brock8024 Posted September 30, 2006 Share Posted September 30, 2006 You are dispatched to a residents for a 54 female. All the dispatch can give you is the pt feels cool and is not responding to her husband. When you arrive on scene you find a over weight female in bed with approximently 4 pillows behind her. She is unresponsive and will slightly respond to painful stimuli. You notice loud noisy respirations. V/S- HR 40 BP- 80/palp RR- 6 and labored Spo2- 80% on RA. Capnography- 55 Skin - Very Very cool to touch. What else you want to know and how you going to treat her. Link to comment Share on other sites More sharing options...
hammerpcp Posted September 30, 2006 Share Posted September 30, 2006 Remove pillows and open airway with positioning. Results? Prepare resuscitation equipment. BVM, Cardiac monitor, Oxygen, airway adjuncts......... When was pt last seen normal? What is her normal? Mentation, level of functioning, self care,etc? Medical history and medications? Link to comment Share on other sites More sharing options...
brock8024 Posted October 1, 2006 Author Share Posted October 1, 2006 You remove the pillows and assist with BVM. What airway are you going to use, and how much O2 On the monitor you see low voltage brady rhythm. Husband said about 4 hours ago pt was not feeing well and went to bed. Pt is over weight about 350lbs. Can walk and is normally responsive. Husband has to help with normal things like cooking, bathing and helping pt dress. PMH- husband states she has not been to a doctor in years. The husband states that she gets tired easy and has not been eating much. He also states that her face has been kind of puffy the last few years but and been a little forgetful but they thought that was due to getting older. Also he has noticed some thinning hair but that runs in her family. What else you want to know Link to comment Share on other sites More sharing options...
hammerpcp Posted October 1, 2006 Share Posted October 1, 2006 Right off the bat, i am thinking about hypothyroidism for this pt. I am not sure what would cause this acute decrease in LOC though. As far as current treatment it will be supportive only at this point. Insert nasal airway, possibly bilat, assist ventilations and increase rate and volume, insert opa if tolerated consider intubation, attain intravenous access. Reassess. Is pt still bradycardic and hypotensive now that pt is being adequately oxygenated? (i assume since you did not state otherwise) Has she been having any other symptoms recently that are unusual? Is she a drinker? Are we seeing edema/ascites/anasarca here? Any signs of stroke? In what respect was pt not feeling well before going to bed? Chest pain/discomfort? Nausea? Dizziness? Increased weekness?SOB? Fever? Bleeding? Link to comment Share on other sites More sharing options...
hammerpcp Posted October 1, 2006 Share Posted October 1, 2006 Myxedema coma. Link to comment Share on other sites More sharing options...
brock8024 Posted October 1, 2006 Author Share Posted October 1, 2006 Your on the right track. On assessment you find the pt to be very very cold. You just happen to have a themomoter on the truck. Her temp is 90F and her skin kind of feels like dough. Pt does have some swelling in her ankles very mild though. Her husband states that over the last few months she has had to use pillows at night to help her breath. Pts husband said she does not drink any acohol. You get in a 7.5 ETT with some difficulties due to her large tongue. You have gained vascular access. BP now 84/p With ventilation her pulse increases to bout 48 and there is no real change in her LOC. Before bed she told her husband she was just not feeling well. He states that there was some SHOB but he did not think it was any worse than normal. As far as a stroke it is hard to assess due to her being intubated and unresponsive. What you going to do for her temp and what is he DX. Link to comment Share on other sites More sharing options...
vs-eh? Posted October 1, 2006 Share Posted October 1, 2006 You are dispatched to a residents for a 54 female. All the dispatch can give you is the pt feels cool and is not responding to her husband. When you arrive on scene you find a over weight female in bed with approximently 4 pillows behind her. She is unresponsive and will slightly respond to painful stimuli. You notice loud noisy respirations. V/S- HR 40 BP- 80/palp RR- 6 and labored Spo2- 80% on RA. Capnography- 55 Skin - Very Very cool to touch. What else you want to know and how you going to treat her. Capnography 55? You have in-line cap? Nice... So lets look at a few things... - Non-compensating hypotension - Is assisted living (essentially) and probably pseudo bed bound - Doesn't take care of herself physically and medically - Likely had some elements of CHF - Perhaps adrenal issue, hair loss could be multiple things... So...Why is she in a shock state? You are probably looking at either cardiogenic or septic. Both could be definate possiblities given this patients status. Or OD....Or hypothermia... 1. When was the person last seen normal? Or as normal as they normally are... 2. General state of health (compared to "normal) for the past few days? 3. Any specific complaints +/- worse than normal today? SOB? CP? increased weakness? Etc... 4. No meds at all? Sepsis... Pseudo bed bound/stagnant life style = pressure ulcers = infection = sepsis...Any fever/cough/flu-like symptoms in the past little while? Chest sounds? Wave form on cap? Cardiogenic shock... Increased SOB/CP/Weakness probably soon before this incident. 12 lead? Likely inferior MI with right vent. involvement. Look for blocks. Clear chest + hypotension + heart blocks + peripheral edema = R. vent failure (query MI and maybe Cor pulmonale - whoa, pulled that one out...) OD? Meh...standard questions and invesigation. Treat based on findings....NO NARCAN! OR FLUMAZENIL! Hypothermia? Check her sugar I won't tell you how to manage. I'm getting drunky tonight and partying. If I remember I'll check my correctness later. NO SPELL CHECK??!??!!?? MOTHER F$^@ER! Link to comment Share on other sites More sharing options...
brock8024 Posted October 1, 2006 Author Share Posted October 1, 2006 That was to easy. You are right with the myxedema coma. How are you going to treat her hypothermia though? Link to comment Share on other sites More sharing options...
Thunderchild145 Posted October 1, 2006 Share Posted October 1, 2006 As far as the hypothermia I'd probably just take hot packs and place them over carotid and femoral arteries. I'd consider a few drugs for the hypotension/bradycardia, mainly epinepherine 1mg IVP, Atropine 0.5mg IVP, or dopamine 2-10 mcg/kg/min IV infusion. I'd definately keep ventilating with BVM and ETT. I'd probably check lung sounds but even if she did have fluid on her lungs her pressure is too low for nitrates, diuretics or vasodilators. Oh yea, and the low amplitude EKG makes me think about electrolytes. I'd probably hand some Ringers and see if it helps any. Link to comment Share on other sites More sharing options...
brock8024 Posted October 1, 2006 Author Share Posted October 1, 2006 Are you sure you want to actively re warm her? Link to comment Share on other sites More sharing options...
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