Student case: near-syncope and left arm numb

[rev ronin]

PA Students!  Welcome to your occasional case study.  Pre-PAs who are reading and following, please feel free to chime in.  Practicing PAs, please allow 24+ hours before filling in the gaps...

You are working as the only provider in an Alaskan clinic.  The radio crackles to life, and your RN gets a short report from a BLS ambulance, who is about 30 minutes out with an early 70s year old female, who nearly passed out on the toilet an hour or more ago, and now has left arm numb and feeling cold to the touch. She is described as conscious, tachycardic and not sat'ing well.

It's middle of the morning on a weekday, so you have scheduled patients in exam rooms, full clinic staff, including 2 RNs (one of whom is new to the facility and orienting) and about 8-9 other staff, including lab techs, pharmacy techs, an X-ray tech, and a couple of MAs. You can call in more folk if needed, including another PA who's probably sleeping.  Fixed wing medevac should be 60-90 minutes out once you call for it, and your ambulance can ground transport to a hospital with surgical, ICU, and full radiology capabilities in about 3 hours.  Your clinic is equipped as a level 5 (lowest) trauma center: http://dhss.alaska.gov/dph/Emergency/Documents/trauma/Level IV-V docx-final.docx

For the first phase of this case, I'd like students to focus on two questions:

1) What is your differential based on this short report?
2) What history are you going to elicit from this patient upon her arrival?
3) What are your orders, both interventions and testing, to be carried out as soon as they roll in?  You have two RNs and yourself, so everything will not be happening simultaneously.

I plan on posting what happens upon arrival in 24 hours or so.

 

[ValPAS]

4 hours ago, rev ronin said:

PA Students!  Welcome to your occasional case study.  Pre-PAs who are reading and following, please feel free to chime in.  Practicing PAs, please allow 24+ hours before filling in the gaps...

You are working as the only provider in an Alaskan clinic.  The radio crackles to life, and your RN gets a short report from a BLS ambulance, who is about 30 minutes out with an early 70s year old female, who nearly passed out on the toilet an hour or more ago, and now has left arm numb and feeling cold to the touch. She is described as conscious, tachycardic and not sat'ing well.

It's middle of the morning on a weekday, so you have scheduled patients in exam rooms, full clinic staff, including 2 RNs (one of whom is new to the facility and orienting) and about 8-9 other staff, including lab techs, pharmacy techs, an X-ray tech, and a couple of MAs. You can call in more folk if needed, including another PA who's probably sleeping.  Fixed wing medevac should be 60-90 minutes out once you call for it, and your ambulance can ground transport to a hospital with surgical, ICU, and full radiology capabilities in about 3 hours.  Your clinic is equipped as a level 5 (lowest) trauma center: http://dhss.alaska.gov/dph/Emergency/Documents/trauma/Level IV-V docx-final.docx

For the first phase of this case, I'd like students to focus on two questions:

1) What is your differential based on this short report?
2) What history are you going to elicit from this patient upon her arrival?
3) What are your orders, both interventions and testing, to be carried out as soon as they roll in?  You have two RNs and yourself, so everything will not be happening simultaneously.

I plan on posting what happens upon arrival in 24 hours or so.

 

1. Sounds like an MI,  stemi or non-stemi

2. History of CAD/ MIs. Any allergies, if she’s Diabetic, has hypertension, or a smoker. Previous medical history, medications she’s on. Previous family history of MIs, patients usual activity level, was she feeling unwell earlier in the day, or was her MI exacerbated by Valsalva Maneuvers by bowel movements. Any previous Vaso vagal episodes Diet. 

3. One nurse obtain vitals, oxygen + stat EKG. To see which is it stemi if so patient needs PCI. Referral needed to an acute facility ?( I am unsure if the lowest trauma care have cath labs; if not request a transfer to an higher acuity facility.) Second RN to insert IV lines and obtain lab tests: trops, CK, d-dimer, CBC, bnp. Order echo if needed after lab results 

Edited July 28, 2019 by Hopefully1DayPAc

[rev ronin]

So, d-dimer is a send-out, report in 24 hours.  Cath lab and echo would both be on the other side of a medevac.  You can get a specialist of your choice on the phone in a few minutes if you want, but as far as what you have yourself... it's pretty minimal.

