Call Analysis

[Arbrow06 5]

Here's the scenario:

Age: 80-95

Medical History:

Pancreatic Cancer, Diabetes

Symptoms:

Hypotension, Pursed Lip Breathing, Accessory muscle use, Shallow Breaths, Unable to speak, Verbal on avpu

BP: 90/40

HR: 95

Resp: 20

O2SAT: 95%

If you need additional info please ask away.

I want you guys to respond with a level of care(EMT-B, EMT-I, EMT-P) and what would you do for the pt. at scene and enroute. NO DIAGNOSIS but feel free to explain your suspicions and your actions to improve the pt condition.

[sympathomedic 383]

I am a medic, so I would do BLS first: Oxygen, then position: If lungs are clear, I may lay him down, if he has rales, then I would sit him up and see how he and his SPO2 respond. Then hit the road, all else in route based on your extrication situation-are you roadside or top floor of a 5 flite carry down?

A 12 lead to see if there is an MI going. Being an elderly diabietic he is at increased risk for a silent (No pain) MI.

He appears possibly dehydrated, maybe cancer related. Again, EVERY call comes down to assesment. If signs like poor skin turger, lung sounds, skin color, texture and temp and past Hx such as missed intake and lots of output via diarrhea or vomiting thatn I would be very suspicious of dehydration. He needs an blood glucose test also.

If he becomes cyanotic, or his SPO2 falls he will neet to be intubated. He kind of needs a tube based on what you have already. You may get by with CPAP. Gotta get the lung sounds, but CPAP is becoming the treatment of choice for just about any respiratory distress scenario.

Be intersting to see where this thread goes and what other providers would to.

[v85 212]

At the BLS level

rapid transport, high flow 02 and trendelenberg positioning.

I would be interested to know what the patient was doing at the time the symptoms started; his blood glucose level; and lung sounds.

At the BLS level, if he becomes unresponsive or the SPO2 or resp. rate starts falling, BVM with oral airway.

How about anaphylactic shock as a possible cause (hypotension, resp. distress), or pulmonary embolism

Edited November 10, 2013 by v85

[Arbrow06 5]

So Blood Glucose at the hospital was 160. Very frail. PTA said they tried a IV but it went right through the vein. Pt. BP dropped about 5 systolic and diastolic by the time you get to the hospital (about 15 minutes). Unable to take manual BP over palp or pulse. No BP or pulse detected via NIBP at ER triage. Call was for failure to thrive ( no eating via spoon feeding for past couple days). Also note shallow breathiing.

Post

POSt

Edited November 10, 2013 by Arbrow06

[Jybehofd 85]

sounds like the patient may need hospice care.

but my treatment would have been,

Capanography CO2 with o2 2lpm and see if the pso2 increased. based on the capanography readings and respirory rate from that along with the patient's lung sounds i would consider the option of CPAP. Also obtain a 12 lead, and a least an 18 gauge IV, with labs and blood glucose stick. I would be careful with the saline but would start small 200-300 cc and see how that did and maybe go too 500 cc and then more then likely kvo unless the patients bp improved. but above all i would make sure the patient was given a warm comfortable ride to the hospital.

[FireMedic049 597]

I don't think there's enough information provided to draw any definitive conclusion. One of the most crucial pieces of missing information for this patient is the lung sounds. The 12-lead is going to be important too. Based solely on the info provided so far, I'd be looking at a respiratory cause since pursed lips and accessory muscle use are typically signs of a respiratory problem. I'd also be suspicious of additional medical history not revealed, specifically COPD or CHF. Knowing the patient's meds could reveal that. Skin color/condition, temperature and blood sugar level would be helpful too.

Based on my local treatment protocols:

If the patient has wheezes present and/or there's reason to suspect a history of respiratory problems, then I'd likely start with an albuterol treatment and see what effect that has.

If the lungs are clear, then I'd suspect that his condition is either cardiac related or cancer related. The 12-lead EKG might be able to help sort that out. I'd start a NS bolus and re-evaluate. If that doesn't improve the BP, then Dopamine might be in order if I'm thinking cardiogenic shock, but given the additional information about "failure to thrive", it's more than likely not going to be cardiogenic shock.

