Syncope

[Shelbmedic]

Here we go again!

Called for 90 y/o/f syncope.

on scene found 90 y/o lying supine on the floor next to her bed with a pillow and a blanket on her.Family states that mom was found semi sitting on the floor next to her bed and she doesn't know how long she has been sitting there Mom says she can't get up off the floor.

90y/yo f. lying on the floor and no obvious s/s of trauma noted pt seems S.O.B. very pale and sweaty looking as you enter her bedroom you and your partner not that she is in content of urine and the obvious smell of fecal is in the air :pukeleft:

A- Codeine

M- ASA,81mg , Nitro spray, Altace, Diuril, dulcolax, Glburide, HCTZ, Lasix 20mg, Leukeran, Lipitor, Norvassc, Motoprol, Ranitine

P- lymphoma, Cabbage x4yrs, diet cintrol diabetic, MIx 4yrs, HTN, angina, CHF, Acid Reflux

L - last meal pan fried fish potatoes, / last Dr. visit last week to the ER by ambulance for syncope. Nothing was found during the investigastion at the ER.

E- O/E Pt. CAOx4, (A) maintained by pt. ( - Rapid/Shallow @ 32b/min © P-88-123 irreg/strong/ equal at both radial,B/P 130/92.

HEENT - clear, no s/s of trauma noted. Pupils E/R @ 4mm, Neck no trauma noted no deformity, no JVD/TD, Chest Obvious s/s of cabbage surgery, Rt breast removed 5yrs due to CA. Pt. Denies any CP, SPO2 @ 83% R/A, lungs A/E crackles @Rt & Lt basesminor wheezes at Rt&LT upper lobes. ABD soft NT/ slightly distended pt states she needs to pee. Pelvis stable. Note pt in content of urine and fecal. Ex pitting edema noted bot Rt and Lt ankles to knees. no s/s of trauma noted, Back normal back pain no s/s of trauma noted. Skin pale/cool very sweaty.

Treatment by us was Vitals P-88-132 irreg strong A-fib in lead II, B/132/92, RR-32b/min blood sugar @ 11.3mmol. IV Lt wrist # 18 TKVO, c-spine cleared on scene. 12 lead obtained A-fib with RBBB, slowly sat pt up. and Re checked pt vitals.

Then it happened Pt became very aggitated yelled at her son for her Nitro spray becasue now She feels very S.O.B and discomfort in her chest. (" I have a heavy Pressure in my chest")

recheck of vitals Now are : B/P of 120/p resp- 42 shallow use of ex muscels / ddecreased LOC,JVD1-2cmm now. HR 130-160-afib pt has audiable wheezes and her chest sounds are very little next to none for air movement in the lower lobes and what I could hear in the upper was crackles/ wheezes. on the monitor as I stand up to ask my partner hit her with the nitro as I get ready to hit her with Morpine 2.5mg I see a run of PVCS 10 in a line I say to Mike it a run of V-Tach. His face said it all. pt converts back to a-fib/flutter on lead II.

Pt was given Nitro x2 sprays, B/P remain @ 110/64 then 2.5mg of MS B/P 90/62 fluid bolus of 100cc brought pressure back to 102/66 Lung sounds improving spo2 up to 90% pt LOC improving . Pt transported 10 min drive Lasix given in route.

CP decreased to 1/10

Pt left ER then went to ICU is still there that was 3 days ago

[paramedicmike]

Is there a question in all of this?

And it's not "in content". The word is "incontinent". As in, "She was incontinent to urine". Please make a note of it.

-be safe

[DwayneEMTP]

"Vitals P-88-132 irreg strong"

Is this showing a range for the pulse rate?

I'm not criticizing, I've just not see a pulse rate described like this before.

Dwayne

[Shelbmedic]

Sorry about the spelling mistake Mike.

Yes Dwayne that is her pulse rate would be from 88b/min to 132b/min

[vs-eh?]

Sounds like CHF and hypoxia potentially due to the lack of medication compliance for whatever period of time she was on the floor (let's assume 24ish hours).

No diuretic therapy = fluid problems, peripheral/pulmonary edema, urinary retention? (Do people who have been on diuretics for some time tend to "rely" on them for urination? I dunno)

Rebound tachycardia from missing the metoprolol = increased myocardial O2 demand, myocardial irritability, increase risk for dysrhythmia = run of vtach... and = CP

Pt was given Nitro x2 sprays, B/P remain @ 110/64 then 2.5mg of MS B/P 90/62 fluid bolus of 100cc brought pressure back to 102/66 Lung sounds improving spo2 up to 90% pt LOC improving . Pt transported 10 min drive Lasix given in route.

I find that a little troubling...You gave 3 medications with vasoactive properties (lasix first action is actually vasodilation) to reduce preload/after load, reduce pain, and diurese presumably all due to the underlying problem of fluid retention. This fluid retention is presumably due to non-compliance with medications...

You then bolus (small bolus or not means little for this patient) because of "hypotension" (and yes it is pretty frank relative hypotension because of the history). I am going to assume that the ACE inhibitors,etc... have a longer halflife and were still currently effective in this patient. I am also going to assume that the afib is normal for this patient (even without obvious antidysrhthmics, save for the rate control of the beta blocker) but the uncontrolled afib isn't. This rapid afib caused decreased FOC, SV, CO egro hypotension without the compensatory renin-angiotensin-aldosterone system able to assist.

I dunno...Just not a good idea to bolus a pulmonary edema patient kinda defeating the purpose...Did you do this on standing order? (And do your standing orders allow bolus/significant fluid to this type of type) or was this given after speaking to a doctor...

[jw-c152]

I might have missed it when reading through, or perhaps it was a typographical oversight....

But I believe the first item on my treatment list would be high flow O2.

Cheers.

[fiznat]

lol, history of a cabbage!!? Times four?!!? Four cabbages!? Thats a lot of cabbage for a lady her age dont you think? Hypercabbagemia I'd call it.

CABG is the acronym, which stands for Coronary Artery Bypass Graft. Times four is probably not 4 years, but rather 4 vessles that were grafted. Sorry to be an a$$ about it but its simple misunderstandings like this that end up making EMS people look like complete morons to docs/nurses/patients.

Your story is kinda hard to read, but I'm seeing basically a hypoxic CHF patient with the typical "maybe MI" S+S who gets vasodialators (two of them), and then drops her pressure to 90 systolic.

A few things:

-You probably forgot to mention it, but I didnt see anything about oxygen? O2 tends to help with hypoxia and PVCs.

-You did a 12 lead so I assume you were thinking cardiac- what about ASA for her chest pain? Couldnt hurt with the a-fib as well.

-Why do morphine before lasix? Seems like an odd order. In my system for CHFers we do O2, IV, NTG, Lasix, and maaybe MS... in that order.

-Fluid bolus is contraindicated in patients with pulm. edema.

[Shelbmedic]

Sorry ASA and O2 both were given to this pt.

My standing order for extreme CHF Pt give o2 Nitro, Salbutamol if wheezes present, Morphine 2.5mg, then lasix only if on diuretic if SBP>100mmHG. So I called on line Dr. explained the story. He said give a 100cc bouls keep an eye on spo2 and lung sounds if B/P >100 give lasix as per standing order.

Cabbage was 4 years ago. According to family.

[Thunderchild145]

Those standing orders seems to contradict one another. You give the fluid bolus to bring pressure up and then you take fluid off with the lasix. End result? That NS that was in your IV bag is now urine covering the patient and overall the condition doesn't change much other than now your pt is probably a little hyponatremic. Anyway, I would not have given a bolus or lasix, as both are contraindicated.

PS. It is CABG, not cabbage. lol