Chime in and diagnose...

[MrBrown]

Damn Vene you make my medical knowledge look like crap, guess thats why I'm not rolling round in an orange jumpsuit yet.

My professional opinion is that this patient is pretty crook :unsure:

 

[Veneficus]

Damn Vene you make my medical knowledge look like crap, guess thats why I'm not rolling round in an orange jumpsuit yet.

My professional opinion is that this patient is pretty crook :unsure:

You are far too kind.

I'd rather have one of the green or red jumpsuits though

 

[jjesusfreak01]

Would it ever occur to you that this should be a flight patient?

Maybe, but not where I live (Wake County NC). Here, flight will be reserved for extrications and extremely complex cases that will need very advanced care. You can get to a level 1 trauma center (Wakemed Raleigh) in 15 minutes by ground, a hyperbaric facility in 20-25 by ground (and thats traveling out of the county), and all of the major hospitals in the area have diagnostic cath labs. WakeMed Raleigh (located right in the middle of the county) has an interventional lab.

I can possibly see a burn patient being flown out to UNCs Jaycee Burn Center or something like that, but unless something happens at the borders of our county, or outside them, there are few reasons to consider lifelight.

So far, in my limited experience (2 ride alongs), our longest time to scene has been around 10 minutes (with traffic, no L&S), the average has been <5 min, and our travel to hospital is less than 10 minutes.

I do know that the lifelight choppers at UNC ran constantly when I was there, so I would imagine that they probably service a very large area outside of their county.

Back to the issue at hand...yeah sure probably not a bad idea to fly him if it would be quicker than driving.

 

[Stephanie.]

I have a feeling you're asking for one of two reasons. A), you're curious as to what could have caused it, or B.) you wonder if there was more you could have done to change the outcome.

The answer to B.) is almost certainly No. This guy's problem was definitely something surgical, and there's nothing else that could have been done in the field to fix it.

As for possible Dx... I think only an autopsy could say the actual cause of death. But from what you're describing, I'm going to agree with everyone else, something tore open/off and he bled out internally.

B is correct. It did turn out to be a AAA. The only reason I was asking was because we had to sit through a class and realize that we could have flown him. But with all the signs and symptoms that were initially revealed, anyone and damn near everyone thinks it would be a kidney stone. That was my guess. Just justifying that I didn't make the wrong decision. That, and if I were to fly him- then what says I shouldn't fly all my pts with abdominal pain?
Its a woulda, coulda, shoulda situation...

 

[MrBrown]

I don't know about there, but here kidney stones do not cause hypotension and tachycardia.

BP- 80P
RR- 32 bpm
HR- 148
BGL-314

Those initial vital signs to me say that this patient is pretty sick.

 

[Aidey]

^^^ Not necessarily.

To all appearances this man had a syncopal episode, and those vitals immediately after aren't surprising. It would be concerning if the patients vitals stayed that way, but this patient's vitals improved, which is what I would also expect in a syncopal episode.

 

[Veneficus]

^^^ Not necessarily.

To all appearances this man had a syncopal episode, and those vitals immediately after aren't surprising. It would be concerning if the patients vitals stayed that way, but this patient's vitals improved, which is what I would also expect in a syncopal episode.

A syncopal episode is always pathologic, even in older people.

Some are aware of the underlying pathology, are managing it, and occasionally need assistance.

Pain is always pathologic, it is the body's response to injurious stimuli.

In my simple mind:
No history + new pain and syncope = ED

Which is what the responders did and cannot be faulted. it seems they were operating presuming a less severe Dx, but what would it really have changed? Even if they called for the Helo earlier, it may not have arrived earlier. Even if it saved 20 minutes, can we say that a patient would still be alive because the pt would have gone straight to emergent surgery and not stopped in the ED for confirmation of DX?

Would the EMS providers have had any treatment options of benefit if they did know? (more on this in the bottom)

The reason EMS has had to incorperate transport destination protocols is because of these very circumstnces.

If you want to lay blame down, why didn't the local hospital recognize it earlier and be more agrresive in treatment?

There are a few reasonable explanations that precludes fault for the ED as well.

1. They knew what they had but didn't have anything they needed to help. Like a surgeon, an available OR, and ICU, massive blood transfusion, autotransfusion, etc.

2. They knew what they had and could not get transport any faster. It is no different than EMS. You can't just teleport people to better facilities. If you have a serious medical even out in the country, you are probably going to die or be severely disabled. It is a hazard of living there. Many rural people I know are aware of and accept such risk because they value the other aspects more.

In medicine, experience counts. Low volume providers who do not see serious patients on a frequent basis are unlikely to accurately identify sick vs not sick. I have met surgeons in smaller hospitals who haven't seen a trauma patient since their 3rd year of residency.