I'll address the substantive findings when we get there.

[EastCoastPA]

1) TIA/Stroke/MI until ruled out
2) above plus OPQRST etc + neuro exam for any additional FND + tPA contraindication questions at this point given the timing

3)really depends on the timing and what we have available in the clinic but I'm probably calling the medivac now. Can we get anything from the BLS crew? EKG, ASA, neuro checks? What's ETA to hospital for medivac once here?

Edited July 28, 2019 by EastCoastPA

[rev ronin]

So, patient arrives, thin body habitus, with a walking boot on one foot.  She had achilles tendon surgery 4 weeks ago, which had not been problematic, with nominal wound healing.  She confirms the initial report, and family notes that she was mumbling at first and blue around the lips.  She denies chest pain; her only discomfort is in her left arm. She did perk up a bit on O2, was initially sat'ing in the 80's, now in low 90s with 2 lpm NC.

She denies history of CAD/MI/CVA/TIA, no previous vasovagal episodes. Diet is unremarkable. Not diabetic, not a smoker, no HTN, is on several supplements and hormone replacement.  She does say she was feeling poorly upon awakening, even before going to the bathroom.

EKG shows sinus tachycardia. Stroke exam is negative.

CBC, CMP, Troponins (that's all you have, sorry) are drawn with the IV line start.

4) What's your differential now?
5) What other non-routine physical exam(s) did I do and why?
6) What's next?

[rev ronin]

Boy, participation is pretty light this time, but moving things along...

The leg with the boot is a bit swollen, but not badly, call it 1-2+/4 nonpitting, and maybe a bit more erythematous.  The surgical site doesn't look bad at all, really. Homan's test is a) mostly useless in the first place, but b) completely out of the question due to the Achilles' surgery.

Ultrasound is not available, but a CXR is unremarkable.

Labs show equivocal troponins, CMP is substantially unremarkable, but CBC shows a white count of 17k.  It's now been 3-4 hours since the start of the event. Medevac would be ~4 hours ground, vs. 45 minutes in the plane.  Patient is keeping her sats up on 2-3L, but is still tachycardic even after 500 mL NS.

7) Do you believe the troponins rule out an MI, or want them repeated? If so, in how long?
8} What concerning criteria does this patient meet, being tachycardic, tachypneic, and with an elevated white count?
9) One of the tests I ordered done promptly was bilateral blood pressures.  What was I looking for, and what finding would have increased my sphincter tone several notches?
10) So... what next?

 

[rev ronin]

Crickets?

[nprice8]

Pre-PA student here, bear with me....

7) Initial troponin readings do not rule out an MI. You would run serial troponins, every 2-3 hours. Troponin elevation can often be delayed by up to 6 hours I believe after an infarction.

8. The patient being tachycardic, tachypneic, and with an elevated white count means that the SIRS (Systemic inflammatory response syndrome) criteria is met, and sepsis protocols should be activated (i.e. NS or LR bolus' of 30 mL/kg of patient's weight administered, barring no hx of renal failure or CHF, draw a lactate and 2 sets of blood cultures and send to lab, and administer a broad spectrum antibiotic)

9) Not sure 

10) monitor patient's blood pressure and oxygenation closely, as both can tank quickly with severe sepsis. Continue to give antibiotics and arrange for transfer

[ValPAS]

26 minutes ago, nprice8 said:

Pre-PA student here, bear with me....

7) Initial troponin readings do not rule out an MI. You would run serial troponins, every 2-3 hours. Troponin elevation can often be delayed by up to 6 hours I believe after an infarction.

8. The patient being tachycardic, tachypneic, and with an elevated white count means that the SIRS (Systemic inflammatory response syndrome) criteria is met, and sepsis protocols should be activated (i.e. NS or LR bolus' of 30 mL/kg of patient's weight administered, barring no hx of renal failure or CHF, draw a lactate and 2 sets of blood cultures and send to lab, and administer a broad spectrum antibiotic)

9) Not sure 

10) monitor patient's blood pressure and oxygenation closely, as both can tank quickly with severe sepsis. Continue to give antibiotics and arrange for transfer

Pre-pa here too ! Virtual high-five ! 

