Vomiting, abdominal pain, significant bradycardia

[TF Medic]

Just looking for a round-table type discussion on this hypothetical scenario.

35 year old male, calls 911 after he been vomiting "nonstop" for the past "three or four hours." Complains of abdominal pain 10/10, has sharp grimace on his face, appears lethargic but restless. Eyes appear heavy but he paces from the bed to the room. Your gut instinct is that he is in significant pain, has been vomiting a lot, and can't find a comfortable position. Toilet has a small amount of bile in it, but he's only dry-heaving now.

History- TBI, hypothyroidism, denies any other.
States he has had these episodes on and off over the past year and a half, has lost a significant amount of weight (100lbs), and has been seen a few times and the hospital "doesn't do anything to fix it."

Meds- Trazodone, Gabapentin, Bupropion, Disulfiram, Levothyroxine. Pill counts are estimated but appear correct for prescription dates.

Vitals on scene
BP 160/100
HR 50
98% room air
RR 16
Lungs clear all fields
Pupils =/R

In the truck you notice the heart rate is 48-50. PT is lethargic but answers all questions appropriately. States his eyes are closed because he is "tired." 12 lead unremarkable - sinus brady.

IV is started, your partner gives 4mg zofran, 100mcg fentanyl, and hangs NS wide open. Normal traffic transport.

Enroute heart rate noted to be as low as 36, BP remains hypertensive, PT states pain is unchanged post Fentanyl. PT still alert and oriented.

What else do you want to know? What else do you want to do? What is included in your field impression/differential diagnoses?

 

[NomadicMedic]

Interesting. Is he bradycardic from increased vagal tone secondary to the vomiting and pain, is he bradycardia from the hypothyroidism or does he have sick sinus syndrome or another issue that's not readily addressed in the back of a truck.

He seems lethargic and a bit bleh. I think I'd try a 0.5 mg atropine dose and see what I saw. It certainly would address the vagal tone question.

 

[Gurby]

Check a blood sugar and repeat 12 lead en route but not expecting to find anything. Does the bradycardia coincide with vomit/wretching episodes?

What has his alcohol intake been like recently? What was his oral intake today? Specific location and character of the pain? Any unusual family history (Addison's Disease, etc)?

I don't have a clue really. I put him in the truck and go lights and sirens to the hospital.

... Did you happen to pick this gentleman up from the Section 8 housing complex? Is he also unable to work, disabled for depression and anxiety? .... Probably doesn't get fentanyl from me.

 

[NomadicMedic]

Check a blood sugar and repeat 12 lead en route but not expecting to find anything. Does the bradycardia coincide with vomit/wretching episodes?

What has his alcohol intake been like recently? What was his oral intake today? Specific location and character of the pain? Any unusual family history (Addison's Disease, etc)?

I don't have a clue really. I put him in the truck and go lights and sirens to the hospital.

... Did you happen to pick this gentleman up from the Section 8 housing complex? Is he also unable to work, disabled for depression and anxiety? .... Probably doesn't get fentanyl from me.

I agreed... right up to the "go lights and sirens" part.

 

[Handsome Robb]

Interesting. Is he bradycardic from increased vagal tone secondary to the vomiting and pain, is he bradycardia from the hypothyroidism or does he have sick sinus syndrome or another issue that's not readily addressed in the back of a truck.

He seems lethargic and a bit bleh. I think I'd try a 0.5 mg atropine dose and see what I saw. It certainly would address the vagal tone question.

Even with the hypertension? Not sure I agree with you on that one my friend.


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[TF Medic]

Is he bradycardic from increased vagal tone secondary to the vomiting and pain, is he bradycardia from the hypothyroidism or does he have sick sinus syndrome or another issue that's not readily addressed in the back of a truck.

If I could answer those I wouldn't have posted here.

To answer some other questions:

Bradycardia seems constant, he only retches once when you first arrive on scene. HR stays under 50 for duration of care.
BGL within normal range.
Unknown recent ETOH intake. Food intake is "breakfast, then I've been vomiting since." (it's ~2pm now)
Housing is low income but not co-op or subsidized. No call history from this address, name/DOB not in system. (IE, appears to be first time caller)
Is able to work but diagnosed with PTSD.
Atropine was not given.
Also, just curious, lights and sirens for an alert and oriented PT who seems asymptomatic (at least in regard to his bradycardia)? Not saying I would have disagreed to a priority transport, just wondering your thoughts. I can see it either way.

Ride in is relatively uneventful. This wasn't my call so I wasn't in charge of treatments/lack of, but I was stumped as well. Trazodone OD crossed my mind but I didn't get a tox screen back. Just wondering if anyone had an off the wall "it's XYZ condition" they could think up.

 

[Hemostatic]

History- TBI

How long ago was his TBI? Cause? Severity? Treatment?

 

[NomadicMedic]

Even with the hypertension? Not sure I agree with you on that one my friend.