Even in the ED the providers (aka physicians) may not be familiar with severe pathologies for a variety of reasons. If they haven't seen a AAA in years it can be as hard to identify as a paramedic trying to grade and stage cancer based on patient presentation.

It is a learning experience for all involved. Anyone who claims such things have never happened to them is either very new and will at some point, didn't realize it did, or their truthfullness may be in doubt.

If the US medics recognized there was a AAA and it was high enough to put on a set of MAST pants (if they even had them) and pneumatically clamp the aorta, I would have had crow for lunch based on my critisism of the ability of EMS to recognize when/how to use the device.

 

[Aidey]

I think you may have misunderstood what I meant.

The syncopal episode is significant, it is the vitals that are not as significant unless they stay that way. Basically what I was getting at is that temporary hypotension and tachycardia are not unusual after a syncopal episode.

 

[Smash]

A syncopal episode is always pathologic, even in older people.

In my simple mind:
No history + new pain and syncope = ED

I like the way your simple minds work. It seems like I have to have the discussion on a daily basis: "Syncope's aren't normal, we're taking this 80 year old to hospital" and then have to put up with the grumbling because the obs are normal.
That or "Anyone who is 80 and has called us for abdo pain goes to hospital"
or any one of a number of variations on that theme.

 

[dmiracco]

Flying him for the presentation that you gave i wouldnt have and it really doesnt match a kidney stone at all. Did you ever get BP on both the arms?

 

[Aidey]

Why do you say it doesn't match a kidney stone at all?

 

[DrParasite]

BP: 148/106
RR: 26 bpm
HR: 134
O2: 99%

He was then rushed and flown to a more advanced hospital to be sent to the cath lab.. He coded halfway in flight and wasn't brought back.

I was thinking AAA until I saw this BP: 148/106? I think I have seen one confirmed AAA, and he was pretty hypotensive the entire way to the hospital. to have his pressure spike like that seems odd to me (assuming it was always taken on the same arm).

btw, the patient I had we transported to a level 1 trauma center, squeezing as much fluid as we could into him to get his BP somewhat stable. he even made it to the hospital alive (after a 25 minute trip). a 20 second exam by the ER attending confirmed the paramedics suspicion of AAA, and off he went to surgery. and we were informed that he died on the table, despite us doing everything right.

Don't worry, you did what anyone else in your position would have done.

 

[Veneficus]

pardon me

squeezing as much fluid as we could into him to get his BP somewhat stable..

I am not really sure this helped. Can you tell me why you did that?

 

[dmiracco]

Perhaps a little initially but not so much for me personally. The decomp shock presentation is clearly representative of more than just kidney stones. Also typically kidney stones by itself usually wouldnt cause someone to fall without defending it or bracing it. Remember that typically an abdomen can hold up to a liter and a half without showing outward signs, rigidity, discoloration, etc. So if you have a rigid and distended abdomen I would be thinking that we have lost alot of blood in the abdominal cavity.
Hemm pancreatitis, bowel perforation, AAA, lower GI bleed, splenic rupture, you get the point.
Hemodynamics typically dont change that much with a kidney stone or appendicitis.
Did the patient see blood in urine? Any associated fever lately? BP and pulses in all extremities, any difference? Associated back/retroperitoneal pain? Shoulder pain or does the patient feel like they have to take a dump?
Lots of etiologies are differential diagnosis by hands on assessment and proper questions.
Sometimes the best thing we can do is take the patient to the hospital.
I was not there so I am not going to arm chair it but hopefully you and your partner can learn something from this patient.
Also for the true AAA we are not going to be able to do anything with it, you just hope you have enough time to get to a surgeon.
Good luck.

 

[Smash]

Cholelithiasis is perhaps the most common misdiagnosis for abdominal aneurysm. The bifurcations to the renal arteries are one of the most common sites for dissection to occur, and the symptoms can initally be identical to renal calculi. A rather significant volume of blood can be lost in the retroperitoneal cavity as well. It is worth remembering that renal calculi is typically (not always, but typically) a disease of white males in their 30s and 40s. Be concerned about anyone over that age group complaining of what sounds like renal colic.

The old saw about unequal blood pressures may be of very little use. It is very common for there to be some variation in blood pressure between the arms, even in normal patients. For there to be a difference in blood pressure due to a thoracic aneurysm, the aneurysm would have to arise from the ascending aorta or aortic arch and impact upon one or other of the subclavian arteries; it would therefore most likely present with different symptoms than the case described.

I have to echo Veneficus with concern regarding the aggressive adminstration of crystalloids to an uncontrolled hemorrhage. I thought that discussion had been had ad nauseam: aggressive crystalloid resuscitation of uncontrolled hemorrhage is bad. Very bad. Very, very bad.

