DartmouthDave Posted June 9, 2012 Share Posted June 9, 2012 (edited) Hello, You are a ACP/PCP crew responding to suburban home for a 24 year-old female complaining of abdominal pain, weakness and worsening shortness of breath. On arrival you find a 60kg female sitting on a coach in obvious distress: tachypena, pale, diaphoretic and in pain. There is a bucket by her side full of emesis. She mumbles that she is pregnant. She is alone and called 911 on her cell phone. He husband is at work but he is on the way home. Cheers Edited June 9, 2012 by DartmouthDave Link to comment Share on other sites More sharing options...
Kiwiology Posted June 9, 2012 Share Posted June 9, 2012 You are a ACP/PCP crew responding to suburban home for a 24 year-old female complaining of abdominal pain, weakness and worsening shortness of breath. On arrival you find a 60kg female sitting on a coach in obvious distress: tachypena, pale, diaphoretic and in pain. There is a bucket by her side full of emesis. She mumbles that she is pregnant. She is alone and called 911 on her cell phone. He husband is at work but he is on the way home. When did the pain start and what was she doing when it started? Has it changed any? Does anything change it? What kind of pain is it? Does she have pain anywhere else or does the pain go anywhere else? How pregnant is she? Has she been seeing the midwife/OB regularly? any problems? Any other pregnancies or births? Any vaginal bleeding? Race? smoker? does she have an IUD? PMHx Primary and secondary survey? Obs? ECG? My immediate thoughts are either PE or some sort of gynaecological catastrophe e.g. ruptured ectopic pregnancy or previd placentae Link to comment Share on other sites More sharing options...
DartmouthDave Posted June 9, 2012 Author Share Posted June 9, 2012 Hello, She is white and she just found out she was pregant three days ago with a home test. She is sheduled to see her GP in a day or so. She has no children. She has had a three year history of abdominal pain and has seen numerious Dr. She said that she has Functional Bowel Syndrome. But, she isn't sure what that means. Her nomal pain pattern is vague dull abdominal pain that comes and goes and usually last for a day or so. Her pain is controlled by Hydromorphone pills which she takes on rare occassions but those things are bad for you. However, today, the pain has become more intense and localized to the abdomen. She says it is the 'Worse pain of her life!!!!' and she says 'Don't touch it!!!' You try and get more history (ETOH,Meds, ect...) but she barfs and says it hurts too #@#%@ much to talk and starts to cry. The PCP conects her to the monitor: HR 120 with ST elevations in V1 ---> V4 and the occassional PVC / Pulse is weak and skin is moist and cool to the touch BP 80/P Resp 30's SpO2 98% on room air Temp 36.0 BGL 10.0 Cheers. Good luck. This is based on a patient that came through our ICU a few months back. Link to comment Share on other sites More sharing options...
Kiwiology Posted June 9, 2012 Share Posted June 9, 2012 Hmmm Her hypotension, cool skin, weak pulse and sweats could be hypovolaemia or PE Her abdo pain could be IBS or it could be some obstetric catastrophe ST elevation could be ischaemic or nonspecific and mean nothing Is the abdo tender or rigid, any discolouration? What is her vomit like? any blood or other abnormalities? Imp - PE or some sort of obstetric catastrophe causing internal bleeding but at 3 days preggo it is highly unlikely Plan - start a drip, give her a litre of fluid and some pain relief if she wants it Link to comment Share on other sites More sharing options...
DFIB Posted June 9, 2012 Share Posted June 9, 2012 (edited) The general rule is "All abdominal pain in child bearing age women is an ectopic pregnancy until proven otherwise" I would consider this patient a probable ectopic pregnancy and treat accordingly. This is a high priority patient. Large bore IV with Ringers Lactate or Hartman's solution. Connect the Dfib pads to her chest. When was her Last Menstrual Period? If requesting Helicopter is the fastest way to the hospital that is the route to go. If not request ALS intercept and Load and Go. I understand this is a ACP/PCP unit but I am only a basic so I will not go into pain management. Edited June 9, 2012 by DFIB Link to comment Share on other sites More sharing options...
DartmouthDave Posted June 9, 2012 Author Share Posted June 9, 2012 (edited) Hello, Her LMP was normal. She missed the last one and took a home pregnancy test and it was positive. She has no PV bleeding or discharge. Her abdomen is slightly distended, firm and very tender to the touch. The pain started out a vague and grew and grew and localized in her ULQ and URQ. She also had pain in her right shoulder. The emesis isn't bloody. You insert one IV (#18) with difficulty and start a fluid bolus. You notice an odd brownish colour to the blood. Her husband arrives on scene. Pain control? ST elevation? STEMI? Cheers Edited June 9, 2012 by DartmouthDave Link to comment Share on other sites More sharing options...
DFIB Posted June 9, 2012 Share Posted June 9, 2012 What color is her skin? Does it have an abnormal color. When was her last bowel movement? Does her vomitus smell like feces? Does our rig carry methyline blue? Does she have a Dialudud induced Methemoglobinemia? Link to comment Share on other sites More sharing options...
ERDoc Posted June 10, 2012 Share Posted June 10, 2012 Does our rig (yeah, I know) have one of those new portable ultrasounds? If not, iv fluids and transport as quick as possible. Link to comment Share on other sites More sharing options...
Kiwiology Posted June 10, 2012 Share Posted June 10, 2012 I am thinking pancreatitis This lady is sick, she needs to go to a large hospital with surgical and ICU capability; give her some pain relief, get her and husband in the ambulance and transport with an early RT call to the hospital. Link to comment Share on other sites More sharing options...
DartmouthDave Posted June 10, 2012 Author Share Posted June 10, 2012 What color is her skin? Does it have an abnormal color. When was her last bowel movement? Does her vomitus smell like feces? Does our rig carry methyline blue? Does she have a Dialudud induced Methemoglobinemia? She is pale and cool. She has frequent lose BM. No fecal smelling emesis. No, it isn't MetHgb. Nice job however. I didn'tknow that Hydromorphone coould cause MetHgb. Does our rig (yeah, I know) have one of those new portable ultrasounds? If not, iv fluids and transport as quick as possible. No u/s on the ambulance. Also, I would know what to do with one at the moment. =) I am thinking pancreatitis This lady is sick, she needs to go to a large hospital with surgical and ICU capability; give her some pain relief, get her and husband in the ambulance and transport with an early RT call to the hospital. I will say that Kiwiology is correct with pancreatitis. With IV fluids and some pain control of choice the patient settles and VS improve some. HR 100 with ST elevations BP 90/60 SpO 98% The husband is on scene and you are loading up and getting ready to transport to the local teaching hospital (10 minutes away). The husband provides some more information. His wife is healthy other than on again off again episodes of stomach pain that goes away when she rests, stops eatting and take some pain pills. She never drinks or smokes. So, what is the etiology of her pancreatitis? The brownish blood? (sorry, it is hard to describe it here online) Have to run. The little ones want to break out the bikes. Cheers Link to comment Share on other sites More sharing options...
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