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Fair enough, but is that BP right? Did they take it with an automated cuff? Was he more symptomatic than was really presented here? I can't tell... I wasn't there. Was he puking and sick (and lethargic) because he was bradycardic? I don't know. Something here doesn't smell quite right. I still think 0.5 of atropine would be appropriate, because I really think the bradycardia is due to excessive vagal tone. But again, I wasn’t there.

 

[Gurby]

I work in a city and do this call probably once per shift. In my experience, 90% of the time, a 35yo with that profile of meds is drug seeking. However, you still need to do your due diligence and assume it could be real. The fact that fire/police aren't familiar with the patient and he's not in your system also makes it more likely that this is real.

Also, just curious, lights and sirens for an alert and oriented PT who seems asymptomatic (at least in regard to his bradycardia)? Not saying I would have disagreed to a priority transport, just wondering your thoughts. I can see it either way.

I agreed... right up to the "go lights and sirens" part.

Lights and sirens because the heart rate doesn't make sense. If he were truly in pain, we expect it to be much higher. If he's truly been vomiting all day we might expect him to be dehydrated which would also bring it up. If he were faking to try to get narcs out of us, I'd still expect his resting HR to be a bit higher. If the low HR was brought on by vagal stimulation, we would expect it to normalize now that he's not vomiting anymore. It's possible that this is baseline for him, I have seen people with resting HR's in the 40's, but that's definitely unusual, and I assume this guy is not an athlete so even more unusual.

I want lights+sirens, but nice and easy. I just don't want to sit in traffic for 30 minutes with this guy, then we get to the hospital and - surprise! - he's having a cardiac event that we missed.

 

[DesertMedic66]

Any recent trauma? How long ago was the TBI? Any complications expected from the TBI? How are pupils?

Based on what has been presented so far I would hold off on the Atropine. His BP Is elevated, he seems to be mentating fine (although lethargic). Skin signs weren't listed but I'm assuming they are going to be somewhat normal.

IV Zofran, Benadryl (if Zofran has no effect), pain meds with repeat doses.

Transport code 2 (no lights or siren) to the ED he is normally seen at.

The unexplained weight loss of 100lbs is a concern for me

 

[bakertaylor28]

This sounds like it is most likely a GI blockage. (The presence of bile being the tale-tale sign, given that it does not appear to be an OD) I would go with a light dose of zofran (at say around 2.5 mg IV ) to deal with the vomiting temporarily, which is most likely causing the Sinus Bradycadia and the hypertension. (assuming it actually IS sinus bradycardia and not 1st degree AVB- given rates as low as the 30's!!!) I would consider pain meds if the Sinus Bradycardia wern't present- but pain meds on top of a brady-arrthmia is asking for trouble.

 

[VFlutter]

This sounds like it is most likely a GI blockage. (The presence of bile being the tale-tale sign, given that it does not appear to be an OD) I would go with a light dose of zofran (at say around 2.5 mg IV ) to deal with the vomiting temporarily, which is most likely causing the Sinus Bradycadia (assuming it actually IS sinus bradycardia and not 1st degree AVB- given rates as low as the 30's!!!) I would consider pain meds if the Sinus Bradycardia wern't present- but pain meds on top of a brady-arrthmia is asking for trouble.

Why the "light dose" of Zofran? Why so concerned about a first degree block?

I would think some of this could be explain by that combination of home meds but I don't have anything specific to cite.

 

[bakertaylor28]

First, the reason I would be careful to evaluate for first-degree AVB is that it can sometimes be mistaken as Sinus Bradycardia- with the difference being that First degree AVB involves a prolonged P-Q segment. (i.e. prolongation between the end of P and QRS), BUT with First-degree AVB there is STILL always a P before every QRS (i.e. unlike the rest of the AV blocks, there are NO dropped QRS complexes). This is virtually the only thing that confirms the difference in lead-2 ECG. (assuming I don't have a full 12-lead).

By a light dose of zofran, I mean at around half of the normal recommended dose of 4mg IV, because of the fact that it's most likely a surgical case, in my opinion. With GI surgical cases, the gastric contents have to be dealt with somehow before surgical anesthesia is induced, to reduce the risk of intraoperative sepsis later down the road.

 

[NomadicMedic]

First, the reason I would be careful to evaluate for first-degree AVB is that it can sometimes be mistaken as Sinus Bradycardia- with the difference being that First degree AVB involves a prolonged P-Q segment. (i.e. prolongation between the end of P and QRS), BUT with First-degree AVB there is STILL always a P before every QRS (i.e. unlike the rest of the AV blocks, there are NO dropped QRS complexes). This is virtually the only thing that confirms the difference in lead-2 ECG. (assuming I don't have a full 12-lead).

By a light dose of zofran, I mean at around half of the normal recommended dose of 4mg IV, because of the fact that it's most likely a surgical case, in my opinion. With GI surgical cases, the gastric contents have to be dealt with somehow before surgical anesthesia is induced, to reduce the risk of intraoperative sepsis later down the road.