 

[Aidey]

Perhaps a little initially but not so much for me personally. The decomp shock presentation is clearly representative of more than just kidney stones. Also typically kidney stones by itself usually wouldnt cause someone to fall without defending it or bracing it. Remember that typically an abdomen can hold up to a liter and a half without showing outward signs, rigidity, discoloration, etc. So if you have a rigid and distended abdomen I would be thinking that we have lost alot of blood in the abdominal cavity.
Hemm pancreatitis, bowel perforation, AAA, lower GI bleed, splenic rupture, you get the point.
Hemodynamics typically dont change that much with a kidney stone or appendicitis.
Did the patient see blood in urine? Any associated fever lately? BP and pulses in all extremities, any difference? Associated back/retroperitoneal pain? Shoulder pain or does the patient feel like they have to take a dump?
Lots of etiologies are differential diagnosis by hands on assessment and proper questions.
Sometimes the best thing we can do is take the patient to the hospital.
I was not there so I am not going to arm chair it but hopefully you and your partner can learn something from this patient.
Also for the true AAA we are not going to be able to do anything with it, you just hope you have enough time to get to a surgeon.
Good luck.

She never actually said the abd was distended though. She said "maybe...maybe not". Given that it is perfectly reasonable for the DD to include kidney stones.

I don't think it's out of the realm of reality for the pain from passing a kidney stone to cause a syncopal episode.

 

[dmiracco]

I said perhaps a DD but not me personally. Anything is possable as is my big toe hurts and I fell and hit my head. Not all AAA will have a difference in BP and not all different BP in arms indicates AAA clearly however its one of many assessment tools you have that could help in your DD.
No different than all wheezing is not asthma and asthma doesnt always wheeze you have to assess and question the patient than utilizing your education and experience come up wuth an educated diagnosis for treatment.
This case essentially is a moo point and anybody wouldnt be wrong in considering a kidney stone however I wouldnt have considered that to be the culprit.

 

[Veneficus]

The old saw about unequal blood pressures may be of very little use. It is very common for there to be some variation in blood pressure between the arms, even in normal patients. For there to be a difference in blood pressure due to a thoracic aneurysm, the aneurysm would have to arise from the ascending aorta or aortic arch and impact upon one or other of the subclavian arteries; it would therefore most likely present with different symptoms than the case described..

Is this some kind of failed shortcut for an Ankle/brachial index?

The A/B indix is very useful but as the name says, it is measuring the difference between the arm and the leg, not both arms.

Also keep in mind that an A/B ndex is not specific, all it tells you is there is some kind of vascular compromise somewhere.

especially in older people, they could have multiple chronic vascular compromises so I am not sure in a case like this if you could call the results indicative of acute pathology.

 

[Veneficus]

She never actually said the abd was distended though. She said "maybe...maybe not". Given that it is perfectly reasonable for the DD to include kidney stones.

I don't think it's out of the realm of reality for the pain from passing a kidney stone to cause a syncopal episode.

There is more than one type of kidney stone. The Struvite stones can be seen in older people.

The Struvite stones are indicative of infection, which in addition to kidney stone adds sepsis and renal failure to your differential. even if not at the sepsis level yet, infections that reach the urinary bladder can become life long infections.

A urethral tear from one of these can not only cause severe bleeding, but spill renal metabolites into the retroperitoneal space.

Even if the Pt. had a history of kidney stones, with the potential sequele, including azotemia from a stone blocking the ureter at the renal pelvis, I would consider this patient emergent until proven otherwise. There are just too many bad things that could be wrong.

Since aneurysms can "leak" before rupturing and I have seen patients who have "leaked" for as long as 9 days (with pain) waiting for a PCP appointment before rupture, I encourage everyone to be highly suspicious for AAAs in the elderly population with recent onset of abd pain.

 

[Smash]

Is this some kind of failed shortcut for an Ankle/brachial index?

The A/B indix is very useful but as the name says, it is measuring the difference between the arm and the leg, not both arms.

Also keep in mind that an A/B ndex is not specific, all it tells you is there is some kind of vascular compromise somewhere.

especially in older people, they could have multiple chronic vascular compromises so I am not sure in a case like this if you could call the results indicative of acute pathology.

I suspect that the ABPI is possibly the genesis of this, but it's hard to say. It is a relatively common "ambulance-ism" that patients with an aneurysm somewhere in the thorax will present with unequal blood pressures. The degree of difference required to be significant is seldom quantified, nor does there seem to be much grasp on the pathology that would be required to give rise to a difference as I usually hear it with reference to abdominal aneurysm.