unresponsive "fall"

[VentMonkey]

You are dispatched to a fall-not alert (priority 1 response). Upon arrival you find an 80 year old male slumped over by their bedside almost like they are praying with their back to you. Immediately you notice that the patient is not responding to verbal stimulus, and barely responds to a deep painful stimulus.

Because of the potential for a high-acuity patient you have your partner, and fire personnel place this patient on a mover and expedite movement from the house to your gurney for a more thorough assessment. While they're loading you begin to ask some questions to the patient's immediate family. They state that they had last saw the patient about an hour ago and that the patient seemed to be fine, and was not complaining of anything specifically. They also state that the patient has no real remarkable history aside from some high blood pressure, and perhaps some cholesterol issues; they hand you about 2-3 pill bottles reflecting this.

Once loading the patient onto your gurney, you place them in a semi-fowler position, and again note that the patient's level of consciousness has not yet improved. Initially, the patient was found in the back bedroom of an older house without central A/C.

You move your patient to the ambulance, and begin the secondary (your primary was negative for any obvious trauma consistent with a substantial fall) assessment. You reveal breath sounds to be clear, and unremarkable, the patient's blood glucose is assessed and found to be within normal limits.

You then place your patient on the cardiac monitor, and SPO2. You find them to be tachycardic in the 140's with no apparent ectopy, or indication of an arrythmia. You note that the patient has remained obtunded, and elect to place a nasopharyngeal airway to elicit a response, which it does, indicating no need for further airway protection at this point.

You note that this patient's SPO2 is adequate with 10 lpm NRB at ~95%. The one thing that sticks out most is that this patient appears extremely hot-to-the-touch even after having been removed from a humid environment. Here are some of the questions for you all to work through:

1. What is/ are your differential diagnosis (es)?
2. What are the order of treatment modalities with regards to their priority from now until ED arrival?
3. Where will you transport this patient, and why (you're 5 minutes away from any hospital ranging from a Level II trauma center, to a stroke/ SRC)?
4. What else do you want to know about this scenario.

 

[ParkMedic]

The Pt is hot to the touch. What is his temperature and skin condition. Sepsis?

 

[Old Tracker]

Sepis was the first thought and then what's his BP? If he has hypertension I would consider possible stroke. 5 minute transport to the stroke /SRC if the BP is high.

 

[CALEMT]

1. What is/ are your differential diagnosis (es)?

Sepsis, heat stroke,

2. What are the order of treatment modalities with regards to their priority from now until ED arrival?

Cooling measures, establish a IV and give a 250ml bolus, reassess and go from there.

3. Where will you transport this patient, and why (you're 5 minutes away from any hospital ranging from a Level II trauma center, to a stroke/ SRC)?

Closest/ most appropriate. At this point I'm considering a stroke center with the information I have been given.

4. What else do you want to know about this scenario.

Any signs of old wounds? Any recent illness or infection? Recent drugs/ drinking? How has the weather been in the area lately and has the patient been hydrating appropriately? Vitals (b/p, respirations, pupils, ETCO2) in addition to whats been given. The only medications found on scene correlate to the patients high blood pressure? No antibiotics?

 

[StCEMT]

1. Stroke, sepsis, hypovolema/hyperthermia in no particular order.
2. Once I got all the assessment info I wanted, right now I am leaning towards starting an 18 ga (two if I can) and hanging fluid. Two of my more immediate thoughts need fluid and all need a bigger IV. If it is a stroke, I don't really want to mess with anything else besides this. If he is hot, cut the clothes and crank the AC (its hot as **** in the truck too anyway, I need my AC)
3. Facility with stroke capability.
4. What is his BP? Nasal EtCO2? Pre supplemental oxygen sat? Respiratory rate? What is his skin like (diaphoretic/dry, good color/pale)? Check the eyes? For the sake of being thorough, do his meds remaining match the Rx date?

