Colonoscopy & SOB

[DartmouthDave]

Hello,

ALS is requested by a BLS crew that is on scene. You arrive to a nice suburban home and proceed inside. You are greeted by one of the responding PCP. She briefs you about the situation.

Walter, a 72 year-old male had his wife call for an ambulance for worsening SOB and fatigue. Walter has a history COPD, NIDDM, CHF, AMI (8 years ago), numerous episodes of VT and had a ICD and Pacemaker inserted as well. He has just came back from the hospital were he had a colonoscopy done as an investigation for a low Hgb. No active bleeding was found during the scope. He has been NPO since yesterday. He also hasn't taken any of his medications since yesterday as advised by the endoscopy clinic.

Walter is sitting in his living room. He appears frail. He is working hard at breathing and has a wet cough. His skin is diaphoretic and pale.

VS as per the BLS crew:

GCS 15/15

BP 120/60

HR 120

Rate 38

SpOs 88% on 15 lpm

Cheers...

Edited August 19, 2010 by DartmouthDave

[chrissym6]

I'm not an EMT yet (my state practical is next Saturday) but I'd like to take a crack at this one if that's ok. Do we know what medications he is on and what, if anything he had been given for the colonoscopy?

[DwayneEMTP]

I'm not an EMT yet (my state practical is next Saturday) but I'd like to take a crack at this one if that's ok. Do we know what medications he is on and what, if anything he had been given for the colonoscopy?

Not only are you certainly allowed to participate here, but good for you for doing so!

I have a couple of pretty high confidence guesses, but lets play with it a bit before going down that road...

Any complications during the procedure? What meds did the clinic recommend that the patient is non compliant with? Why was is he non compliant?

Dwayne

[uglyEMT]

I know he has not taken any meds since yesterday. Was any of his meds an expectorant? Wet cough with COPD and CHF sounds like a fluid buildup. The 88 on 15 is telling me alot of fluid. Time for CPAP.

Vitals indicate elevated HR but with a pacemaker it should be regulated. Ask wife for the card to see the max and min of the unit settings. The 60 on the BP does seem low considering the age and hx. Vasodialation may be caused by the low O2 levels.

One thing I would say is get the Sp levels UP he cant keep the 38 breaths up for long. CPAP and call med control for instructions on meds. After getting the O2 levels up recheck BP and see if it has come up and HR has come down. I feel the BP and HR are being caused by the low O2.

Im only BLS so the meds I dont know what to administer thus the call med control.

I have a few guesses on the underlying cause besides the fluid

Being he hasnt taken anything by mouth in a day and is diabetic could we be seeing dehydration with an insulin buildup thus leading to the tiredness, dyaforetic pale skin?

[rock_shoes]

In the short term let’s get some lung sounds ASAP. The PCP crew should be able to provide some PPV with a BVM right off the bat.

Now let’s get some complete vitals. BP, SPO2, ECG, BGL, Temp, Overall appearance, SPCO and SPMetHgb if you’re monitor is so equipped. Patient’s regular meds are? Meds and dosages used for the colonoscopy where? Spec information on the patient’s implanted pacemaker/defibrillator? Did the PCP crew initiate vascular access? Are you equipped with CPAP or BiPAP? Why hasn’t he gone back on his medications yet? Allergies? Any other medical history?

[Chief1C]

May have not had any bleeding before.. But it's possible that it caused bleeding, afterward.

[DwayneEMTP]

May have not had any bleeding before.. But it's possible that it caused bleeding, afterward.

Yeah, I'm thinking along those lines as well. Need a good set of lung sounds, but I have a feeling that fluid isn't going to be the issue. In fact I have a feeling other than some minor rhonchi, that the tidal volume will be good. (possible hint, but more possibly just crap)

(Not trying to be a smartass without bothering to ask my own questions, but the others that are exploring this scenario have asked several intelligent questions that haven't been answered yet. I want to allow them the opportunity to ask follow up questions based on those answers without my questions moving the conversation off on a different track. See what I mean? I'm proud as hell that we finally have some BLS providers that are interested in ALS assessments and not just the drugs.)

Just a guess though. But in case the stars have lined up and I'm accidently right I don't want to queer the conversation until others have had a chance to explore for a bit.

Dwayne

Edited to correct a spelling error and to add the text in italics. Second edit because I forgot to explain my first edit. No other changes made.

Edited August 19, 2010 by DwayneEMTP

[Adam Swartz]

As I just passed my NREMT-B Written today I think I will take a crack. If I was ALS my first thing is ABC= does he have an airway. If so lets get Oxygen on him NOW. Second lets get him on a full twelve lead. What meds did the Endoscopy center give him for sedation? I have had one every year and normally get a mix of Demerol, Versed and also Benadryl. Now I am under general anaesthesia. Is he having any pain? If so my guess is a possible perforation of the colon leading to severe pain and SOB due to that in addition to the sedation received at the endoscopy center. Also does he have any other symptoms. Any hx of Asthma? With the hx of COPD would an Albuteral 2.5 ml neb help? Or do we need to be ready to intubate? Also did they find polyps? Biopsies can bleed and occasionally severely. Lets get hauling to the hospital. Lets get an IV established and push D5 at TKO or if available lets put in a lock. Thats my opinion.

[chrissym6]

Please bear with me when I repeat what others may have already mentioned but this is how I work though scenarios and will hopefully make it easier to see where I went wrong if I end up on the wrong track or missing something important. Based on the tachycardia and low diastolic pressure I too am leaning towards a bleed, whether it was caused by the colonoscopy or missed becasue it was occuring somewhere outside of the colon is not my main concern at the moment. I would like to know if there has been any improvement to his respiratory rate since he's been on the 15L or do I have to get ready to bag him? I'm not worried about his cough right now but I'm not ready to write of the paleness as dehydration just yet (although he is undoubtably dehydrated). I'm also curious as to why he hasn't been eating, drinking, or taking his meds since the colonoscopy-- I've had a few of those myself and normally the first thing I do when I wake up is get something to eat and have a nice drink of water or ginger ale. Was he not hungry/thirsty, at which point there is probably more than a bleed going on (inflammation in the small bowel comes to mind or he could have picked up a virus somewhere) or did he simply get confused and not realize he was allowed to go back to eating, drinking, and taking his meds following the procedure? As a basic I wouldn't be able to do much more than give him oxygen and transport but if I were a medic I'd like to get a line in him and given his cardiac history would put him on a monitor as well just as much to avoid any surprises as to keep an eye on whats going on in there. I'm not familar enough with ALS protocols to say definitivly that I would give him anything more than saline because not only do I not know exactly which medications I would have at my disposal I have no idea how they work or what the possible side effects are and am not comfortable giving someone something if I don't know exactly what it should (and shouldn't) do.

[Jeepluv77]

You say he "just got back". Is that meaning within the past half hour or so of the call or was that several hours ago? What meds is he supposed to be on? I'd definately check his blood sugar, look for skin tenting, JVD, and tracheal deviation, place a line, and get lung sounds and ecg. If lungs are wet I'd go to CPAP and, if my service carried it, consider Lasix. What is his normal activity rate and, as mentioned before, were there any polyps removed? I'd try to rule out a PE in the absence of wet lung sounds while headed to the hospital, especially if they removed polyps or if he's normally sedentary. Also would attempt to rule out MI although I'd have a lower level of suspicion for it. Was he sedated and intubated? If so, I'd like to think they gave him some fluids as well which would make serious dehydration less likely. What meds were given on discharge for pain and inflammation?