*Note: The story below is a call we ran in class.
We got called to a law firm, code 3 for an unconscious collapse on the 15th floor. Me and my partner got our gear, and entered the fancy building with polished floors. We were met by a frantic looking secretary as we wheeled our stretcher into the elevator.
Secretary: “Oh I’m so glad you’re here.”
Me: “Why did you call us today?”
Secretary: “Well I found my boss slumped over on the floor and she won’t wake up.”
Me: “And when was that?”
Secretary: “About 30min ago.”
The elevator came to a halt. We stepped out and hung a right. The office was beautiful, with an unobstructed view of the mountains. Unfortunately there was no time to admire the view. On the office floor was our patient, she appears to be in her 40s and was lying on her back. She was in business attire and was clean-cut. It was obvious from the first look that she wasn’t doing well. She’s unconscious, and does not respond to any form of stimulus. She also has cheyne-stokes respirations and weak rapid radials. My partner got an airway in and high flow oxygen set up while I did a quick physical assessment. I found no track marks, no medical alerts, no incontinence, no sweat breaths (ketones), nothing of significance aside from pinpoint pupils. I thought it was an odd place to have an overdose, but I kept that possibility in the back of my mind.
Me: “Do you know if she’s a diabetic?”
Secretary: “No, not that I’m aware of.”
Me: “Do you know if she’s been drinking lately, or have taken any medications or recreational drugs?”
Secretary: “Oh no, she doesn’t do that sort of stuff, she goes for a drink once in a while, but she hasn’t had any today. She’s a wonderful mother, I’m sure she doesn’t do recreational drugs…”
Me: “Okay, thank you. Do you mind staying nearby, I may need to ask you a couple more questions later on.”
Secretary: “Yes, of course. Is she going to be alright?”
Me: “We’re doing everything we can for her right now.”
As my partner worked on getting me a baseline set of vitals. I went about starting an IV for a bag of normal saline. I’m hoping the vitals will come up with some clues as to what’s going on with this patient.
Partner: “I’m done the vitals.”
He hands me the clipboard and this was what I read:
LOC: 3 (1,1,1), HR: 130 W/R, RR: 8 Irreg C-S, BP: 108/70, Skin: PCDry, Pupils: pinpoint, SpO2: 94% 15Lpm, BG: 6.0mmol/L, Temp: 37C.
Hmmmmm, great. The vitals doesn’t offer me any better clues to what I’ve found on my RBS (rapid body survey). Blood glucose (BG) is normal, she doesn’t have a fever, the only abnormalities are the pinpoint pupils and the cheyne-stokes respirations, with the decreased LOC (level of consciousness), and she looks like she’s going into shock. I’m still suspecting a possible narcotic overdose (OD), but an OD on opiates won’t cause cheyne-stokes respirations, which is a sign of brain injury or increased ICP (intercranial pressure). My differentials were now narrowed down to two:
As my partner readied the main stretcher, I talked to the secretary again.
Me: “Do you know if your boss has taken a fall lately?”
Secretary: “No, she’s never mentioned it, and I know she’s been so busy, she hasn’t been able to go skiing or hit the gym the past several weeks.”
Me: “Okay, and does she have a history of epilepsy or seizures?”
Secretary: “No, or at least she’s never had one when I was around and has never mentioned of such. As far as I know, she’s a fit, healthy lady.”
I agreed with her, she looked healthy, so kidney issues is out the window as well on my differentials, and poisoning doesn’t seem likely here. I told the secretary which hospital we’ll be taking her boss to as we lifted our patient onto our cot and got her all buckled in.
A mneumonic we use for common causes of unconsciousness/altered mental status is the following:
A – alcohol, acidosis
E – endocrine, epilepsy
I – infection
O – overdose
U – uremia
T – trauma, tumor, toxemia
I – insulin
P – poison, psychosis
S – stroke, seizures
From the questions I’ve asked and the vitals I’ve obtained, I’ve basically narrowed it down to two. “O” and “S”. Yet I had a feeling I was missing something.
I hopped into the back of the ambulance while my partner started driving code 3 to the hospital. I drew up 0.4mg of Narcan since I’m still suspecting an overdose. Narcan also known as naloxone competes with the same receptors that opiates bind to. In fact, narcan sort of knocks those opiates out of the receptors and blocks the “door” so to speak, hence reversing the effects of the opiates. So if my patient is overdosed on opiates such as heroin, then a dose of narcan should bring her back. I injected the dose through the IV med port. I took another set of vitals which were unchanged compared to the previous set of vitals. While I waited for the narcan to work, I did my more detailed physical assessment. I found nothing new with this assessment compared to my RBS aside from getting a positive babinski reflex on both her feet. A positive babinski reflex is when you stroke the inside of the bottom of the foot causing the toes to go up and the toes to splay. This reflex is normal in infants (eventually disappears), but is a BAD sign in adults, since it means some sort of central nervous system problem, or brain lesions/damage.
I looked at my patient and applied some pain stimuli. Its been almost 10min since I’ve given her narcan, and there’s still no change in LOC, so the narcan didn’t work. I guess I can rule out overdose. Yet I had a feeling that I’m still missing something. Then I had this idea to do a blood pressure on both my patient’s arms (since I remember our teacher mentioning something about that when he taught us neurological assessments). I had some time on my hands so I thought it wouldn’t hurt. And walla! On the right arm I got a BP of 108/70 while the left arm I got 78/55. I knew it meant something significant, but I couldn’t quite place it to the pathophysiology behind it. I assumed it must be the hemorrhagic CVA that’s causing it. Regardless I called triage and told her what I found and what we’re coming in with.
At the hospital they did a CT scan only to come up negative for a brain hemorrhage.
I talked to my teacher after the call. It was a tricky call. I asked him why the blood pressures were different between the two arms. He gave me a clue: Lets say prior to the collapse the patient was complaining of severe pain in between his shoulder blades.
I wanted to smack myself so bad!
Me: “ARGH! It was a thoracic aortic dissection!”
If only I got there before my patient was unconscious! Or if only the secretary told me her boss was complaining of pain in between her shoulder blade (unfortunately she never knew)! I would have solved it with a snap of my finger. If only life was that easy.
A thoracic aortic dissection is basically a tear in the lining of your aorta (the largest artery in your body that runs from your heart down your chest and also connects with your carotid arteries) causing it to balloon and bleed out. The difference between blood pressures of the arm was the only clue that my patient was having a thoracic aortic dissection and is a classic sign. As for the signs of brain damage, that was because the artery had dissected up to the carotid arteries, causing hypoxia (lack of oxygen) to the brain from decreased blood flow, resulting in brain damage; hence the pinpoint pupils (suggestive of global cerebral ischemia and/or pons hemorrhage), cheyne-stokes respirations and positive babinski reflex.
In summary our patient had: Thoracic aortic dissection up to the carotid artery and cerebral ischemia.
I definitely got smoked and frustrated by this call, but I learned a ton. These are the types of calls I really enjoy, where I get to really use my knowledge in pathophysiology to figure out what is really going on with my patient.
*For those who are curious about the title: NYD = Not Yet Diagnosed and is one of the protocols we have as PCPs to run for an unconscious patient who’s NYD