 

[VentMonkey]

All good differentials so far everyone. The blood pressure is 88/62 (I don't recall all the specifics, this was ran a while back), respiratory rate was irregular and in the mid-20's IIRC, but not acutely alarming, St.

The skin is extremely dry, and cracking. There also appears to be a potential for a stroke workup, and given the inadequacy of family reporting you can't quite make out if there is a clear facial asymmetry, nor can you perform a full and thorough neurological exam. No oral antibiotics, CAL.

Pre-supplemental SPO2 was low, however, quickly rised with very basic maneuvers (sitting upright, and positioning the head). No in-line ETCO2 on ground ALS units here (I know, I know; it's a work in progress, and I wasn't CCT-capable this day). There was no conjugate, or dysconjugate gazing (good catch, BTW).

Here are some more questions to consider, and/ or would they potentially effect your treatment?

Would you treat for a stroke, or sepsis? How would you spin it to the ED upon base contact? If you're concerned about a stroke v. r/o sepsis where does your delivery of O2 begin? Are you going 2 lpm N/C to prevent any possibility of cerebral vasospasm, or are you more inclined to deliver a high FiO2 with concern for a distributive (septic) shock?

I like the train of thoughts thus far, and I'll give more info as well as provide you with my treatment modalities, and their priorities and why once I get some more feedback, thanks.

 

[CALEMT]

Would you treat for a stroke, or sepsis?

With the heart rate, b/p, BGL, and skin signs I'm going the sepsis route. The body appears to be compensating from the third spacing of fluids due to an infection. Has the family been in contact with the patient in the days prior and if so did he/she have any complaints then or appear to be sick? For O2 I'm titrating to maintain greater than 94% (depending on what book you read) and aggressive fluid therapy is really all you can do in the field tx wise. Closely monitor vital signs and transport. I'm not completely sold on the idea of a stroke just yet. Theres a lot of ideas floating around in this "para-maybe" head but stroke just isn't in the picture. I like the sepsis route due to what I've stated above and am going to treat it as such.

 

[StCEMT]

I don't think I am completely sold on any one in particular, I would rather transport and treat what I can and get him to a higher level of care. His MAP actually isn't that bad, so I would just let fluids go wide open since such a short transport time isn't going to dump a huge amount. With the potential of a stroke, my O2 delivery would be titrated to around 94%, whatever gets it there and stick to the middle ground.

If I had to choose a direction I am heading, it would be neuro. Based on lack of complaint prior to this and nothing else pointing to a cause of sepsis, I don't think that is it. CVA or some neuro event mixed in with the hot environment he was found in. A neuro condition would cause the irregular respirations and the hot environment would cause the hypotension, tachycardia, and dry skin. I am not 100% sold on the idea of it being something in the head, but I think that a lot of things about this scenario would throw out false positives for sepsis.

 

[DesertMedic66]

I am also going down the sepsis route. Hypotensive, tachycardic, dry/hot skins speak more of a sepsis or hyperthermia patient over a stroke patient.

Treatment wise I would give the least amount of FiO2 to maintain an SpO2 greater than 94% but I'm also not trying to shoot for 100%. Bi-lateral large bore IVs and fluids wide open. Due to the patient being hot to the touch and found in a hot environment I would also start active cooling techniques on the patient. Transport to the closest facility that takes sepsis patients.

 

[VFlutter]

Serotonin Syndrome. Because I want to be different.

 

[StCEMT]

Serotonin Syndrome. Because I want to be different.

I swear, I cant read anything by you without having to go to Google immediately after.

 

[DrParasite]

I was thinking stroke.... What was the patients temp?

 

[VentMonkey]

So yeah, pretty straightforward but figured I'd let some of the newer posters get a crack at it. Again, good job by the way.

I never got an actual temperature prior to ED arrival. The patient ended being 109 temporally, 106 rectally.

As far as my care and train of thought: initially it was an acute CVA given a sudden onset from last known normal of ~1 hour prior to nearly completely comatose. However, once I was able to get a better assessment and saw he met more markers for a sepsis work up (FWIW, the BP given was arbitrary; I recall the initial MAP being way less than 60 mmHg).