If it appears that there is fluid in the lungs, then depending on the level of respiratory distress, I may just give O2 or start CPAP.

[FireMedic049 597]

He kind of needs a tube based on what you have already.

Why is that? He could easily get to the point of needing one, but I'm not seeing anything in the initial post to support the need for a tube.

[sympathomedic 383]

I made that based on pursed lip breathing, shallow breathing (ineffective breathing?), accesory muscle use and lastly, cannot speak. Maybe he cannot speak every day? In the limited story, I made the jump that unable to speak meant that he did not have enough breath to speak.

I strongly prefer NOT intubating folks. I feel it tends to extend their recovery, and our goal here is recovery. If I can BVM or CPAP to avoid a tube, I will always go with that option. But in this pt's case, there may be no recovery without the tube- he sounds quite bad. That 95% SPO2 could be Co2 retention, and not actual blood oxygen.

Reading the scenario again, if this is a 45KG 95 YO female, her speaking days may be behind her and the vitals are not too bad, but the level of DIB is worrisome.

[Arbrow06 5]

I love all the input. I would love to make this a weekly thing just regular old calls that make you ponder.

I figured the pt. was crashing being he is usually hypertensive also suffering from dehydration. His SPO2 as per NIBP was borderline hypoxic and with no history of like COPD or any sort of respiratory disease. His breathing was shallow a a bit rapid for my liking but i decided against being rough on him to BVM him which could do more bad than good. So just went with high flow oxygen. I also treated for shock which with the new protocol isn't much more than O2 and a warm blanket considering hypovolemic shock possibly. Was really puzzled and it's good that I did the best I could.

[Hudson61 11]

As a medic this is how I would deal with this patient.

Based on the information given, my first step would be O2 by NRM at 12+ LPM. The pursed lip breathing, accessory muscle use and respiratory rate at 20 is telling me the patient is starving for oxygen. However with that, I would also throw on an end tidal filter to get that level. I need to find out what both side of the respiratory system is doing. I am also thinking there may be more to the history then reported.

At this point, transport is in order. And no doubt a 12 lead will be taken.

Will take a listen to the patients lungs to see if wheezing or something else going on. After the end tidal and listening to the lungs will determine if I give a neb treatment or CPAP.

If wheezing, go with a xopenex treatment, if rhales, I would be going with CPAP. Xopenex has less cardiac affects then Albuterol.

If the 12 lead does show a cardiac event, I will go down that road and treat it.

An IV is in order here, after IV access, I would hang a 1,000 bag with a bolus of 250 cc NS, then slow to KVO and re-evaluate. I do not want to give too much fluid.. Also will do a blood sugar reading. If low, will give dextrose, plus looking at the patient and the enviornment the patient was in, I may also give thiamine to help get the dextrose cross the barrier to the brain.

If the blood sugar is very high, will be looking at starting a second line.

As far as transport position, the patient may not go for laying down, so if the patient states he feels better sitting up, then that is how I will transport.

[jhg10538 1]

Obviously this is hard to say for certain without being able to actually eyeball the patient and without a complete history and physical, but when I read the case description, my first impression was "dying as a result of the natural course of their disease." In a case like this you MUST be proactive and gain a solid understanding of what the goals of care are for the patient -- talk to the family, figure out how aggressively the patient wants to be treated if he can't tell you himself. I agree totally with the assessment strategies mentioned (ekg, capno, etc.) and if the patient wants to be aggressively resuscitated, everything said here regarding treatment is right on the money.

However, there's a good chance a patient like this will have some sort of advance directive (DNR/DNI, etc.) If they do, this DOES NOT mean do not treat. A doc I worked with used to say that palliative care is intensive care. You still need to do everything in your power to make the patient comfortable...in this particular case, you need to treat the patient's "air hunger." That may be as simple as supplemental O2, a warm blanket, and an easy ride, or it may mean nebs, lasix, or CPAP if they'll allow it. If you're going to be with the patient for a while (long txp), small doses of morphine or are useful (but good luck getting that order from medical control.) The patient may (probably) still be dying, but if you can make the process more comfortable and less stressful, you've done right by him.