medic112 Posted January 12, 2009 Share Posted January 12, 2009 Dispatched class 1 for a fall victim. additional info provided by county, 89 y/o female, conscious / breathing, not alert, fell from standing. AOS to find FD and BLS treating an 89 y/o female, lying supine on the floor inside doorway, strong smell of urine. No acute respiratory distress, eyes are open, following people with eyes, incoherent when spoken to. Per family they found her laying on the floor when they came in the house, pt was lying prone when they found her. Pt stated that she fell yesterday (approx 24 hrs ago), family states she not acting normally. she lives in the residence alone. No complaints from pt other than being cold. (-) pain. pt does not know why she fell or exactly when,. PMH: TIA, A-fib, HTN, high cholesterol, dementia. Meds: Beta blocker (cant remember exact which one), no digoxin, ASA 81mg / day. NKDA VS: Pulse Rate 86, A-fib on monitor 110, Pulse Ox 95% RA, 97% on 4lpm NC, BP 150/60. BGL 174 from finger stick. PE: pt conscious / breathing normally without difficulty, originally able to answer some questions, slow to respond at times. following later pt was AAOx4, with no complaints. Patent natural airway, No JVD, trachea midline, ENT clear, PERRL. Oral mucosa dry. Skin: cool / dry. mild tenting. head / neck / back atraumatic. Chest unremarkable. lungs clear and equal bilaterally. abd SNT, (-) distension, no pulsating masses. pelvis stable with incontinence to urine. extremities: PMSx4, no pedal edema. Pt weights approx 50kg. question is how do you treat this pt? does anyone have protocols for adult rhabdomyolysis? Just wondering. Command did not agree with that treatment and only monitor / transport. wanted other opinions. Our protocol is 500mL fluid bolus. 1 amp Sodium bicarb in 250mL bag running at 100mL / Hr. thanks, and enjoy. Link to comment Share on other sites More sharing options...
mobey Posted January 12, 2009 Share Posted January 12, 2009 The lack of pain makes me wonder about rhabdomyolysis. Do you think she moved around much within the 24 hrs? with a Hx of dimentia, I have to wonder how long she really was there.... maybe only a few hrs. Was she hypothermic? With the TIA history I wonder about neuro on this one. Side note: I really like the way you presented the whole case and asked for feedback rather than the guessing game type scenario. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted January 12, 2009 Share Posted January 12, 2009 Ok, call me dense but I am not sure why you considered Rhabdo on this patient? Can you elaborate??? Here's a link for a good info article on Rhabdo http://www.nlm.nih.gov/medlineplus/ency/article/000473.htm Link to comment Share on other sites More sharing options...
rdelisle Posted January 12, 2009 Share Posted January 12, 2009 Tell me if I'm out in left field here, but I think the A-fib caused her to have a syncopal episode and now she's dehydrated from lying on the floor. Link to comment Share on other sites More sharing options...
p3medic Posted January 12, 2009 Share Posted January 12, 2009 An elderly woman lying on a hard floor for an extended period of time can develop muscle breakdown and rhabdo from pressure necrosis, however we usually see other signs such as EKG changes secondary to hyperkalemia, both from the cellular breakdown and eventual acute renal failure. Without a complaint or a worrysome EKG, I'd probably hydrate with saline and transport. Link to comment Share on other sites More sharing options...
CTXMEDIC Posted January 12, 2009 Share Posted January 12, 2009 i agree with P3, and also was wondering if she was hypothermic. Link to comment Share on other sites More sharing options...
crotchitymedic1986 Posted January 12, 2009 Share Posted January 12, 2009 Although it may have nothing to do with this case, I remember a class I took regarding head injuries in the elderly. It seems that your brain shrinks over the years, leaving pockets between the brain and the skull. Which means that when the elderly fall and suffer head injuries, they may not exhibit signs for hours later because there is space for the blood to go before it starts compressing the brain. Here are some statistics regarding elderly falls: http://www.ncsl.org/programs/health/shn/2008/gs519.htm Link to comment Share on other sites More sharing options...
CTXMEDIC Posted January 12, 2009 Share Posted January 12, 2009 to pile on that last post, we had a crew awhile back respond to a lady that fell out of a wheelchair. she bent forward to pick up her phone and fell onto her forehead. the crew c-spined her to the objections of the fire crew on scene. lady ended up having a c3/4 fx. Link to comment Share on other sites More sharing options...
EMT Foose Posted January 15, 2009 Share Posted January 15, 2009 I was thinking about possible hyperkalemia until I got to the ekg, and would r/o depending on: Did the family or BLS crews move the pt at all? Any bruising or anything on the body parts she was laying on? What type of floor surface? Any other new onset neuro besides decreased LOC and dysphasia? Gotta keep TIA and syncope in mind, but otherwise usual c-spine stuff, O2, warm blankets, and 250-500 bolus depending on her size. I'm concerned about being too aggressive with anything because of the a-fib, high cholesterol, and possibility of laying still for 24 hours. If she hasn't thrown a clot already, I don't want to cause it. Link to comment Share on other sites More sharing options...
iMac Posted January 23, 2009 Share Posted January 23, 2009 I know nothing other than the general indications for most ALS drugs, dosages etc etc, so you won't be getting my input in that sense. I would have boarded her, been careful doing the transfer (hyperthermia from being on the ground), hooked her up to the monitor, start a line, monitor vitals and keep her company all the way to the hospital. Link to comment Share on other sites More sharing options...
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