A bilateral BP is often used to rule out an aortic dissection 

[rev ronin]

Ok, so now we have multiple differential diagnoses:

* Possibly an MI, but troponins are "meh" at the moment.  We have no cardiac history and no chest pain.  While this was always in my differential, folks jumped on it more as a possibility than I would have.
* My big sphincter-squeeze fear was aortic arch dissection.  Review the arterial flow anatomy and understand why that was one of the things I thought of as a worst case scenario.  Thankfully, roughly equal arm BPs ruled this out.

So, the two big DDx left are sepsis and PE.  Without D-dimer or U/S, I'm flying blind as to what's going on inside the veins.  My initial inclination was to order Rocephin, Levofloxacin, lots of NS, and call for medevac: If it's a PE and I order sepsis treatment, that should be less bad than NOT ordering sepsis treatment if it is, in fact, sepsis.  I got an ED attending at the receiving hospital on the line, who spent a few minutes collaboratively quizzing me on how her leg and surgical site actually looked, who redirected me to Lovenox and following the PE pathway--and still Medevac'ing her.  Not every SIRS is sepsis, and in this particular case, while I should have started the broad-spectrum antibiotics per protocol, a *potential* infection source isn't always.  The leg didn't look infected, it looked swollen, and between the self-admitted inactivity and hormone replacement therapy, I was able to get the right treatment for my patient.  Never be too proud to be redirected; never be too enslaved to an algorithm to ignore other possibilities.

I didn't end up repeating troponins; the medevac came and got her before it would have been time.  She transferred reasonably comfortably, was started on anticoagulation and her hormone replacement was stopped, and she was discharged in good condition promptly.

Oh, and I'm working to get point of care ultrasound deployed in this clinic soon.

[EastCoastPA]

Sorry for jumping on and off, this thread happened to be during EOR season. Point of care US is actually something I'm really interested in. Can I get CME for taking classes for that? We got a few days worth in school but not nearly enough

[rev ronin]

4 hours ago, EastCoastPA said:

Sorry for jumping on and off, this thread happened to be during EOR season. Point of care US is actually something I'm really interested in. Can I get CME for taking classes for that? We got a few days worth in school but not nearly enough

Sure. There are multiple entities offering CME courses; I'm going to the Practical POCUS one in Missouri next week.

[crcrown]

On 7/27/2019 at 4:57 PM, rev ronin said:

PA Students!  Welcome to your occasional case study.  Pre-PAs who are reading and following, please feel free to chime in.  Practicing PAs, please allow 24+ hours before filling in the gaps...

You are working as the only provider in an Alaskan clinic.  The radio crackles to life, and your RN gets a short report from a BLS ambulance, who is about 30 minutes out with an early 70s year old female, who nearly passed out on the toilet an hour or more ago, and now has left arm numb and feeling cold to the touch. She is described as conscious, tachycardic and not sat'ing well.

It's middle of the morning on a weekday, so you have scheduled patients in exam rooms, full clinic staff, including 2 RNs (one of whom is new to the facility and orienting) and about 8-9 other staff, including lab techs, pharmacy techs, an X-ray tech, and a couple of MAs. You can call in more folk if needed, including another PA who's probably sleeping.  Fixed wing medevac should be 60-90 minutes out once you call for it, and your ambulance can ground transport to a hospital with surgical, ICU, and full radiology capabilities in about 3 hours.  Your clinic is equipped as a level 5 (lowest) trauma center: http://dhss.alaska.gov/dph/Emergency/Documents/trauma/Level IV-V docx-final.docx

For the first phase of this case, I'd like students to focus on two questions:

1) What is your differential based on this short report?
2) What history are you going to elicit from this patient upon her arrival?
3) What are your orders, both interventions and testing, to be carried out as soon as they roll in?  You have two RNs and yourself, so everything will not be happening simultaneously.

I plan on posting what happens upon arrival in 24 hours or so.

 

Could the patient also have had a LUE arterial occlusion with the cold/numb left arm + a PE? Have seen this once previously in a post surgical patient. Were pulses diminished at all?

[rev ronin]

3 hours ago, crcrown said:

Could the patient also have had a LUE arterial occlusion with the cold/numb left arm + a PE? Have seen this once previously in a post surgical patient. Were pulses diminished at all?

She didn't.  Bilat radial pulses were one of the first things I checked upon her arrival.