43 female/unconscious

[NomadicMedic]

1630, on a Thursday. Dispatched for a sick person/unknown. Two medics on the a fly car, 2 EMTs in a BLS ambulance <5 minutes behind you.

Arrive at a well kept, single story ranch style home. You walk in to find a 43 year old woman, supine on the floor. She is pale, shallow resps and is wearing jeans and a t shirt. No shoes or socks.

The husband says he just came home and found her like this. He talked to her 20 minutes ago on the phone and she asked him to get a pizza for dinner, and indeed there is a Little Cesear's pizza on the table. He says she hasn't been sick, doesn't take any medication that he knows of and was fine 20 minutes ago! WTF!

Vitals are:
Skin is pale and cool. Pupils are 4mm and sluggish. HR is 54, sinus. No ectopy. Pressure is 104/54. Resp rate is 10 and shallow. Glucose is 92. Lactate is 1.1 mmol/L.

You are 25 minutes from a hospital.
And you can have a helicopter if you really want one.

And go...

 

[VFlutter]

Responsive to any stimuli? Any obvious signs of trauma?

Lung Sounds?

I am assuming no acute ST changes...

Outside Temp? Hypothermic?


I am guessing there is a clot or an empty bottle of pills somewhere....

 

[STXmedic]

Lupus. Next.

 

[teedubbyaw]

What Chase said plus o2 sats, start bagging her, check for any indications of substance abuse, rapid head to toe and get her on the ambulance. 12 lead and IV en route.

 

[exodus]

Any oral trauma? Sounds neuro.

 

[STXmedic]

My initial thought is neuro, too.

What Chase said, plus any family history of CVA/hyperlipid/MI? Recent traveling? Recent doctors appointments? Birth control?

 

[Handsome Robb]

Why bagging her? Lets get a room air SpO2 and find out how well she's ventilating and oxygenating herself on room air then titrate her SpO2 to an appropriate level.

Definitely sounds neurological. Any history of drug/ETOH abuse? Smoker? Recent pregnancy? Incontinence? STX asked the next few questions I was going to put here. Recent traumatic injury? Any signs of a traumatic injury? What's her GCS? Any signs of funniness? I don't know why but it seems like the pizza has some relevance here otherwise why would you tell us it's right there on the table? ...

DDx:
CVA/Neuro
Fall -> CHI/TBI
DV -> CHI/TBI
Lupus.

 

[Handsome Robb]

I want to add OD to my list...maybe TCAs? Early on, but she's not that hypotensive although her diastolic is a touch on the low side and her MAP is only ~70. Still perfusing but at a metabolic acidosis and that'll change things. No signs respiratory alkalosis though... Right season, starting to get to that right age bracket. Any recent fights or trouble at home? Added stressors? Trouble at work? history of suicidality?

There's no sign of increased ICP with this young lady's vital signs either so that points away from my trauma theory.

I need to reinstate my premium+ membership, I finally got onto a computer and realized it was gone. I was wonder why I couldn't edit posts.

 

[Razorbackgirl]

I don't know why but it seems like the pizza has some relevance here otherwise why would you tell us it's right there on the table? ...

Is the pizza there as possible corroboration of the husband's story?

Is the patient a smoker? Any evidence of trauma (lac, disturbed surroundings, etc.)?

I'm just a student, so I may be off-base here - forgive me, if so. I was originally thinking CVA, DV, PE, OD (accidental or suicide attempt), ruptured ectopic pregnancy, unless evidence of trauma exists. But that lactic acid reading is making me think trauma, PE, and ectopic pregnancy rupture are less likely.

So, CVA, DV, OD?

 

[TheLocalMedic]

I'm thinking an OD. Benzos?

 

[Handsome Robb]

I'm thinking an OD. Benzos?

Definitely crossed my mind. Not horribly respiratory depressed yet but the timeline would fit. Pops the pills, aren't working fast enough, calls hubby and sends him for pizza to stall him... h34r:

 

[NomadicMedic]

Okay. Here's more stuff, since you asked.

The house is warm, 70 degrees. Her room air sat is 82. Lungs are clear in all fields. She is Unresponsive to anything but painful stimuli. When you give her a sternal rub, she lets out a bit of a groan and brings up her arms in a decorticate posture.

Husband says no drugs. No cigarettes. No birth control pills, she had her tubes tied after the 2nd kid. He doesn't know what's going on, he just came home from work and WHY AREN'T YOU HELPING MY WIFE!!!

