volume fluid resuscitation in pts with injury to the large arteries can be detrimental, and permissive hypotension might be the best way to treat these pts. As previously stated when you increase the pressure, you have the potential to blow off whatever clot has formed. The same has not been shown for less severe injuries such as splenic and liver lacs and things such as extremity trauma. Obviously, in the field, with blunt abd/chest trauma you have no way of knowing what is injured so, I don't think you will ever see any conclusive evidence either way, so you will end up at the mercy of your medical director and his/her beliefs.

At my hospital, the way we do it is two large bore IVs (not necessarily with fluids going). Any pt with AMS or hypotension gets one cordis by the ER and usually the trauma service will put in a second one. If they are hypotensive and do not respond to the first fluid bolus they get blood going, this is usually after CTs have been obtained and we know what their injuries are.

Craniorectal inversion.

Anthony, before we start talking treatment, let's talk diagnosis. You are on the right track, but just haven't quite hit the nail on the head.

On a side note; your transport time to the ER is 30 minutes.

Any thing else?

Call medical control!! 8)

Has the pt ever been given Haldol before? How hot is hot (get a rectal temp)? I suspect that this pt has a syndrome that is probably malignant, but I guess we'll see.

My partner and I had an EMT student last year and during his hx of our 90+ year old female patient, he asks "Any vaginal discharge". (Pt was a general malaise call) I am looking down at the floor in the ambulance trying not to explode in laughter, and thinking, WTF did that question come from. After the call while we were going over things my partner lets into him about that question, then he says "Well I was going to ask about her period"................ :sign3:

He will make a great internist some day, don't laugh too hard at him (okay, maybe the period thing).

I just had a crew bring in a CVA and the medic told me, "She doesn't have her dentures in but her gait is still off." Those must be some heavy dentures.

Must.........stop..........looking...........ahhhhhhh!!! I can't fight it! 8)

chbare, you are half right about the LP before CT. There is no problem in doing an LP on someone with a bleed. CTs sometimes miss the bleeds so we actually do an LP to make the dx. This issue, and it is a theoretical one, is that if you have an increased ICP you can cause herniation. This has never actually been shown in the real world, but would you want to be the test case? The CT in this case is negative.

Now that she is not shaking you can do a full physical exam. You find nothing including track marks. She is still afebrile and her vitals are stable. There was no recent travel or unusual foods. Rid, all of the labs you mentioned are negative, as is a beta.

The neuro team shows up and says, "You have the answer already. Look over what you have and you will see it. Call us if you need us."

She had the PPD as a part of a routine initial physical at the county clinic. The pt had a nl cxr so she was started on INH. EKG is pretty useless due to seizure activity (for those that decided to RSI, it shows sinus tach at a rate of 126). VS BP 167/100, but difficult to assess accuracy due to pt seizing, about 126/72 when paralysed. Tha family denies any recent illness or special pets/herbs/plants. So, let's assume that she has gotten 3 doses of your benzo with no improvement. You decide to RSI her and once your paralytic of choice is onboard, she no longer has seizure activity. Someone brought up a good point here; just because her body is no longer seizing, her brain still is. Obviously not something that can be done in the field, but she needs to be on an EEG monitor.

Rid, I will give you a progressive ambulance with a CT which is read by the onboard radiologist as normal. You also have such a long transport time that you perform an LP and get the results before arrival at the ER (sounds like my job may be obsolete) and it is normal. I would not recommend doing the LP without doing the CT first though (extra credit for anyone that can tell me why). Your onboard EEG shows diffuse seizure activity.

The husband is now grabbing at you, praising your ability to make his wife "stop shaking. But can you tell me why she is doing this?"

Yup, this was quinine toxicity. The Ophthamologist didn't think she was ever going to regain her sight.

There is no petechiae or rashes and she is afebrile. The only known history that the family is aware of is a positive PPD when she went to the doctor recently. She was born in Central America and moved to the US about 3 years ago. Other than the shaking, her exam is pretty unremarkable.

AZCEP, you are correct. The optic nerve (cranial nerve 2) is pure sensory providing info from the retina. The occulomotor nerve (cranial nerve 3) innervates most of the extraoccular muscles to allow the eye to move (cranial nerves 4 and 6 also provide some innervation). You have some good thoughts.

chbare, your ambulance also has its own MRI (you work at a very progressive ambulance service ). The MRI is also negative.

