Hurry Hurry Oh Please Hurry!

[fma08]

Called for a 79 y.o. female who's not acting her usual self and low BP. (actual call i had) Ask for info and you shall receive (to the best of my knowledge).

[mikeylikesit]

info please. history, pulse, resp. etc just the basics for now. could be CVA, Orthostatic hypotension making her feel not her self, dehydration, CHF, Myocarial infartion, or she may be on a new medication.

[fma08]

Pt is in a care facility (officially a hospital, but this particular place is renowned where i work as taking not so great care of their patients), had a stroke about a month ago. been in CCU for a while, had been coming around from it, trach was placed and removed by her about a day ago. staff said she fell yesterday. around 1600 noticed a decreasing LOC. (now its about 1830) currently pt is lying on back with feet elevated, staff was kind enough to put a NRB on, snoring/gurgling respirations at about28-30. BP is 50's/30's. Staff had just connected a Dopamine drip as you walked in. no radial pulse present obviously.

[mikeylikesit]

after they took out the trach if not treated properly she could be experienceing these symptoms from septicemia. is she still on meds or were there any that were discontinued recently? the CVA is she still on meds for that? has she been recieving the proper nutrition?

[fma08]

shes on antibiotics and blood thinners, BS is 200 (i think thats where you were headed with the nutrition thing right?) and aside from a 3" stack of papers the staff hands you they dont give you anymore info, (honestly, we fought with them to just get this much)

[mikeylikesit]

is she feeling any pain in her chest, like when she breaths? (thinking pulmonary emboli after ET tube removal) what was she doing before whe started acting funny?

[fma08]

shes unresponsive, sorry, forgot to say that, around 1600 when she started the decreasing LOC her family was there visiting her. she was laying in bed, and it was the family that alerted the staff to her not acting right.

[mikeylikesit]

Do we have an ECG reading? Does she have Parkinsons?

[fma08]

ecg is junctional in the 50's, no to parkinson's

[Flight-LP]

What did the hospital OD her on???

Does she take Beta-blockers?

[BossyCow]

Could we have full vitals? You said no radial pulse but what is her heart rate? Does she have a fever? Is her skin blotchy? Red? Gray? I'm thinking sounds like septic shock but tough to tell without vitals.

[fma08]

hospital swears no OD, no beta-blockers. been fairly healthy till the stroke. vitals, RR 28-30 snoring/gurgling, pulse matches the monitor, BP now 60's over 40's thanks to the dop. temp of 99.0 (but she had about a dozen blankets on her when we walked in) skin some bruising noted in several spots on her hands and arms and on her head otherwise pale, clammy, cool on the forehead, warm at the core.

[BossyCow]

So, why did she fall yesterday? Syncopal episode, or did she trip and fall?

[mikeylikesit]

or is the hospital staff abusive and neglective?

[fma08]

arguably neglective due to past patients.... as for the fall, tripped

[mikeylikesit]

is she still on her meds for the stroke? is she on meds for the ET? does she show Erythema around the healing ET?

[fma08]

she's on blood thinners, antibiotics, and the staff just put her on dopamine... aside from that you don't know (like i said earlier... we had to fight with the staff to get just this much)

[mikeylikesit]

she's on blood thinners and she had a fall. how do the contusions feel? are they riggid?

[fma08]

there's a small hematoma on her head up under one of the contusions, staff said it was there yesterday shortly after she fell, has not gotten any bigger

[mikeylikesit]

Pupils, reactions, how do they move side to side? up and down?

[fma08]

fixed at 5mm

[ukmedic]

she has had a brain stem cva? fall yesterday was the start of it with loss of coordination hence the fall...there rest fits into place

[BossyCow]

Sounds to me like the pt was fine prior to the fall. If she tripped, that means she was up, mobile and active before she tripped. Sick people lying in bed or sitting in chair don't trip. I'm not buying the 'she tripped' completely, because a loss of coordination, diminished LOC or sycope, could have caused her to 'trip'. Are the blood thinners something she's been taking for a long time, or are they new?

[fma08]

she had been getting better from the stroke... but again... thats the story from the staff... we weren't buying it much either, not even joking, hard to run this call with out any cooperation from the nurses eh? she's been on them since she had the stroke.

[Medic9]

could it be a subdural hematoma?

[fma08]

certainly could be

[Medic9]

Ok, so fill us in with more info so we can start treating, please.

[fma08]

well you gotta transport her to the ER, you got at 10 min transport time, check over the info everyone else asked, see what else you want to know, and start treating

[Medic9]

Okay, went all the way back and took notes:
snoring, gurgling resp 28-30
BP 50/30
no radial pulse detected
BiS 200mg/dL
BP 60/40 after dopamine drip
pupils are fixed 5mm
extremities are cool, clammy. core is warm
meds- antibiotics, blood thinners
No beta-blockers
Small hematoma appeared shortly after the fall and has not grown in size.
monitor shows a junctional rhythm

Pt hx- Stroke but has been improving since coming to the nursing facility. She "tripped" and fell yesterday. Her family noticed a change in her and is now unresponsive.

The staff is like most at nursing home, less than helpful. I am going to load and go with the patient. Considering c-spine immoblization because of the fall. Contact the receiving hospital, give a report and ask for further orders. Suction the airway, continue supplimental O2. Vitals are telling me she is in some kind of shock. Now what...

[mdkemt]

My first thought is head injury. I would be thinking subderal bleed.

MDKEMT

[Medic9]

A subdural bleed is what I said a few posts back. So... after the dopamine drip and getting her BP up is she starting to become responsive in any way?

[fma08]

still unresponsive

[Medic9]

Is there any fluid coming from the ears?

[fma08]

none noted, respirations around 6 and shallow now

[Medic9]

should have noted at this point she is intubated, does that make any change?
I have a feeling that no treatment at this point is going to save her. Did the hospital give me any orders when I called in my report?

[fma08]

no orders, however pt's face starts swelling with massive sub-q emphysema after bagging through the tube

[Medic9]

Did she get a pneumothorax from the fall?

[fma08]

bagging is increasingly difficult and you are not hearing much if anything for lung sounds

[Medic9]

needle decompression?

[fma08]

no air/blood return

[Medic9]

My tube is good, I listened to lung sounds and over the epigastrum, end tidal Co2 is changing colors. So, I give up. I'm at the hospital helping them now.

[fma08]

We did all the same, except for no needle decompression, the ER coded her shortly after we got her there. Our tube was "good" as well, but it turned out that the genius that put her trach in for the first time, didn't place it in the right spot creating a false track, where our tube ended up in. So visually it passed through the chords but did not end up where it needed to be. So when we bagged her, each time we could see her face swell up a little more. We pulled the tube out, and just used an OPA and BVM. But while one of us was bagging her, the other had to hold her trach site closed so air didn't leak out.

[Medic9]

I was beginning to think I was missing something really big and was going to get the smiley rolling on the floor laughing. How sad that a medical error beyond your control sealed her fate. I would have filled my pants if I saw my patient blow up right before my eyes.
Thanks for making me reallying think about this scenario, it made me think outside the box and I love learning!

So, whats the next challenge?

[fma08]

Yeah, it was a combination of several things outside of our control that screwed her over... That was really my (insert curse word here) call that I had in school because it turned out to be the grandmother of one of my class mates... But as for the next challenge, we'll see who posts the next scenario :P Glad you enjoyed it and hope you got something out of it.