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At this point any changes in LOC?

No temp not septic...?

What are distal pedal pulses like...thinking disecting AAA.

Anyone check CBC, Lytes, dif?

I am thinking maybe D.I. but thats a stab in the dark.

Call attending M.D.

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U said she has had some N/V. What Color is it, and how often. She could have a mass in her esophagus or stomach. I would almost bet a Esophagus veracious about to rupture. I would keep her pressure around 80 systolic if she is perfusion is good.

TX- iv fluids

12 lead

CT of ABD and chest

keep NPO

CBC,CMP,PT/INR, PTT, T&C a couple,

Call her oncologist

talk to family bout a DNR

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There was nothing impressive about the color of the vomit (no blood etc). What makes you think esophageal varcies? The 12 lead is unremarkable. All the labs previously requested were unimpressive. No fever. Your pts BP is now down to about 50/42 HR still in the 150s. Obviously at this point there will be no pedal pulses. You use your US again and there is still no AAA. Come on folks, your pt is crashing before you. As a hint, no matter how much fluid you dump in, the BP will not improve. Let's recap some of the pertinent findings:

Pt with cancer

Not feeling well

Hypotensive (look at the BP again) and getting worse

BP not responding to fluids

EJs look like a CFR could hit them blind folded

Lungs clear

EKG nl

Not septic or febrile

Any more thoughts?

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Start some pressors - dop or levo, maybe neo (or all three) - to try and get pressure up. Send for stat head CT - looking for increase in brain mets which could be causing the problems (brainstem issues).

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Start some pressors - dop or levo, maybe neo (or all three) - to try and get pressure up. Send for stat head CT - looking for increase in brain mets which could be causing the problems (brainstem issues).

We are crashing here big time, do we need to protect airway with a tube?

Agreed, "TFT" Time for tropes, but caution with that tacky rhytum just may see VT of VFib quik like.....but where are the labs ERdoc..?

Some Penta span or PRBCs may fill up the tank a bit looks low

Please explain?

EJs look like a CFR could hit them blind folded

are they flat or engorged? I suspect the pt supine by now, I am missing something here?

Flat fluid

JVD---- Chest sounds ie Lung again, not in failure if not bubbling!

any muffled heart sounds?

Treat the:

Fluid

Pump

Container

What if any urine being produced...I am looking to rule out Diabetes Insipitus...or am I way off base? :oops:

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We are crashing here big time, do we need to protect airway with a tube?

Agreed, "TFT" Time for tropes, but caution with that tacky rhytum just may see VT of VFib quik like.....but where are the labs ERdoc..?

Some Penta span or PRBCs may fill up the tank a bit looks low

Please explain?

EJs look like a CFR could hit them blind folded

are they flat or engorged? I suspect the pt supine by now, I am missing something here?

Flat fluid

JVD---- Chest sounds ie Lung again, not in failure if not bubbling!

any muffled heart sounds?

Treat the:

Fluid

Pump

Container

What if any urine being produced...I am looking to rule out Diabetes Insipitus...or am I way off base? :oops:

Pt is crashing, you're not going to get a CT. The EJ are engorged supine and upright. Pressors help bring the pressure up, but only momentarily. Her heart rate is now sky high. Pt is still conscious and maintaining her own airway, no need to tube. The labs will be of little use. Heart sounds are very muffled. Lung sounds are clear still. Pt does not report any problems with urination.

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Holy heck batman

well with muffled heart tones I suspect that she has cancer around the heart and it's prohibiting her ability to pump. Or she could have a tamponade.

Any history of trauma after her syncopal episode??

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Check pts pupils. Is the pt still breathing effectivley on there own or is there some suppression. If there is any evidence of increased ICP think about pushing some mannitolto draw the fluid out of the head. Pt is gonna get a tube. With that pressure and heart pt is gonna crash soon I would RSI them. If it doesn't seem like an increase in ICP maybe use some vasopressin to get the pressure up and the HR down. Whats the pts skin color and quality? If it is pw+d it is probably going to be neurogenic shock. Can we use a capnograh to see what the CO2 is doing as far as too high or low. The CO2 might explain the autoregulation problem with the pressure. Could be throwing off acid base balance. :lol:

Patrick

EMT-B

Paramedic Student

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well with muffled heart tones I suspect that she has cancer around the heart and it's prohibiting her ability to pump. Or she could have a tamponade.

:thumbleft:

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