Bieber Posted May 30, 2012 Share Posted May 30, 2012 Dwayne, by orientation I actually meant his workplace orientation, lol! So what we've determined so far is that he's ventilating fine. Short of being unaccustomed to oxygen levels at that altitude, that leaves pulmonary gas exchange, gas transport and peripheral gas exchange as the three locations where the problem must lie. I'm still leaning toward high altitude issues on this one, though pulmonary embolism is still on my list as well. Without further diagnostic scans and without the ability to test to see if he improves with descent, I'm kind of at a loss as to how to rule in/rule out any more diseases, however. My best guess for now would be to keep him on bed rest for a few days and see how he does. If he acclimatizes and the dyspnea and hypoxemia resolve then that would support a diagnosis of high altitude illness. Link to comment Share on other sites More sharing options...
DwayneEMTP Posted May 30, 2012 Author Share Posted May 30, 2012 Chris, blood sugar is within normal limits. Biebs, good summation. You may be at a loss, but you're not without the skills. There is one part of this presentation, from the beginning, that didn't make sense to me, though Chris may say that he sees it all the time. I didn't really get it until I'd trialed him on room air several times though and then it finally clicked. I came up with only one theory that made any real sense to me, I consulted with some Aussie docs in Sydney who agreed, and then it was 'verified' though I've no idea how, at the hospital in Lae. You're thinking possible altitude sickness, possible P/E, both of which come with significant hypoxia, right? Link to comment Share on other sites More sharing options...
DFIB Posted May 30, 2012 Share Posted May 30, 2012 Chris, blood sugar is within normal limits. Biebs, good summation. You may be at a loss, but you're not without the skills. There is one part of this presentation, from the beginning, that didn't make sense to me, though Chris may say that he sees it all the time. I didn't really get it until I'd trialed him on room air several times though and then it finally clicked. I came up with only one theory that made any real sense to me, I consulted with some Aussie docs in Sydney who agreed, and then it was 'verified' though I've no idea how, at the hospital in Lae. You're thinking possible altitude sickness, possible P/E, both of which come with significant hypoxia, right? Drumroll .. And the theory is ...... Link to comment Share on other sites More sharing options...
DwayneEMTP Posted May 30, 2012 Author Share Posted May 30, 2012 A couple of things bothered me... That his mentation seemed unaffected at an SPO2 of 72%, as well, I saw no increase in mentation at 100%. I expected him to be 'sharper' or more alert with increased sats. Also, that when given oxygen, his sats jumped to 100% in, probably, less than 30 seconds, while it took them 6 or 7 minutes to drop back down again. He was pretty thin so I would expect it to take him a while to de-sat, but it still seemed odd to me... After I removed his oxygen, at rest, and monitored him closely, I saw no change in breathing effort nor change in mentation as his sats settled back down to the low 70's. Also, he reported no relief when given Oxygen except in the few minutes immediately following the effort of walking, but after those few minutes had passed he didn't care about the O2 any more. Anyway, that's what I noticed...and could only resolve in my mind in one way.. Link to comment Share on other sites More sharing options...
DFIB Posted May 30, 2012 Share Posted May 30, 2012 But wouldn't anemia make it abnormally low on the top end too? When you put him on Os his sats jump up to 100% very quickly. I did consider that the machine was off and tried him on two battery powered and one wall mount SPO2 unit, and they all agreed. Why did I try so many? When I argue that we don't need them if we're decent clinicians? Because I just couldn't make this patient match what the pulse ox was telling me. Washed his hands, warmed them, he had good cap refill in all fingers, etc. I was thinking of abnormally low oximetry reading in anemic patients as an error variant and not a expected abnormal low. This would translate into a quick drop into an inaccurate low saturation reading whereas the sat reading on O2 would be more accurate. I don't think i explained my idea very well the first time. This time is probably not much better. Here is a reference to the inaccuracy % of Oximeters in anemic patients on both the high and low end. http://www.springerlink.com/content/w737506850077063/ I had read this before elsewhere but cannot find the source right now, Link to comment Share on other sites More sharing options...
DwayneEMTP Posted May 30, 2012 Author Share Posted May 30, 2012 In this patient you can assume that the pulse ox is telling the truth... What other symptoms would we expect to see with anemia? Are we seeing them here? Link to comment Share on other sites More sharing options...
chbare Posted May 30, 2012 Share Posted May 30, 2012 Dwayne, it will be exceeding difficult to definitively rule in and rule out a specific disorder. The patient will need a workup. Another additional consideration is the presence of a haemoglobinopathy. Sickle cell anaemia being a fairly common one. Additionally, we need to consider equipment limitations. I wanted to wait to point this out; however, is the patient dark skinned? Link to comment Share on other sites More sharing options...
DwayneEMTP Posted May 30, 2012 Author Share Posted May 30, 2012 Very dark skinned.... Hmmm...I thought that the above would clear this up. I'm glad it didn't, as I always assume you guys will figure out instantly what took me hours and I feel smarter when you don't. It truly hit me in the face when it occurred to me... Of course the second phase of insecurity is preparing to explain my reasoning and have someone say, "What? That doesn't make any sense at all? You guessed wrong but got lucky..." Who is unaltered at 72% SPO2? And who might get little or no relief by relieving that condition? What class of patients? Link to comment Share on other sites More sharing options...
chbare Posted May 30, 2012 Share Posted May 30, 2012 Dwayne, there is a laundry list of conditions that may result in low saturations that are reasonably well tolerated. You have chronic lung disease with polycythemia and alteration of the curve being one such example. Link to comment Share on other sites More sharing options...
DFIB Posted May 31, 2012 Share Posted May 31, 2012 (edited) In this patient you can assume that the pulse ox is telling the truth... What other symptoms would we expect to see with anemia? Are we seeing them here? Some of the symptoms of anemia are weakness, general malaise, headache, SOB upon exertion, tachycardia, increased cardiac output, pale skin and mucosal linings. Some people have "restless legs" when trying to sleep and crave dirt. If I checklist our guys symptoms we have SOB upon exertion, increased cardiac output (because his pulse pressure is 60), tachycardia, and his eyelids are slightly pale. Are his lung sounds still clear? EDIT: If his hypoxemia were solely altitude related wouldn't his systolic pressure decrease? EDIT: I am not saying that anemia is his only problem but could be a contributing factor. EDIT: I agree with cbare, he possibly has a confluence of several disorders or sickness. EDIT: One of them being anemia, of course. Edited May 31, 2012 by DFIB 1 Link to comment Share on other sites More sharing options...
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