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Scenarios Got a scenario you want to run by the others? This is the place.

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Old 02-04-2008, 07:30 PM   #1
JPINFV
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Scenario: I can't move my arm.


Ok, since I don't see very many scenarios here, I'll start one. I'm putting this here since there isn't a scenario forum.

Rules: You are ALS, regardless of level. Points awarded for thought process in figuring out what is going on. At the start, you are on a standard ALS unit. This might change.

Again, I'm looking for "what's going on and how to treat it" than "high flow O2, IV, monitor, transport."

This is run by you, the posters. When you ask questions, you will be rewarded with answers. The opening post is vague for a reason. Feel free to assume that you have taken BSI and that the scene is safe because this is not about those.


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Old 02-04-2008, 07:31 PM   #2
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20y/o male complaining of sudden onset paralysis to right arm.

Go.
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Old 02-04-2008, 08:18 PM   #3
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Originally Posted by JPINFV View Post
20y/o male complaining of sudden onset paralysis to right arm.

Go.
What's the pt's LOC?
How are his ABCs?
Partner to take c-spine control due to potention for trauma.
Baseline vitals?
Onset of paralysis?
What was he doing when the paralysis started?
Any recent trauma/falls/injuries (even if they seem insignificant)?
Medications?
Allergies?
Medical history?
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Old 02-04-2008, 08:44 PM   #4
MikeRi24
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my first thought would be to look for any signs around the scene for a mechanism of injury, and ask anyone around if they saw anything and ask the patient what happened. depending on what i can gather from that, I could go a bunch of different directions in my pt assesment and tratment.

But, assuming that no one saw anything, and the patient says that thier arm just went numb and they cant move it, and I have NO other information as to how this happened, I would then move on to an exam of the patient to try and narrow it down.

Again, without knowing much else than what you provided, its kinda hard to pick a direction to go in. Obviously as a trained EMS provider, one would be able to get a better grip on the situation once a patient assesment was started, but, just being given that information, I would maybe consider a stroke a high possibility. I can't really think of much else that would just cause a sudden loss of motion and feeling in a limb like that. Obviously I would look for other signs to support that, and I would also check for a neck or back injury as well. With just the information given and the knowledge that I have (which isn't much since I'm still in EMT classes), I would go with a stroke.
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Old 02-04-2008, 08:50 PM   #5
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Well, since I do not have the means or training to test for any of the diseases, infections, or toxins that can cause paralysis, my course of action would be to bring them to a hospital.

If it wasn't trauma related, not really much I could do. And if it was, board 'em. And of course, examine for other signs or symptoms of a stroke.
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Old 02-04-2008, 08:53 PM   #6
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Originally Posted by MikeRi24 View Post
my first thought would be to look for any signs around the scene for a mechanism of injury, and ask anyone around if they saw anything and ask the patient what happened. depending on what i can gather from that, I could go a bunch of different directions in my pt assesment and tratment.

But, assuming that no one saw anything, and the patient says that thier arm just went numb and they cant move it, and I have NO other information as to how this happened, I would then move on to an exam of the patient to try and narrow it down.

Again, without knowing much else than what you provided, its kinda hard to pick a direction to go in. Obviously as a trained EMS provider, one would be able to get a better grip on the situation once a patient assesment was started, but, just being given that information, I would maybe consider a stroke a high possibility. I can't really think of much else that would just cause a sudden loss of motion and feeling in a limb like that. Obviously I would look for other signs to support that, and I would also check for a neck or back injury as well. With just the information given and the knowledge that I have (which isn't much since I'm still in EMT classes), I would go with a stroke.
There are many things other than stroke that can cause sudden paralysis. Stroke is usually the most obvious, though. TIA ("mini stroke"), head injury, burst aneurysm/intracranial bleed, arterial blockage, spinal cord injury, psychiatric disorders (think depersonalization disorders), hyperventilation (though this is more numbness than actual paralysis), nerve injuries, vitamin deficiency.

Given the patient's age as 20, I wouldn't necessarily lean towards stroke unless he had very high blood pressure or a history of a previous stroke or TIA. My first thought was more towards a head injury, drugs, or some sort of intracranial bleed.
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Old 02-04-2008, 08:55 PM   #7
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Quote:
Originally Posted by Emt /b/ View Post
Well, since I do not have the means or training to test for any of the diseases, infections, or toxins that can cause paralysis, my course of action would be to bring them to a hospital.

