Vital Problems

[traumasurg]

So my partner and I are dispatched to a 48yo female complaining of stomach "pressure" and diabetic problems. Bg=442 pt took insulin 1hr prior to our arrival. Hx=DM, HTN, distal amputation of left leg due to necrosis, triple bypass=3 yrs ago, stroke=10 years ago. Pt. states she hasn't moved bowel or urinated in 3 days. I think.. ah yes the pressure in the abdomen. pt. has been eating and drinking sufficiently. Now the weird part.... I get the first responder observer to take bp, he says I can't hear anything I say try again. He says I still can't hear anything. I take stethoscope and bp cuff and try and I hear nothing. I listen w/stethoscope and hear nothing. I feel for radial, brachial, and carotid pulses on both sides and feel nothing. Pt is talking and carrying on with us with no altered mental status. Pulse ox isn't registering anything. I call hospital to let them know we are coming and nurse says ok. We get there and the nurse is like... so you couldn't get vitals (very provocatively but that is beside the point). She hooks up monitor and first bp the monitor gets is 61/48. Nurse says... that's not right. She changes cuffs and switches to the other arm and monitor reads 48/52.... I think wow that's interesting. Multiple attempts show routinely 61/46, 63/44. I have no clue what happened but I haven't been doing this very long so I thought maybe someone could educate me. Thanks.

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[Dwindlin]

I'm not entirely sure what you're wanting explained. But I will say that if the patients pressure really was 60ish/40ish then I'm not at all surprised you weren't hearing it or getting a radial.

 

[DitchDoc73]

I agree with atkinsje. The Pt was apparently hypotensive, and that led to your inability to obtain a bp through auscultation and by palpation. Yes most people are not alert and oriented with significant hypotension, but that is not always the case. More than likely this Pt has probably been experiencing the hypotension for an extended time (probably days) and the body has compensated for the hypotension.

I have had a Pt in the past who was A&O with a GCS of 15, and a glucose reading of "LO" (less than 26 mg/dL on our meters). I have also had the pleasure of seeing a Pt during my paramedic clinicals who was concious, alert, and talking with a heart rate of ~16. It just goes to show you that there are no absolutes when it comes to medicine!

 

[traumasurg]

I guess it just struck me odd that she wasn't complaining of weakness and that she was seemingly normal. I also wondered whether or not that backed up fluid was keeping the pressure there and what would happen if they placed a catheter and drained the bladder.

 

[Altruist]

This is EMS, weird **** happens sometimes. Not sure what the explanation would be for the lack of carotid pulse, except maybe that this patient was "pleasantly plump" and all that excess tissue made palpating a carotid difficult... I imagine a systolic pressure of 60 probably wouldn't make that any easier. Don't know if you tried this, but laying the patient supine might have made it easier to find something in the carotids at least.

Ditchdoc is right; when things develop slowly, it's amazing what you can compensate for. I saw a guy in the ER who'd driven himself in with a pulse of 18. Crazy.

Also, don't know if this patient was on dialysis (from the oliguria and diabetes, it's in her future), but when I was an EMT-Basic and worked the dialysis taxi route, some of those folks had systolic pressures of 80 on a good day. That was a little hard to get used to.

 

[traumasurg]

This is EMS, weird **** happens sometimes. Not sure what the explanation would be for the lack of carotid pulse, except maybe that this patient was "pleasantly plump" and all that excess tissue made palpating a carotid difficult... I imagine a systolic pressure of 60 probably wouldn't make that any easier. Don't know if you tried this, but laying the patient supine might have made it easier to find something in the carotids at least.

Ditchdoc is right; when things develop slowly, it's amazing what you can compensate for. I saw a guy in the ER who'd driven himself in with a pulse of 18. Crazy.

Also, don't know if this patient was on dialysis (from the oliguria and diabetes, it's in her future), but when I was an EMT-Basic and worked the dialysis taxi route, some of those folks had systolic pressures of 80 on a good day. That was a little hard to get used to.

Renal failure had come to mind. Went back and found dialysis is the prescription.

 

[jwk]

I have had a Pt in the past who was A&O with a GCS of 15, and a glucose reading of "LO" (less than 26 mg/dL on our meters). I have also had the pleasure of seeing a Pt during my paramedic clinicals who was concious, alert, and talking with a heart rate of ~16. It just goes to show you that there are no absolutes when it comes to medicine!

I'll see your 16 and raise...er...lower it. Ever seen a patient eyes open and looking around while having really good CPR performed on them? VERY wierd.

 

[DitchDoc73]

I'll see your 16 and raise...er...lower it. Ever seen a patient eyes open and looking around while having really good CPR performed on them? VERY wierd.

lol You win on that one! The best I have for that is an old hippy (kinda reminded me of Tommy Chong) that was experiencing recurrent episodes of V-Fib. He would convert every time he was defibrillated, and would come back saying "WHOA!!! What a dream!!!" It happened about 10 times in 20 minutes...

But back to your guy...I guess it's a situation of one of the new mantras in EMS...Be the heart until you can fix the heart!

 

[Dwindlin]

I'll see your 16 and raise...er...lower it. Ever seen a patient eyes open and looking around while having really good CPR performed on them? VERY wierd.

Sort of related but my favorite quote ever from a 1st responder when I arrived on scene. "We tried to start CPR but the patient was fighting us."

 

[proman]

As sad as it is, I saw this 2 weeks ago in our cardiac step down unit. Apparently his BP of 45/30 was enough to feel ribs breaking.

 

[Altruist]

lol You win on that one! The best I have for that is an old hippy (kinda reminded me of Tommy Chong) that was experiencing recurrent episodes of V-Fib. He would convert every time he was defibrillated, and would come back saying "WHOA!!! What a dream!!!" It happened about 10 times in 20 minutes...

Classic!

I was pacing a guy once as we brought him into the ER, and after we transferred him to the ER bed, a nurse unhooked our patches (after I'd specifically told her not to--but she had to untangle all those wires, you know!)... guy goes back to asystole until we hook back up and I turn the pacer back on and (thank god!) get capture, which seemed like it took forever, but was probably around 30 seconds. The guy looks up at me, all confused, and says, "Hey, did I pass out for a minute there?"

Uh, yeah, sure...

 

[traumasurg]

Classic!

I was pacing a guy once as we brought him into the ER, and after we transferred him to the ER bed, a nurse unhooked our patches (after I'd specifically told her not to--but she had to untangle all those wires, you know!)... guy goes back to asystole until we hook back up and I turn the pacer back on and (thank god!) get capture, which seemed like it took forever, but was probably around 30 seconds. The guy looks up at me, all confused, and says, "Hey, did I pass out for a minute there?"

Uh, yeah, sure...

ha wow....

 

[AegriSomnia]

I had a 40ish y/o guy code on me a couple of years ago as we were backing into the ER bay. He was in VFIB so we shocked him and he was still in VFIB so we started CPR and ran inside with him. As we were about to transfer him I was still doing CPR when he sat bolt upright and started screaming. It scared the S&@# out of me.

 

[heinzmoleman]

hmm not trying to be rude but what do you need answered. I believe that you answered yourself. PT had a very low blood pressure it's no wonder you couldn't hear it. I don't know how long you have been doing this before but EMS is rarely ever routine. Every call and every PT presents a unique problem.