emtashelyb Posted November 25, 2009 Share Posted November 25, 2009 You have a 80 y/o pt with hx of htn, aortic regurgitation and acute renal insufficiency. Pt is being transported from hospital back to normal nursing home. You get a set of vitals before leaving the hospital bp is 176/70 pulse 80 resp 20. Nurse states he has had his htn medications pt walks to your stretcher. During transport pt begins to complain of abdominal pain around and below his belly button. You check vitals bp is now 196/60 pulse 54 resp 18 and some what labored. You notice when taking the pts pulse his brachial arteries are pulsating out of his arm about 1/4 inch. Pt begins to complain of abdominal pain now from bottom of sternum to groin and describes it as stabbing/tearing. You are a BLS unit. What would you do? Link to comment Share on other sites More sharing options...
streethealer535 Posted November 25, 2009 Share Posted November 25, 2009 O2, Bi lat B/Ps (femeral if poss or at least compare pulses), Injection of Diesel therapy back to the ED. Link to comment Share on other sites More sharing options...
Timmy Posted November 25, 2009 Share Posted November 25, 2009 (edited) Turn around and go back to the hospital. High flow 02. Is there any abdominal pulsating mass? Any difference in bilateral blood pressure? Could we get an exact location of the abdominal pain? Rebound tenderness? Is there any difference in the level of pain with change of position? Does he have a Phx of angina? Why was he in hospital? Does he have pain on excretion of urine? He needs a CT and bloods please. As for the brachial artery pulsating from his arm... Was it actually pulsating or just distended? This may be caused from the increase in systolic stroke volume. The hypertension can be caused by renal problems like glomerulonephritis which can occure in patients with ARF. Has he just had dialysis? I'm not sure what your scope of practise is but do you have access to analgesia or ECG (even 3 lead)? Edited November 25, 2009 by Timmy 1 Link to comment Share on other sites More sharing options...
emtashelyb Posted November 25, 2009 Author Share Posted November 25, 2009 Turn around and go back to the hospital. High flow 02. Is there any abdominal pulsating mass? Any difference in bilateral blood pressure? Could we get an exact location of the abdominal pain? Rebound tenderness? Is there any difference in the level of pain with change of position? Does he have a Phx of angina? Why was he in hospital? Does he have pain on excretion of urine? He needs a CT and bloods please. As for the brachial artery pulsating from his arm... Was it actually pulsating or just distended? This may be caused from the increase in systolic stroke volume. The hypertension can be caused by renal problems like glomerulonephritis which can occure in patients with ARF. Has he just had dialysis? I'm not sure what your scope of practise is but do you have access to analgesia or ECG (even 3 lead)? No palpable pulsating mass No difference in bilateral bp Pain is central beginning at beginning of sternum ending at the top of the groin No rebound tenderness No change in pain when pt placed flat on stretcher Pt has no other cardiac hx other than stated in OP Pt was in the hospital for UTI Yes the brachial arteries were actually pulsating 1/4 inch out of the arm. Pt is not on dislysis. As far as my scope of pratice no monitor avaiable. Most we can do is place pt in position of comfort, administer high concentration 02, monitor vitals and run hot to the closest ER Link to comment Share on other sites More sharing options...
P_Instructor Posted November 25, 2009 Share Posted November 25, 2009 PUHA (poohaa) back to the ED. This is a perfect example of BLS providers recognizing an acute situation. Provide the high flow O's, position of comfort and BLS care and get them back. Dependant on where you are in your transport, consider nearest appropriate facility, and even rotorwing if feasible. 1 Link to comment Share on other sites More sharing options...
HERBIE1 Posted November 25, 2009 Share Posted November 25, 2009 PUHA (poohaa) back to the ED. This is a perfect example of BLS providers recognizing an acute situation. Provide the high flow O's, position of comfort and BLS care and get them back. Dependant on where you are in your transport, consider nearest appropriate facility, and even rotorwing if feasible. I suggest that even with an ALS provider, this is an issue that needs an MD ASAP. The only thing an ALS provider could do at this point is work the code after the patient crashes but I think the outcome would not be good. Link to comment Share on other sites More sharing options...
Timmy Posted November 25, 2009 Share Posted November 25, 2009 (edited) And his Temp? There's no vomiting? What meds is he on? Renal calculi can cause radiating groin pain but you haven't mentioned anything about flank pain. Peripheral artery aneurysms could be another possibility, as is end stage renal failure. Were not going to get far with this until we get back to hospital. I think we should just provide oxygen therapy, monitor vital signs, offer position of comfort, reassure and monitor vital signs. Once in hospital I'd like: Abdo CT. Ultrasound. ECG. Urine analysis. Full bloods including proteins, potassium,WBC, U&E, KF, LFTs, serum, creatinine etc etc. If you could shed some light on the results of any of these that would be awesome? Treatment: IV access. Morph. Surg consult. If our BP isn't improving with morph then I may consider Labetalol or similar. Awaiting results for further treatment. Edited November 25, 2009 by Timmy Link to comment Share on other sites More sharing options...
P_Instructor Posted November 25, 2009 Share Posted November 25, 2009 I suggest that even with an ALS provider, this is an issue that needs an MD ASAP. The only thing an ALS provider could do at this point is work the code after the patient crashes but I think the outcome would not be good. MD......aah, surgeon (yes I know they are MD's also). Agree with you on the outcome.... Link to comment Share on other sites More sharing options...
JPINFV Posted November 25, 2009 Share Posted November 25, 2009 What would you do? Link to comment Share on other sites More sharing options...
HERBIE1 Posted November 25, 2009 Share Posted November 25, 2009 LMAO MD......aah, surgeon (yes I know they are MD's also). Agree with you on the outcome.... Yep. Working in the ER, I had a running gag with one of the trauma surgeons. When we had someone who was stabbed multiple times, broken up, or shot and going down the tubes, I would look at this doc and tell her- "Time to do that doctor stuff!" which meant getting the person to the OR and under the knife ASAP. She would look at me and just laugh. Link to comment Share on other sites More sharing options...
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