What is this?

[Medico]

For the life of me, I cannot remember what this lady had going on.

Called for a 33 year old SOB. On scene we find a 33 year old white female sitting on her couch, in obvious emotional distress. AOx4, GCS 15. She states that she has been having shortness of breath for the last four hours. She woke this morning to find her hands and feet blue. They were indeed cyanotic, cool to the touch. Radial pulses present and regular. Pedal pulses absent, +1 pitting edema new onset. Pain described as a pressure 10/10, she requested that we cut her feet off or lance her feet to remove the pressure. Breath sounds clear, equal bilaterally, non labored.

Pulse: 100 weak and regular.
BP: 70/52
RR: 18, 100% 4LPM, 100% RA.
ECG: Sinus Tach, negative ectopy.

NKDA
Takes lisinopril.
Hx of heart valve replacement.
The above MAR and PMH is all we were able to obtain.

Please excuse my brevity, I'm typing this on my phone.

*EDITED*

She also had cyanosis of her nose.

 

[VFlutter]

Hx of heart valve replacement.

Which heart valve? Systolic/Diastolic Murmur?

Valve replacement in a 33 year old is concerning for congenital abnormalities or endocarditis. This could be an acute valvular insufficiency or an embolic event.

Any JVD?

 

[Medico]

Which heart valve? Systolic/Diastolic Murmur?

Unknown. She was a poor historian.

 

[VFlutter]

Unknown. She was a poor historian.

Did you listen for a murmur? You can usually figure it out with an assessment.

 

[NomadicMedic]

Acrocyanosis is what the condition is called. Important to know if it has has it happened before. Risk factors for PE or other embolism? How long has she been taking the Lisinopril? Is she urinating as normal? ETCO2 waveform and capnometry?

Zebra of the day TM: renal tubular acidosis secondary to ACE inhibitor.

 

[VFlutter]

I really want to say PDA but I assume it would have been repaired when they replaced the valve. But the surgical repair could have failed.

 

[Medico]

I did not listen.
I believed it was acrocyanosis too, but is it not acrocyanosis when they are cyanotic else where as well?

She has been on the lisinopril for 2 years.

 

[VFlutter]

I did not listen.
I believed it was acrocyanosis too, but is it not acrocyanosis when they are cyanotic else where as well?

She has been on the lisinopril for 2 years.

I do not want to harp on it too much but cardiac auscultation can give you a ton of information but is rarely done, not only in EMS. But I am biased since all I do is listen to hearts all day.


Acrocyanosis is usually not painful and not accompanied by other symptoms. At least from what I understand.

 

[Medico]

I do not want to harp on it too much but cardiac auscultation can give you a ton of information but is rarely done, not only in EMS. But I am biased since all I do is listen to hearts all day.


Acrocyanosis is usually not painful and not accompanied by other symptoms. At least from what I understand.

I'll confirm with those who were on the Medic unit what her cap. was and waveform. Unfortunately, I did not get to run this call to the hospital and did not get to participate with the initiation of all treatments/assessments.

I agree with you. Its a habit I need to get into. One I will promptly begin.

I understand acrocyanosis the same as you. This is one reason I'm questioning.

 

[hogdweeb]

I do not want to harp on it too much but cardiac auscultation can give you a ton of information but is rarely done, not only in EMS. But I am biased since all I do is listen to hearts all day.

Please excuse this... cardiac auscultation. What points do you auscultate? with lung auscultation you auscultate fields of the lungs. heart, not having as much surface area would be harder to auscultate, or would you go for the atrium and ventricle? would there be any benefit for a Basic doing it? Could a basic do it and learn anything about the pt.'s current illness?

 

[abckidsmom]

Please excuse this... cardiac auscultation. What points do you auscultate? with lung auscultation you auscultate fields of the lungs. heart, not having as much surface area would be harder to auscultate, or would you go for the atrium and ventricle? would there be any benefit for a Basic doing it? Could a basic do it and learn anything about the pt.'s current illness?

Watch this. http://www.youtube.com/watch?v=cE8X1nwZWC4

 

[Medico]

The transporting medic unit did not do capnography.

She had acute rightsided CHF, stated the MD. However, that does not explain the cyanosis, which he did not know what it was either.

The pt said multiple time throughout transport that she believed she was going to die. I'll follow up and provide an update.

 

[jefftherealmccoy]

12 lead?

 

[MSDeltaFlt]

Sounds like she threw a clot somewhere important.

 

[Medico]

12 lead?

Below is a 12Lead from the call.

 

[Amberlamps916]

Interesting 12 lead consistent with right-sided cardiac pathology. I second the possibility of a clot.

 

[Medico]

Interesting 12 lead consistent with right-sided cardiac pathology. I second the possibility of a clot.

But what area could a blood clot be to cause isolated cyanosis to only the hands, feet, and nose?

 

[MSDeltaFlt]

But what area could a blood clot be to cause isolated cyanosis to only the hands, feet, and nose?

I'm thinking the same clot that caused the sys of 70.

 

[tacitblue]

I am gonna disagree with a thromboembolic event and instead suggest she has eisenmenger syndrome.

In these patients, long standing left to right shunting from a PDA, ASD, or VSD leads to increased RV volumes and pulmonary artery pressures. Without intervention, intimal scarring and irreversible pulmonary hypertension results, and outflow from the right ventricle is obstructed. Reactive right ventricular hypertrophy begins to develop. Eventually, the septal defect becomes the path of least resistance and the shunt reverses, causing cyanosis, shortness of breath, and signs of right sided failure including edema and hepatic congestion.

Your patient's dyspnea along with cyanosis, edema, and right ventricular hypertrophy on the EKG are strongly suggestive. This is a rare entity and the ED physician would have diagnosed her with right sided failure, but I have a suspicion that a chest xray would show evidence of pulmonary hypertension and an echo would demonstrate a right to left shunt, which is really the only reason for bilateral and central cyanosis.

 

[Amberlamps916]

From what I've gathered, someone with Eisenmenger's syndrome is highly likely to suffer from both uncontrolled bleeding due to damaged capillaries and high pressure, and random clots due to hyperviscosity and stasis of blood.