75yo Male - post LOC wrist #

[Melclin]

I've noticed that there is a tendency not to post scenarios unless they are supposed to be particularly difficult, strange etc and I don't like it, cos it doesn't help us youngins learn and we all know how a good convo can start over a seemingly simple case. So I thought I might post some real cases, but not necessarily not overly difficult ones; lets remember our manners and include everyone in the process (EMTs with 15 mins of class time welcome). Will continue this idea depending on how useful it appears to be.

Dispatch: Priority 2, 75 year old MALE: Possible fracture, non dangerous body area. TIME - 15:32

O/A: Met at the door of an expensive looking house by a older man in obvious pain and is glad that "the doctor could come at such short notice". Complains that he was walking to the toilet, fell and broke his wrist. You all take a seat in his living room. He also complains that he feels quite sick because of the pain.

I assume you'll ask for the following.

Allergies - nil.
PHx- AMI x 2 (2004,2007). CABG x4 (2007). Hypertension (but his doc says his bp has been great lately) and he's been fighting off a nasty chest infection lately.
Meds- Diformin, aspirin, atacand.

Event history - Complains that he was walking to the toilet, felt dizzy and then he woke up on the ground, with a "badly broken wrist" and called the "the doctors" straight away on account of the pain.

Pulse- 190 (weak & regular) BP- 95/75 RR-22 SpO2:95 on room air. Skin is cool pale and dry.

Wrist is obviously swollen and deformed but there is no haemorrhage or damage to the skin.

Everything else you'll have to ask for.

 

[mycrofft]

The drug names are unfamiliar.

Many brands in other countries are rebranded here, or simply unavailable.

I would be assessing this man's orientation as I splinted his wrist for comfort (good distal circ/sense/ROM?Versus other side?) and maybe do a postural BP before we load-ed and go-ded.

Pneumonia in the elderly more easily brings on CNS signs than it (also) does in younger folk. Temperature?

 

[NYBLS]

What was his BP last doctors appt?
Was he spinning or was the world around him spinning?
Pulse seems a little too tachy, what is his usual pulse rate?
Does he seem anxious or nervous?
Does he feel dizzy currently?
Chest pain, abdominal pain, SOB, excessive thurst, numbness/tingling?

Start with a BG, rule out C-Spine, pupils, lungs.

Immobilize arm, apply ice as needed (assuming were BLS here).

Transport and finish physical exam enroute.

 

[NYBLS]

Also, what position was he in when the pressure was taken? Consider taking an orthostatic pressure/H.R.

 

[mississippimedic]

EKG needed. HR, LOC, weak pulse, cool pale skin. Probably time for chemical or electrical cardioversion.

 

[Melclin]

Many brands in other countries are rebranded here, or simply unavailable.

I would be assessing this man's orientation as I splinted his wrist for comfort (good distal circ/sense/ROM?Versus other side?) and maybe do a postural BP before we load-ed and go-ded.

Pneumonia in the elderly more easily brings on CNS signs than it (also) does in younger folk. Temperature?

Diformin is a type of metaformin, first line treatment for type 2 diabetes. Atacand is a angiotensin II antagonist - for Hypertension, I forget its proper name.

He is happy to nurse his own wrist and gets quite upset when you try to do otherwise. good distal circ, sensation, range of movement is pretty much nil due to pain. Wrist is obviously deformed.

A postural BP wasn't done, and I'm not sure of how I should make it up given the wrest of the scenario..:wacko:

Temp is 38.1 (100.58).

What was his BP last doctors appt? Doesn't remember
Was he spinning or was the world around him spinning? He wasn't spinning himself, he felt dizzy and fell over. That's all you get from him
Pulse seems a little too tachy, what is his usual pulse rate? No idea.
Does he seem anxious or nervous? He seems a little anxious or perhaps agitated with your questions, and just wants to see the doctor
Does he feel dizzy currently? Yes, a little, When he stands up.
Chest pain, abdominal pain, SOB, excessive thurst, numbness/tingling?
No CP, Abdo pain (just nausea), very mild SOB, no excessive thirst, no numbness or tingling.

Start with a BG, rule out C-Spine, pupils, lungs.

BGL: 3.9 (70.4). No indications for c-spine immob. PEARL. Faint, fine basal crackles left and right.

Immobilize arm, apply ice as needed (assuming were BLS here).

Transport and finish physical exam enroute.

ECG shows SVT @ 200

 

[Aidey]

"Sir, I'm concerned because your heart is beating too fast. Have you ever had this happen before?"

and "I know your wrist is what is bothering you, but right now I really want to figure out what is going on with your heart. Its possible that your fast heart beat is what made you feel dizzy and fall."

 

[Melclin]

"Sir, I'm concerned because your heart is beating too fast. Have you ever had this happen before?"

and "I know your wrist is what is bothering you, but right now I really want to figure out what is going on with your heart. Its possible that your fast heart beat is what made you feel dizzy and fall."

"No body has ever said that before", "Possibly I suppose. You tell me, you're the doctor, I have no idea what made me fall, I pay my taxes and I expect to get better care than this"

 

[Aidey]

oops...forgot the versed before the cardioversion....

KIDDING! Really guys, kidding, I promise.

That is usually my cue to ask the patient what it is they expect me to be doing/what I need to do to make them happy. When they say something like whip out the mobile x-ray and apply a cast I will start correcting their expectations. If it is something more realistic I will do my best to oblige.

In his case prep for transport, IV, O2 via cannula. Attempt to cardiovert via vagal manuvers, which are likely to be unsuccessful because I doubt the pt is going to comply. After that it's keep a close eye on him and how stable he remains. He is just a tad too stable for me right now to shock him. He's really currently not unstable.