With no clear cut way to get a complete neuro exam, or a reliable historian description I went with a sepsis workup v. r/o CVA, which is exactly what I told the stroke center I transported to. "This patient definitely meets a sepsis work up (hot, dry, tachycardic, hypotensive with a poor MAP), but still fits r/o for a stroke alert via CT".

Treatment-wise I did passive cooling (again, very short ETA with no reliable indicator that it wasn't from him lying in a humid room on a hot day for too long). The patient got bilateral 18 gauge IV's with one continuously opened (in case there was a bleed I elected to top my "large bore campaign" off here), and high flow O2 @ 10 lpm NRB.

There were too many feelers screaming at me that this patient was in--at least--severe sepsis which to me, stroke or not, indicated a higher concentration of oxygen delivery. They CT-d the patient and activated a Stroke Alert on arrival, however, began treating immediately for the severe hyperthermia with cold packs as well as a cooling blanket once confirming the core temp. They also opened up a second liter from the lock I had placed on the other arm.

There was some movement on the patients behalf before I left, but it was hard to know if it was reflexive or voluntary. Is there anything else anyone would have done differently, and why or why not?

 

[Old Tracker]

Thanks for the post, I always learn something from these.

 

[CALEMT]

Is there anything else anyone would have done differently, and why or why not?

Tx wise there's really nothing more to do, especially when you're <5 from the ED. Thanks for the scenario, I had a gut feeling this was gonna be sepsis.

 

[VentMonkey]

I had a gut feeling this was gonna be sepsis.

TBCH, I still don't know that this patient's CT wasn't positive for an bleed. I didn't stick around too long, I had places to go and people to see. It was a late call for me.

Edit: if this was indeed a head bleed, hypoxia and hypotension need to be remedied posthaste. So again, would this change anyone's train of thought or treatments?

 

[Old Tracker]

Initially I would have gone with a NC @ 4 LPM, possibly an IV, but with a 5 minute run to the hospital there really wouldn't have been a whole lot more a Basic could do.

 

[VentMonkey]

While this study alone is one of many, and highlights the traumatic brain injured patient, any patient thought to present with even an atraumatic brain injury should be dealt with in a similar fashion; obviously I could not rule this out in the field. It showcases the importance of maintaining an adequate level of oxygenation, but moreover, the importance of properly managing and maintaining blood pressure, and in return cerebral blood flow. I'd also argue that any patient who suffers an injury or infarct to their brain is in fact traumatically, if not dramatically affected.

http://jamanetwork.com/journals/jamasurgery/fullarticle/392263

I don't disagree with the "titrate to an SPO2 (>/ =) 94%", I simply went more with a septic (shock) treatment approach which is why I treated with a higher concentration of FiO2 sooner rather than later, and treated him as a basic shock work up without the "keep them warm" portion. Also, I felt in the event that this was also a bleed coupled with sepsis, I would not be "behind the eightball" so to speak, and would cover my bases with logic on the front side, and in the presence of a patient very susceptible to the rigors early hypoxia may indeed bring.

Sometimes we tend to get caught up in what we're taught in school, and without furthering our knowledge base, and/ or approach how can we begin to critically think, and approach the patient that may indeed have a myriad of problems that they're undergoing. As always, good learning opportunities are plentiful if we know where, how, and why to look for them.

 

[Old Tracker]

Thank you, makes a lot of good sense. Appreciate ya.

 

[GMCmedic]

Im working without further description of the environment. I know youve hinted at it at least being hot enough to suspect hyperthermia. That said it still sounds like sepsis and id likely add cultures and Zosyn.

Acute mental status changes, tachycardia, hypotension, and a temp (which I could take in our unit), covers 4 of the 5 justifications....just missing a suspected or confirmed cause.

I like the passive cooling, even in a hyperthermia vs sepsis it will help. The only other thing I would add is, if we were going to my base hospital we would probably go Straight to CT if we can get the pressure up.

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