Kiwiology Posted July 27, 2009 Share Posted July 27, 2009 You are called to a 35 year old man who has been nonspecifically well x 2 days. He has recently returned from Fiji where he recieved a lot of misquito bites. He complains of a sore throat and achy joints but denies photophobia, stiff neck or a headache. RR 30 SP02 96% RA BP 110/90 HR 140 Cap refill > 3 sec All over his body are spots that look like this - What are these spots called? - What is going on inside this guy? - What is your priority going to be? - You are 45 minutes from hospital, what do you do? Link to comment Share on other sites More sharing options...
crotchitymedic1986 Posted July 27, 2009 Share Posted July 27, 2009 petechia rash, most likely malaria, but could be any infection (or blood disorder from an infection) from a third world country ---- put on the yellow suit, mask, gloves --- ABCs, IV, get to hospital where antibiotics could be started --- decon the hell out of your truck. Dont lick the open sores. Link to comment Share on other sites More sharing options...
chbare Posted July 27, 2009 Share Posted July 27, 2009 1) Looks like a petechial rash 2) Most obvious concern is coagulopathy 3) Supportive care, isotonic volume expansion, detailed history 4) Obtain vascular access and provide an initial fluid bolus, obtain a temperature, BGL and XII lead. Assessment questions: -Lung sounds -Abdomen -Focused Neuro Exam -Place Foley and monitor urine if possible -Head to toe exam looking for gross abnormalities Taking any medication? Any Allergies? Any medical history? Any surgical history? Anyone else ill? Travel to any other areas? Vaccination history? Any meds while in Fiji? Considerations -Malaria is a consideration; however, it is not typically associated with Fuji -Dengue Fever--->Potential progression to Dengue Shock Syndrome -Other rickettsial infections Treatment -Monitoring -Supportive Care -Contact medical control after comprehensive assessment and history -Limited definitive work up and treatment modalities in the pre-hospital environment Initial Hospital Work up -CBC with differential -Chem panel with LFT's -Coags (PT, PTT, INR, FSP) -Myoglobin -UA -Stool Guiac -Blood Cultures -Chest X-Ray -Consider CT for any neurological deficits -ABG & serum lactate Treatment -Supportive care -Analgesia and fever control -Consider antibiotics with an unclear picture (doxycycline) -Treat underlying coagulopathies and electrolyte abnormalities -Consider central line for ongoing resuscitation and monitoring of fluid status (CVP) -Monitor I&O and labs -Infectious disease consult Take care, chbare. Link to comment Share on other sites More sharing options...
Kiwiology Posted July 28, 2009 Author Share Posted July 28, 2009 (edited) No meds No allergies No PMHx Had appendix out 10 years ago Nobody else sick Only went to Fiji and came home No Fijiiian meds This is from the July issue of our Clinical Matters newsletter so I will provide the information put in there: What is the most likely diagnosis? Meningococcal septic shock,or some other form of septic shock, although bacteria Neisseria meningitdis is the most common cause. What are the spots called? The small spots are called petechiae and the large ones, purpura. They appear when small blood vessels rupture and bleed into the tissue of the skin. This process is going on throroighout the entire body and in all organs -- it is just that we see it in the skin. What is causing the spots? This process is called disseminated intravascular coagulation or DIC. It is a process of widespread formation of small blood clots throughout small blood vessels. This widespread clotting is triggered by endotoxin. As the clots form they block small blood vessels and then these vessels break down and repture -- forming the visible spots. Widespread clotting and bleeding causes clotting factors to deplete which only makes the bleeding worse. What do you do? This patient is time critical! - A scene time of under ten minutes is expected, load and treat en route - Advanced Paramedic backup should be called for unless already present - Advanced Paramedic backup should be intercepted en-route, do not wait for them to come to you - These patients are often profoundly shocked and require agressive fluid volumes - Antibiotics from a GP. PRIME doctor or doctor coming out to meet you can be helpful if this can be arranged without delaying transport to hospital - This close (!) to hospital do not call for a helicopter, you will get Advanced Paramedic backup and the patient to hospital faster by road than air Jeez looks like I can't run anything by you guys anymore! Edited July 28, 2009 by kiwimedic Link to comment Share on other sites More sharing options...
