Live from Peachtree Street

Case Presenter ~ Jeff Brosius, NREMT-P
Peachtree Street ~
a rough and tumble area of Atlanta 
that produces a wide variety of EMS runs.

Current Case

 

 

 " No Joke "

submitted by 
Tom Bouthillet, Paramedic
Hilton Head, SC.


You show up for duty at 0745, get yourself a cup of coffee and put a bagel in the toaster. Moments later, your supervisor walks in and says, "What are you doing here?"

"I work here." you reply.

"You're at Station 6 today."

You abandon your bagel, grab your gear bag, and head back out to your car.
You arrive at Station 6 at 0801 and the Captain says, "Hurry up and get dressed. Medic 6 just went on a call. We'll take you there on Truck 6."

You're very accustomed to practical jokes. "Yeah, right."

"I'm serious. Do you see Medic 6?" You don't. "Get dressed. Hurry up."


Five minutes later you are pulling up on scene as Medic 6 is pulling away.
Truck 6 stops and lets you out. You run over to Medic 6 and open the side door. You jump inside to see a large man sitting up, dry heaving into a red bag. A nervous and diaphoretic paramedic is taking a knee and looking for IV access.

"What do you need?"

"Look at the monitor." You look and see [ Field Strip Lead II  in a new window]

"The Captain wanted me to take the call so you could go home."

The nervous looking paramedic flies out the back door of the ambulance before you can stop him, and you are left with an EMT Basic. Another is driving the ambulance, and you start moving again immediately. You know you are only 5 minutes from the hospital.

Vital signs:

Skin: Dusky, diaphoretic.
Respirations: Intractable vomiting (dry heaves).
Pulse: 80 (never budged) Patient denied pacemaker.
BP: 150/100
pSO2: 92% RA
Increased to 97% with NRB mask.

Denies chest pain.
Admits to mild dyspnea.
Nauseated for 24 hours.
Vomiting since 0500.

Patient feels "awful".
Has "never felt this bad" before.
All questions are anwswered between dry heaves.

PMH:
"Heart problems"
Diabetes
Renal disease.

Meds:
Aspirin.
Beta Blocker.
Lasix.
Others.

[ EKG on  arrival at the ER in a new window ]

[ 12 lead EKG in a new window ]

Comments, anyone?

 

   Outcome

Howdy gang....

Sorry I've been so slow getting the results to you on the case. There are lots of things happening in the EMS world (you'll see what I'm talking about 
shortly,) and I've been trying to get things done.

Also, it is with much sadness that I report that this will be the last "Live from Peachtree Street" case review. I'm overwhelmed with work, both on the 
ambulance, and on another project, and neither Valerie or myself has the time to get the cases available. There will be a case review forthcoming on 
another website, and when it's ready, I'll drop ya a line to let you know. I want to thank each and every one of you for your input on the previous 
cases, discussion, and efforts to improve EMS. It's folks like you that make me proud to be a part of the EMS community.

(note: Valerie will archive this site soon so you can still review the cases or send others to review them)

Anyway, if you recall, we have the case of the month from Tom in Hilton Head: Adult male, c/o nausea and vomiting, with poor vital signs and one very ugly EKG. The 12-lead was posted.

According to Tom, here's the lab values from the ER:

Time: 0845

K+ ^ 7.8 (3.3 - 5.1)
Sodium v 128 (133 - 145)
Chloride v 90 (96 - 108)
CO2 v 19 (22 - 29)
Creatinine 1.7 (0.4 - 1.2)
BUN 44 (6 - 19)
Glucose 206 (70 - 110)
CPK 146 (24 - 195)
CKMB 4.3 (0.0 - 5.0)
Troponin < 0.15 (0.0 - 1.50)


Time: 1037

K+ ^ 8.2 (3.3 - 5.1)
DIG ^ 2.6 (0.8 - 2.0)
WBC ^ 13.2


Urine:

Yellow, turbid appearance
+ Large Blood
- Glucose
- Ketones
+ Large Protein


CxR > Generalized cardiac enlargement w/moderate pulmonary congestion.
Impression: moderately severe CHF.

Abdomen: Negative series.


So, does this help any?

It does, and if you look at the lab values, he's severly hyperkalemic, moderately hyponatremic, and is also in acute renal failure.

Hyperkalemia is a lethal condition that can progress VERY rapidly. Typically, increased potassim will first manifest as tall, narrow, and spike T waves. As it progresses, the P waves will flatten out (or become absent,) the QRS complex will widen, and eventually he EKG will become a "Sine Wave."

The EKG changes might be hidden or altered due to any underlying pathology (i.e. bundle branch block, other conduction defects,) and clinical presentation may vary, but every hyperkalemic patient has one thing in common: They don't have much time left if you don't catch it and treat it quickly. Standard care of hyperkalemia in the prehospital setting includes 
rapid transport, along with pharmocology interventions: Sodium Bicarb, 50% Dextrose, Insulin, and Calcium Carbonate (these meds consititute the 
"Hyperkalemia Cocktail," and work by facilitating the transport of sodium across the cellular membrane.)

Adjunctive treatment includes Albuterol Inhalers (large volume nebulizers,) and kayexelate retention enemas. The only long term treatment is hemodialysis...obviously not an option in the EMS setting.

So...standard supportive care in the form of Oxygen, IV access, EKG monitor, and transport. 12-lead if possible, meds as mentioned (with the approval of 
medical control if necessary,) and get thee to an ER promptly.

Thanks a million to Tom for the case, and thanks even more to all of you who helped me bring this Website to fruition. It's been a fun ride. Keep in 
touch.

I'll be seeing you in all the old familiar places.



With best regards,

JRB

 




The smart whippersnapper.
Jeff Brosius, of course
I wonder how long before we have a case about his own head trauma -MOI falling texts?


The 'grand poopah of nothing' who tries to keep Jeff in line.

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