Bieber Posted September 10, 2012 Author Share Posted September 10, 2012 DFIB, why do you want to give epinephrine or atropine? Doc, no chest discomfort or difficulty breathing. No ultrasound, alas. Link to comment Share on other sites More sharing options...
Canuck_EMT Posted September 10, 2012 Share Posted September 10, 2012 Treatment: O2 IV NS bolus for 250ml, reasses BP Monitor ECG, acquire 12-lead. Trendelumberg pos if pt is comfortable with it. Transport, reasses vitals, aquire further pt hx. Possible cholecystitis? Haha wow sorry my entry was late. Link to comment Share on other sites More sharing options...
Happiness Posted September 10, 2012 Share Posted September 10, 2012 Okay Im going to ask how big was the baby. I was going with pre eclampsia but not really at this point. I would also like know if there is any SOB as pulmonary embolism could be a factor. Did she tear while in childbirth. Link to comment Share on other sites More sharing options...
HarryM Posted September 10, 2012 Share Posted September 10, 2012 (edited) After about 60 mcg of Fentanyl and 500 ml of NS, patient's heart rate and blood pressure rise. Your new set of vital signs are: HR: 70 BP: 96/60 RR: 16 Patient adamantly denies any intentional or accidental overdose. Great. In that case I'd continue with another 250ml of NaCl. Does the 60mcg of Fentanyl relieve the pain? If not then I'd keep going with the Fentanyl...by which time we would be 20min in, at hospital and she is all handed over I wouldn't give 02. SPO2 was good and there is no evidence of SOB so far and RR is normal. No clinical indications for it at this stage. Edited September 10, 2012 by HarryM Link to comment Share on other sites More sharing options...
Bieber Posted September 10, 2012 Author Share Posted September 10, 2012 Treatment: O2 Why? IV NS bolus for 250ml, reasses BP BP has raised following 500 mL of fluid and 60 mcg of Fentanyl to around 90 systolic. Monitor ECG, acquire 12-lead. Now a regular sinus rhythm, rate of about 70. 12-lead is non-diagnostic and shows no conduction abnormalities. Trendelumberg pos if pt is comfortable with it. Done. Possible cholecystitis? Patient had her gallbladder taken out about a year ago. Okay Im going to ask how big was the baby. I was going with pre eclampsia but not really at this point. I would also like know if there is any SOB as pulmonary embolism could be a factor. Did she tear while in childbirth. About eight pounds. Why eclampsia? No dyspnea, no complications during childbirth. Great. In that case I'd continue with another 250ml of NaCl. Does the 60mcg of Fentanyl relieve the pain? If not then I'd keep going with the Fentanyl...by which time we would be 20min in, at hospital and she is all handed over I wouldn't give 02. SPO2 was good and there is no evidence of SOB so far and RR is normal. No clinical indications for it at this stage. After another 40 mcg of Fentanyl and 250 mL of NS patient's pain is down to a 2/10 and her new vitals are: HR: 70 BP: 110/64 RR: 16 SpO2: 98% on room air. Thoughts on a diagnosis? Or why she was hypotensive and bradycardic? Anything else anybody wants to add? We'll say we're transport complete now at the hospital, patient's blood pressure and pain have been adequately managed with fluids and Fentanyl. Let's focus on our diagnosis. There's two questions we need to answer: What is the cause of the patient's pain? Why was the patient hypotensive and bradycardic? Ideas? Link to comment Share on other sites More sharing options...
Happiness Posted September 10, 2012 Share Posted September 10, 2012 For me the reason for eclampsia is because I have known of one mother who did die 2 weeks after birth, she had no complications during the birth but the baby was about 12 lbs. I dont remember why the babies weight had anything to do with it but anyways it was a tragic event in the community. Well I hope the answer is something rare because I havnt a clue at this point. Link to comment Share on other sites More sharing options...
HarryM Posted September 10, 2012 Share Posted September 10, 2012 Something liver/kidney related? Is it possible that she has hepatitis of some sort which would cause liver inflammation? Although that doesn't quite explain the hypotension or bradycardia (I'm throwing straws out here). Link to comment Share on other sites More sharing options...
scubanurse Posted September 10, 2012 Share Posted September 10, 2012 Mike, no history of liver problems, alcoholism. HIV negative per patient. Patient denies history of aortic aneurism, Marfan's syndrome or Ehlers-Danlos syndrome. I just want to say you rock for ruling out EDS and Marfans :) Link to comment Share on other sites More sharing options...
Bieber Posted September 11, 2012 Author Share Posted September 11, 2012 Thanks, Kate! Happiness, I'm afraid to say that it's not eclampsia. An obstetrical emergency is definitely a good thing to consider, though, and something I considered as well. Harry, you're on the right track, but you're right, it doesn't explain the hypotension or bradycardia. This has been a great scenario so far, guys! I'm glad to see so much participation. I'm going to wait a few more hours to let some other folks throw out some final diagnoses and then I'll give you guys the answer by about midnight central time. Link to comment Share on other sites More sharing options...
Chief1C Posted September 11, 2012 Share Posted September 11, 2012 Not once in fourteen years, have I seen pain management used in non-traumatic abdominal pain. Several times they called for permission, and every time, doc said no.. Likely b/c of the difficulty to diagnose, once it doesn't hurt anymore. A couple times, not only did I feel bad for the patient, I was offended on behalf of EMS in general. Cancer patient, in extreme pain, gonna die anyway, no treatment possible, on hospice.. Calls b/c the pain is out of this world.. and the medic released care back to me. Like WTF am I supposed to do, take the patient home and help *the patient* load a gun to kill themselves? That bothered me more than anything I'd ever seen, in fact, the deep helpless feeling kinda made me tear up. Got the medic fired, that helped me a bit. Link to comment Share on other sites More sharing options...
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