 

[Melclin]

That is usually my cue to ask the patient what it is they expect me to be doing/what I need to do to make them happy. When they say something like whip out the mobile x-ray and apply a cast I will start correcting their expectations. If it is something more realistic I will do my best to oblige.

I like your approach.

In his case prep for transport, IV, O2 via cannula. Attempt to cardiovert via vagal manuvers, which are likely to be unsuccessful because I doubt the pt is going to comply. After that it's keep a close eye on him and how stable he remains. He is just a tad too stable for me right now to shock him. He's really currently not unstable.

I agree with not shocking him. Any other options?

Have the BLS chaps considered back up? I know you don't have a monitor but does a weak pulse at 190, a bp of 95/75 and cool, pale skin warrant any concern?

 

[mycrofft]

No one was addressing that.

Amazing he's still talking with that crummy a set of vitals.

 

[8jimi8]

blood glucose,
ECG
Move to the stretcher
Vitals q5
IVs on scene,
Start transport
start a 250cc bolus
splint the arm, but no sling (occlusions)
Attempt a vagal maneuvers -
Monitor LOC and vitals for deterioration.

How's my pressure and rate after that bolus?

 

[MrBrown]

Never fear, Brown is here! (No really, run, do it now, just run)

Pop in an 18 and run 250 of fluid
Oxygen, two litres on an NC
Splint wrist
Maybe a toot on the green whistle (methoxyflurane) if indicated.
12 lead
Valsalva
Some midaz and cardiovert if he drops out anymore

 

[Veneficus]

Did I miss a post?

Vagaling a pt with a HR of 190 but no indication of the rhythm? What if he is in Vtach?

Maybe check for rubs, gallops, and other abnormal heart sounds?

 

[MrBrown]

Did I miss a post?

Vagaling a pt with a HR of 190 but no indication of the rhythm?...

ECG shows SVT @ 200

10 char

 

[Veneficus]

thanks, didn't see that in all the words.

 

[8jimi8]

lol i'm usually reluctant to reply to scenarios.

i feel like i know alot, but i seriously need some more ride time. haven't been able to volunteer in a while

 

[Melclin]

Amazing he's still talking with that crummy a set of vitals.

Its an interesting thing that no one has measured conscious state, but given our recent discussion of the popularity of the GCS in America it makes sense. I don't know that I can speak to its true efficacy in assessing perfusion, but I've always been taught that conscious state in these sorts of cardiac scenarios is important because when you have a cardiac condition causing a drop in CO such that it affects conscious state, then you have a problem.

blood glucose,
ECG
Move to the stretcher
Vitals q5
IVs on scene,
Start transport
start a 250cc bolus
splint the arm, but no sling (occlusions)
Attempt a vagal maneuvers -
Monitor LOC and vitals for deterioration.

How's my pressure and rate after that bolus?

Yep, results of most of those in the previous post. RE his blood sugar, didn't really think it was involved with his presentation but it was a tad low and we gave him a few lolies to nibble in the mean time. BSL up to 8 something, 15 or so mins later, no change in presentation.

Whats the logic behind the bolus? A small bolus may be appropriate in some contexts, but think about the reason why this bloke's perfusion is rubbish. Is it because he's volume depleted? Or is it because he's cardiac out put is rubbish? Vene, can you enlighten us as to the appropriateness of fluid in SVT?

Never fear, Brown is here! (No really, run, do it now, just run)

Pop in an 18 and run 250 of fluid
Oxygen, two litres on an NC
Splint wrist
Maybe a toot on the green whistle (methoxyflurane) if indicated.
12 lead
Valsalva
Some midaz and cardiovert if he drops out anymore

Finally some pain relief!

Maybe check for rubs, gallops, and other abnormal heart sounds?

Wasn't checked, but from my limited knowledge of such things, I'd say not.

lol i'm usually reluctant to reply to scenarios.

i feel like i know alot, but i seriously need some more ride time. haven't been able to volunteer in a while

Reply all you want, I was hoping that people who don't usually reply will get involved. They're not medical mysteries, just everyday scenarios, albeit with one or two things going on worth talking about. I need the learning experience as much as anyone.

 

[exodus]

Effectiveness of air intake?
How are his lungs?
Does he remember falling?
How are eyes?
He says he remembers waking up, I'd like a Trauma Resources for the +LOC.
He's still stable as far as the BP is concerned, I'd like to watch the monitor for any changes.
How has he felt over the past few days, has he felt dizzy at all, sick at all?


Zofran 4mg SIVP for the nausea. Pain already taken care of in above posts.

 

[Melclin]

Effectiveness of air intake?
Normal tidal volume and air intake.

How are his lungs?
Breath sounds? Faint basal crackles.

Does he remember falling?
He get confused about what you're asking. "I fell over, I don't take notes, where's the doctor? I'll tell him that these nurses of his are idiots. Fell over?...I did nothing of the sort, I'm not a cripple! Where's my doctor?"

How are eyes?
"Pupils? PEARL. Anything else and you'll have to be more specific.

He says he remembers waking up, I'd like a Trauma Resources for the +LOC.
I'm not sure what 'a trauma resources' is, Im afraid.

He's still stable as far as the BP is concerned, I'd like to watch the monitor for any changes.

How has he felt over the past few days, has he felt dizzy at all, sick at all?
He's had a chest infection lately but he feels mostly okay now. No dizziness.

Zofran 4mg SIVP for the nausea. Pain already taken care of in above posts.
What are your options for pain relief?

10 char