Ahem.

Your partner goes on a hunt through the medicine cabinet in the bathroom. He finds a bottle of 10mg Buspirone, empty. But the script is several month old. Nothing else, aside from OTC vitamins and allergy meds.

 

[unleashedfury]

Okay. Here's more stuff, since you asked.

The house is warm, 70 degrees. Her room air sat is 82. Lungs are clear in all fields. She is Unresponsive to anything but painful stimuli. When you give her a sternal rub, she lets out a bit of a groan and brings up her arms in a decorticate posture.

Husband says no drugs. No cigarettes. No birth control pills, she had her tubes tied after the 2nd kid. He doesn't know what's going on, he just came home from work and WHY AREN'T YOU HELPING MY WIFE!!!

Ahem.

Your partner goes on a hunt through the medicine cabinet in the bathroom. He finds a bottle of 10mg Buspirone, empty. But the script is several month old. Nothing else, aside from OTC vitamins and allergy meds.

why have an empty script that's several months old in the cabinet? whos script is it? Buspar is a antianxiety medication any history of mental health issues.

with the painful stimuli perceiving a decorticate posture I am suspecting a possible overdose of benzo's or the said Buspar.

Neurological would be my second suggestion, but the patient complained of no illness, any recent falls, complaints of severe headaches?

 

[VFlutter]

IRRC Buspar is relatively safe and requires high dosages for OD. How many pills in the bottle? Unless it was a 60 or 90 day script, which is rare with psych meds, I am not sure the dosage would be significant enough. The symptoms somewhat fit but not quite.

I am leaning towards a Neuro event. Spontaneous bleed r/t undiagnosed aneurysm?

Either way she needs a head CT and Tox screen ASAP.

 

[unleashedfury]

IRRC Buspar is relatively safe and requires high dosages for OD. How many pills in the bottle? Unless it was a 60 or 90 day script, which is rare with psych meds, I am not sure the dosage would be significant enough. The symptoms somewhat fit but not quite.

I am leaning towards a Neuro event. Spontaneous bleed r/t undiagnosed aneurysm?

Either way she needs a head CT and Tox screen ASAP.

I stand corrected then,, I just researched that and a study showed that healthy male volunteers showed minimal drowsiness symptoms while being dosed 375 mg of Buspar, I know Zoloft requires extremely high dosages for effects Buspar was a new one to me.

 

[NomadicMedic]

The Buspar had her name on it. I have no idea why she kept an empty bottle.

What else do you want to know? What would you do?

(You're all doing an excellent job with this...)

 

[Rialaigh]

Edit

 

[Akulahawk]

Is the patient taking any herbal supplements?

 

[unleashedfury]

The Buspar had her name on it. I have no idea why she kept an empty bottle.

What else do you want to know? What would you do?

(You're all doing an excellent job with this...)

Well based on the information you have posted to include vital signs and a primary assessment, I would start by oxygenating the patient securing the airway with a BLS airway. and prep for transport.

I am suspecting a Neuro injury so I would go to the appropriate center, In my area ground 30 minutes if I don't already have aeromedical in the air you said 25 minutes If that's a stroke center that's my destination by ground. (give or take 25 minutes for aeromedical to get up in the air and arrive if not incoming already)

As far as treatment Monitor BLS airway, hi concentration 02 to supplement the depressed respiratory rate, establish IV access, and a diesel bolus.

 

[abckidsmom]

Okay. Here's more stuff, since you asked.

The house is warm, 70 degrees. Her room air sat is 82. Lungs are clear in all fields. She is Unresponsive to anything but painful stimuli. When you give her a sternal rub, she lets out a bit of a groan and brings up her arms in a decorticate posture.

Husband says no drugs. No cigarettes. No birth control pills, she had her tubes tied after the 2nd kid. He doesn't know what's going on, he just came home from work and WHY AREN'T YOU HELPING MY WIFE!!!

Ahem.

Your partner goes on a hunt through the medicine cabinet in the bathroom. He finds a bottle of 10mg Buspirone, empty. But the script is several month old. Nothing else, aside from OTC vitamins and allergy meds.

Are we managing her airway? Let's do that. What's her EtCO2? What does that waveform look like? What's her 12 lead show?

Meanwhile, I'll start an IV and drive her to the closest tertiary care center.