tom5706 Posted July 29, 2009 Share Posted July 29, 2009 Looks like petechiae possibly related to a mosquito borne viral illness like dengue hemorrhagic fever, since he was in a tropical region recently. His clotting mechanism is messed up. Priority: ABC's, IV line in case he crashes, draw purple, red, and clot tubes of blood with IV start, HOB at 45, start O2, cardiac monitor, scoop and run. Link to comment Share on other sites More sharing options...
cosgrojo Posted July 29, 2009 Share Posted July 29, 2009 Was this patient recently bitten by an animal? Endotoxins are commonly found in animal saliva. Endotoxin from animal saliva enters blood stream, causing blood vessels to lyse, clot, and create petechiae. I don't know what knowing the cause of the bacterial infection will change any patient care... but it would be great information for the hospital. Link to comment Share on other sites More sharing options...
chbare Posted July 29, 2009 Share Posted July 29, 2009 Let's not let this one die, more people need to see this scenario. A very important lesson is presented with this scenario. Let's be honest guys. the reality is we bombed this scenario initially. (my self included) Most of us went for malaria, dengue, or another illness. However, I think we missed an obvious meningitis: acutely ill with a charateristic rash. The history led me to suspect one problem, while de-emphasizing the pragmatic answer and deadly problem. For shame chbare, for you could have delayed treatment with your bias and tunnel vision. A great teaching point here. Point well taken. Take care, chbare. Link to comment Share on other sites More sharing options...
speedygodzilla Posted July 30, 2009 Share Posted July 30, 2009 When I first read the 1st message I immediately thought meningitis, yet was quickly turn in another direction when pt denies photophobia, stiff neck or a headache. The three classic signs of meningitis. Still kind of confused as to if this was the pt's diagnosis? The question was most likely not what is? According to my paramedic book Nancy Caroline's Emergency Care in the Streets. "The classic signs and symptoms of meningitis are the same for both viral and bacterial forms: sudden-onset fever, severe headache, stiff neck, photosensitivity, and a pink rash that becomes purple in color. The patient almost always experiences changes in mental status, ranging from apathy to delirium. Projectile vomiting is common..." How is it most likely meningitis when he seem to have most of the classic signs? I have no picture of the rash however the description in the book does not describe spots. I know patients do not always or even present in a text book manner, but he was the exact opposite. What do you think? PS I use yahoo image search and found some good meningitis rash that do resemble the one posted! Link to comment Share on other sites More sharing options...
cosgrojo Posted July 30, 2009 Share Posted July 30, 2009 (edited) Kiwi- Does this patient have a Temperature? I'm still not sure how we landed on bacterial meningitis... It is very rare for meningitis to exist without at least one of the triad (nuchal rigidity, High temp, Altered Mental status). What do we know about how he acquired it... Animal bite? Some sort of blunt trauma to the nose or face? A different viral infection that broke down the sinus cavity causing the Bacteria to be introduced? After doing a bit more research, it appears that meningitis that exhibits the petechiae rash, almost has to be bacterial in nature... so that makes sense. Just a few more thoughts on the subject.... thanks for the scenario. Edited July 30, 2009 by cosgrojo Link to comment Share on other sites More sharing options...
cosgrojo Posted July 30, 2009 Share Posted July 30, 2009 You are called to a 35 year old man who has been nonspecifically well x 2 days. He has recently returned from Fiji where he recieved a lot of misquito bites. He complains of a sore throat and achy joints but denies photophobia, stiff neck or a headache. HR 140 The more I look at it... it more closely resembles signs and symptoms of Ebola virus... yes? no? Or am I just crazy? BTW - to answer many of my own questions... I, for some reason, kept completely skipping over the mosquito bite part of the opening sentence. Just caught myself, that would explain the route... but I still think it would be difficult to come to that conclusion (meaning meningitis) based on the complaints at hand... unless you are going to tell me he has a fever, then we are talking... Although Ebola fits just as well. Link to comment Share on other sites More sharing options...
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