If it wasn't trauma related, not really much I could do. And if it was, board 'em. And of course, examine for other signs or symptoms of a stroke.
Think outside the box. This is more of a critical thinking exercise than a "pack em up, high flow O2, immediate transport" exercise. You can always test the extent of any paralysis.
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Old 02-04-2008, 09:06 PM   #8
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You are escorted to the patient's room by his friend and find him sitting in a chair. Behind the chair is a spot of half dried vomit. You notice that the patient's eyes are slightly sluggish and bloodshot as a slight whiff of alcohol reach your nostrels.

He doesn't know when the paralysis started, but it's not new and his memory is a little hazy from last night. He doesn't think he fell and you don't notice any swelling, bruising, or deformaties on him. There is some reddness in the right axillary region though.


He denies having any medical problems or taking any medication, leisure or otherwise. Your partner grabs a set of V/S which comes out with a pulse of 90 beats/min, blood pressure of 130/78 mm/Hg, and 20 breaths a minute.


Quote:
With just the information given and the knowledge that I have (which isn't much since I'm still in EMT classes), I would go with a stroke.
There's always more information when you do an exam and history...

Quote:
I would maybe consider a stroke a high possibility.
Would you like a Cincinnati stroke scale or a Los Angeles Prehospital Stroke Scale?
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Pain Management [X] Step 2 [X] Cardiology [X] EM: Arrowhead [X] EM:Westlake, OH [X] EM: Kern, CA [X] Gastrology [X] IM [X] Neuro Surg [X] FP [_] EM: Miami, FL[_]

Holy EMS Trinity: Backboard, oxygen, lights and sirens.

Last edited by JPINFV; 02-04-2008 at 09:08 PM.
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Old 02-04-2008, 09:38 PM   #9
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oook, now that we have a little more information.....

based on what I now know, I would go with this:
Patient was presumably out drinking, doesnt remember much of the outting. He could have also fallen, hitting his head and if he was sober, he may not remember the fall anyway. So, I'm going to start thinking that he fell, causing a head and/or neck injury. At this point, im going to immobilize the neck and spine. I'm also going to further evidence my thoery of falling by the redness on the right axillary region, however that could be totally unrelated and maybe he fell asleep against something that caused that, but I would prefer to err on the side of caution and stay away from that idea.

The vomit, which appears to have been semi-recent, is most likely because he drank a bit much and vomited as a result. But again, that could be caused by something else, and I'm going to take all precautions here.

At this point, he appears to have a sufficient airway because he is talking to me, however I would like to see more description in the vitals rather than "respirations: 20/min." I will still put him on high flow O2 with a non-rebreather because it's our protocol to give that to every patient. I'm going to have suction ready just in case he vomits again so that I can keep the airway clear.

Now that I have him on a backboard, I am going to do a quick assessment of the rest of his body, when I get to his hands and feet, I will do a quick neurological exam ("push down on my hands...pull up....can you wiggle your toes for me....can you feel me touching your toes? squeeze my hands...wiggle your fingers....which finger am i holding?"). At this point, I would pull out my mini mag light and check the pupils, which was already stated that they were bloodshot and sluggish. This could be due to the alcohol or a head injury, and again, im going with the head injury.

At this point I'm probably going to prepare to transport. his friend that is with him probably knows what happened durring his friend's drunken stupor, so I'm going to try and get as much information out of him as possible. once I have the patient in the ambulance, I am going to re-assess everything, and continue my evaluation. At this point, I am really really starting put more of my eggs in the head/neck injury basket. Still have a little bit of concern for a stroke or realted condition, but knowing what I know now, I'm starting to veer off that path, but I am also not going to completely rule it out.


Thats where I'm at now. I'm anxious to see others responses, and I'm going to bring this up in class tomorrow and see what others have to say about it. I like this stuff...makes me think!
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Old 02-04-2008, 09:50 PM   #10
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Does he have a palpable radial pulse in the affected arm? Sometimes I wake up with a dead arm and all I have to do is get the blood back.

Just a thought.
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