Are you a brand new medic? (Asking for a friend.)

 

[Handsome Robb]

Why on earth would you half a dose of zofran?

We routinely give people 18-16mg IV in two doses.


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[bakertaylor28]

Are you a brand new medic? (Asking for a friend.)

I'm still doing collegiate education.

 

[bakertaylor28]

Why on earth would you half a dose of zofran?

We routinely give people 18-16mg IV in two doses.


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Obviously, you haven't read the FDA's dossage guidelines. The standard dose of Zofran in surgical cases is 4mg IV Q 4 Hours. See rxlist.com/zofran-injection-drug/indications-dosage.htm The reason for giving half the standard dose is because of the fact that you want it to wear off by the time a surgical consult rolls around, given the fact that it is statiscally likely to be GI obstruction, given the whole bile thing.

 

[VFlutter]

Obviously, you haven't read the FDA's dossage guidelines. The standard dose of Zofran in surgical cases is 4mg IV Q 4 Hours. See rxlist.com/zofran-injection-drug/indications-dosage.htm The reason for giving half the standard dose is because of the fact that you want it to wear off by the time a surgical consult rolls around, given the fact that it is statiscally likely to be GI obstruction, given the whole bile thing.

First, the reason I would be careful to evaluate for first-degree AVB is that it can sometimes be mistaken as Sinus Bradycardia- with the difference being that First degree AVB involves a prolonged P-Q segment. (i.e. prolongation between the end of P and QRS), BUT with First-degree AVB there is STILL always a P before every QRS (i.e. unlike the rest of the AV blocks, there are NO dropped QRS complexes). This is virtually the only thing that confirms the difference in lead-2 ECG. (assuming I don't have a full 12-lead).

By a light dose of zofran, I mean at around half of the normal recommended dose of 4mg IV, because of the fact that it's most likely a surgical case, in my opinion. With GI surgical cases, the gastric contents have to be dealt with somehow before surgical anesthesia is induced, to reduce the risk of intraoperative sepsis later down the road.

Oh boy where to begin...

Obviously you have no experience working as a health care provider and have no factual basis for anything you are suggesting.There is absolutely no reason to reduce the dose of, or withhold, an antiemetic so that the patient is nauseous when the surgeon happens to wander by. That is even more ludicrous than not adequately treating pain to help the doctor diagnose.

"Hey Doc, this guy was nauseous on arrival but is much more comfortable after some Zofran and Compazine"
"What?!? How am i supposed to assess him?! Call me when the meds wear off and he is nauseous again so I can order a CT scan!"

Furthermore throwing up bile rarely a true bowel obstruction and is likely just from repeated vomiting on an empty stomach. What statics are you using?

Gastric contents causing intraoperative sepsis? What? I won't even touch that one.

Thank you for regurgitating that information about blocks however that does not really answer the question.

 

[Handsome Robb]

Obviously, you haven't read the FDA's dossage guidelines. The standard dose of Zofran in surgical cases is 4mg IV Q 4 Hours. See rxlist.com/zofran-injection-drug/indications-dosage.htm The reason for giving half the standard dose is because of the fact that you want it to wear off by the time a surgical consult rolls around, given the fact that it is statiscally likely to be GI obstruction, given the whole bile thing.

Umm...yea not going to touch that with a 10 foot pole.

There is absolutely zero reason to withhold antiemetic from a patient who is nauseous. The first thing a surgeon is going to do if they're nauseous is order an antiemetic. They don't want to be puked on anymore than we do.


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[dutemplar]

((blinks)) Given the current symptoms, release to Alpha (two EMT-Is, more or less) truck with instructions to monitor and transport non-emergent to RIAMS (medical, via ambulance triage). Lethargic, but puking his guts out for hours, probably get a sending dose of Zofran 4mg. Due to the lethargy, probably no opoid narcotics although I'd consider Penthrox inhalation an option for the Alphas to give while transporting without lights and woowoos.

That is assuming I don't look at the guy and go "Oh schnikies..." But based on the rest of the assessment, and stable BP, blood glucose, etc...

..as far as halving the dose, if it's going surgical - I'm betting that his gastric contents are already pretty emptied from the current amount of reported puking, and nothing an NG tube can't resolve perioperatively. Similarly, we stopped withholding pain meds on general abdominal pain about two decades ago. First thing the hospital will do is take the nausea and pain away. Especially while he's uncomfortable and can't lie still for a CT scan and all that happy stuff. Likewise, with his pain I would be dancing around the heart rate/ level of consciousness a little bit and not wanting to outright put him to sleepyville for the ride, and any potential downward spiral in the back of a box. Non-emergent transport that although I want this dude to get there, he likely doesn't need the rougher ride bouncing up and down getting there pushing the pain, and adding motion sickness to the deal.