A simple fall goes wrong

[medicgirl05]

Possibly the 10mg of Morphine is masking the severity of her pain?

Or maybe she has peritonitis as a result of the rupture?

I'm in over my head. Help!

[mobey]

Yup....

That's the problm with this call, not enough informion to make a good Dx.

Deprioritize the Dx and start treating the symptoms.

[Arctickat]

Ahem

[medicgirl05]

So do you know what the outcome was?

[HarryM]

Treating the symptoms:

firstly I'd take her off a simple mask at 10L/min and see what her SPO2 does. I want to see if the O2 is actually helping an acutely low SPO2 or if someone just decided to blast her with a lot of O2 when she was saturating on room air at 88-90%. Then based on that, adjust my O2 therapy. Then run another 500ml NaCl to see whether it increases her BP or not. Then based on that, decide if there is any point pushing through more fluids if it's not helping her hypotension. On the ride I'd lay her flat and elevate legs to see if positioning increased her BP.

T wave inversion + SOB + tachypnoea + low SPO2 + hypotension = all pointing to a suspected PE

Edited January 10, 2013 by HarryM

[Kiwiology]

Could be a slowly developing pneumothorax or lung contusion; does the CXR reveal the fractured ribs or are they evident visually or upon palpation?

If it's bilateral consolidation makes me wonder if it might also be respiratory tract infection - elderly people are known to get pneumonia pretty easily and this would seem to fit the bill aetiology wise.

I definitely agree with Harry that her symps are suggestive (but not specific for) PE however I am unsure if a PE would "suddenly develop" out of thin air without some significant underlying pathology such as a DVT.

Titrate oxygen therapy and analgesia and transport nice and slow, Harry you can drive.

[Secouriste]

Do we know what ribs were fractured? Also, what's the aspect of the skin at the elbows and knees, the lips and conjunctivas?

How is her breathing, beside the noises does she makes extra-effort to breath-in? Is there a paradoxal breathing or seesaw respiration? Does she spits during the coughing?

Is there anything abnormal on the chest upon visual inspection? Palpation?

Can she bear to lie flat on her bed?

[mobey]

Yes, increased pain with cough.

For all questions regarding x-ray - I have given all I was given.

Nothing noted on chest exam, except obeisity and pain on palp consistant with the fractured ribs.

You take the 02 off long enough to move her to your cot. He Sp02 drops to 82% and she is c/o increased SOB.

Accessory muscle use is noted in the abdomen with or without 02.

500ml does nothing for her BP.

Now loaded into the ambulance she is back on the simple mask @10lt. Sp02 88%.

Pale, diaphoretic.

BP 76/42 HR70 Resp unchanged

[HarryM]

Ok so start another bag of fluids TKVO and switch onto a reservoir mask at 15L/min if the pt can tolerate finds that comfortable enough, otherwise reduce flow rate.

If pain increases enroute then possibly look at some ketamine to get an increase in sympathetic response as well as pain relief.

If things turn south and it is a pneumothorax then be prepared to decompress enroute if it tensions. Otherwise not a hell of a lot to do treatment wise unless your service allows the use of vasopressors for hypotension.

[Kiwiology]

Do we have her temperature? Any signs of an infection in her blood chemistry e.g. leukocytosis, increased ESR, bands/segs?

I am thinking either a PE or sepsis but cannot think of an aetiology for either?

I'd give her another litre of fluid and if that does not improve her BP then I'd be keen to hang an adrenaline drip

Harry my friend, step a bit harder on that gas pedal mate