The husband says that when he returned he found the pill bottle empty and many pills spread throughout the house. He says it looks like she did not take all of her oxy and methadone. It appeared that the BP meds were taken appropriately. There were no qunine left, including the ones that were in the bottle in the cabinet. So, what do you think now?

The husband says that she has never had seizures before and there is no history of trauma, although she is recently from Central America and did not have much medical care there. The family also says that the pt does not drink, smoke or take any illegal drugs. She has not been sick recently. She was sitting at the dinner table talking with the family and just fell over and seized. There are no known allergies. As far as the husband knows she is not pregnant, "But I guess anything could be possible." The pt weighs about 180 lbs (sorry my Canadian friends). Her FS is 134. You put in an NPA and start an IV. You give your benzo and get no response. What do you do now? Is there anything else you want to know?

What is my general impression, is the patient currently having a seizure and what does it look like? Is there a patent airway and does she have a pulse? What is the son looking for?

Thank you,

chbare.

The seizure is gneralized/clonic-tonic/grand mal (take your pick). She is foaming at the mouth and you her gurgling sounds. There is a good, strong pulse. The son is not looking for anything in particular, he just doesn't have anything else to do.

Hmmm...

Well, I still cannot rule out conversion. I guess I should have asked this question much earlier, is the pupil dilation a new thing.

Thanks,

chbare.

Husband is not sure, but he doesn't remember them being so big. Do you really think at this point that you can feel comfortable to a physchiatric dx? Would you feel comfortable sending this wman home if you truly believe it to be a psychiatric cause?

You are called to the house of a 43 y/o female who has been seizing for the last 10 minutes. The son is running around the house like he is looking for something but can't find it. The daughter is at the pts side, crying, saying, "Mommy don't die!!" The husband is leaning over the pt saying, "Damn, I never seen anything like this before. Can you guys do something to make her stop?"

What do you do?

Sorry I haven't answered any posts in a while. There was some good discussion going on and I didn't want to pollute with more info. The husband says that the pt has been clean for almost 5 years. He says that this is her normal mental state. He left on Friday and came back today (Monday). He normally handles her meds, but since he had to leave he left them in one of those pill bottles that have the days of the week on them. The quinine script is not new, she has been using it for leg cramps every since the back injury. Ethnicity is whatever you want it to be (she does not have G6PD).

AZCEP: There is no facial droop, arm drift or slurred speech. How would optic nerve compression limits your ability to move your eyes?

chbare: I will give you your pixie dust. EKG is unremarkeable, CT head normal, tonometry reveals IOPs of 10 on the left and 12 on the right. What are you looking for with a slit lamp (there is no corneal abrasion or hyphema)? She was on interferon about 7-10 years ago, but has not followed up with her GI doc, but the husband thinks her last set of labs were normal. There is no jaundice. Her ammonia level is normal. Even with the pixie dust, the quinine level is a send out lab and has to go to a lab 2000 miles away (which you find out after a 30 minute discussion with the lab that you have in your ambulance).

There are no track marks that you can see. Her neuro exam is pretty normal, execpt for the blindness (she does not respond when you present a threating stimulus to her (you make it look like you are going to hit her)). Hope this helps, and it actually reminded me of another case (see you in the next thread).

Can we get any medical history on the patient? Does she take any medications or have any history of trauma? I would also like to get a set of vital signs and a blood sugar.

I am thinking out loud about the ddx's;

Allot of obstructive causes of vision loss result in sudden onset not gradual over days.

Perhaps an atypical presentation of glaucoma, acute closure with no pain or undiagnosed chronic angle closure. I know a fixed pupil in mid position with vision loss may suggest angle closure.

History of methanol ingestion? I also know this can cause vision loss and fixed/dilated pupils.

This may help us reach a diagnosis.

Take care,

chbare.

Your pt is a former heroin abuser and also has a h/o htn, herniated lumbar disk with chronic back pain and Hep C. There is no h/o trauma. She is taking atenolol, norvasc, quinine, oxycontin, robaxin, motrin, methadone, lasix and Kdur. FS is 106. 114/68 68 14 98.2.

sudden onset.. versus slow, curtain shade description, bright objects, painful, H/A, peripheral vision, pupillary reflex.. retinal detachment vs occulusion or cerebral bleed.. or the old hysterical conversion ?

R/r 911

Pt is not able to answer questions well, but from what you can get from her the vision loss was gradual. It started centrally and has progressed outward over the period of 2 days. No headaches or eye pain. There is complete loss of all visual fields. Pupils are fixed and dilated. I think this puts conversion higher on the ddx .