78 y/o F presented to the hospital for a complaint of stomach       pain. Patient diagnosed with a leaking AAA §, and underwent  surgical repair. Afterwards, patient began developing  progressively worsening dyspnea §, and also became  hypotensive §. Repeat CT scan failed to show any bleeding,  and exploratory  laparotomy § concurred with this. However,  there was an extensive build-up of  scar tissue at the surgical 
site, causing a wound dehiscence §. This dehiscence began causing a pressure on the hepatic § vein, the inferior vena cava,  and the hepatic portal.

Medical History: 
Appendectomy as a child. NIDDM §. Glaucoma §. Hypothyroidism §    (secondary to removal of thyroid approx 8 yrs ago.)  Osteoporosis §.  Recurrent UTI §. Mild CHF §.

Medications: 
Glyburide. Synthroid. Multi-vitmain. Lasix.
 No known drug  allergies.

Physical Exam: 
Frail appearing elderly woman, in obvious respiratory 
distress. Alert and Oriented x 3, skin jaundiced, warm,
 diaphoretic.

VS: 
NIBP 90/38, P 112, R 46, SpO2 86% @ 20lpm O2 via NRB  and Nasal Cannula.

Airway open and patent. No JVD or tracheal deviation. Breath  Sounds scattered rhonchii bilaterally, with wheezes in all fields.
 Abdomen shallow, rigidity over BUQ. PEG feeding tube in place,  secured. Foley Cath, with approx 300 mL cloudy urine.  Extremities 2+ pulses, normal 
sensation and motor function. EKG = Sinus Tach with rare  unifocal PVC. SpO2 as mentioned above. 
IV lines: Multi-Vitamin drip at 60 mL/hr. NS at  75 mL/hr.
 Dopamine at 10 mL/hr.

Other info: 
Patient is being transferred to a higher level facility for close  pulmonary evaluation and care, possible further surgery. 

Crew configuration: 
The ambulance is ALS staffed with one paramedic 
and one EMT-I. 

Questions: 
What is this patients problem? 
What can you/are you going to do about it? 
What other medications would you consider giving? 
note: You have a 30 minute transport if you run L&S.

Have at it, y'all. 

   Outcome
posted July 20, '00

We certainly had some great discussion about this case, and I  enjoyed hearing the different thought processes that went into your posts. 
Keep up the good work in your replies, and this case-discussion list will really take off. 

While we often think of 9-1-1 emergency responses for 
critical patients as the most challenging (and they can be challenging, I admit,) when I ran this call, it really got my brain working overtime. Unfortunately, I could not follow up as much as I'd have liked to on this patient, or I'd have a whole lot more information for you.

Refresher info: 78 y/o F transfering to a different facility for pulmonary problems status-post operative repair of a AAA.

Treatment rendered enroute: I kept the patient on the oxygen, and did my  best to maintain the 20+ lpm. I hooked the NRB to the portable tank until we got her from the ICU to the ambulance. Then I switched the NRB to the main tank, and hooked the nasal cannula to the portable tank. Enroute, I maintained the dopamine drip, watched the EKG closely, and did a continual 
SpO2 (Pulse Oximeter) reading. I gave her 40mg Lasix SIVP, and dropped in a slow bolus of 250 mL Saline. A nebulized Albuterol treatment completes my transport treatment. When we arrived at the destination hospital, her B/P was 96/58 (on the Dopamine drip,) pulse 118, and R 36. The crackles and  wheezes had cleared up slightly, and she stated a decrease in WOB (Work of Breathing...i.e "It is easier to breathe.") Her SpO2 was up to 92% or so, and remained there all the way to the ICU. She was transferred to the ICU bed, and they (the RNs and the PA) switched her to Dobutamine, did a quick  spirometry test (volume ventilation test....basically how much air the patient is moving on their own,) and then sedated, paralyzed, and intubated. Hooked up to a ventilator, and that's when I left. I shoulda jotted down the vent settings, but I forgot.

Comments:
1. Many of you talked of Dobutamine, and while I agree with you, I don't carry Dobutamine on the truck.
2. Remember the dehissance wound from the surgery? It was putting pressure on the vessels into the liver, and that caused her to enter early acute liver failure. Someone mentioned this, though I don't remember who. Good catch.
3. Sepsis was brought up a few times. Also a good catch. She was well into septic shock, and this certainly didn't help matters. I recall that she had rec'd IV ABx at the original hospital, but I do not recall what it was (i.e Vancomyacin, Levaquin, etc.)
4. Air transport was not available.
5. I'd really have liked to see a summary of her lab work over the last week or so. CBCs, Chem profiles, U/A, Liver panle, and (perhaps most important for the transport) ABG results. I'd have given anything for a set of ABGs showing the changes over the past four or five days.
6. The most challenging thing for me on this call was trying to figure out what was the root problem: Is it the sepsis, the liver failure, hypovolemia, heart failure, respiratory failure, or something else? If I can find out what caused what, then it is easier to direct my treatment. 

Analogy: Little old lady who fell. Did she fall because she tripped? Or did she fall because she had a syncopla episode? If she had syncope, why? Did she hit her head? If so, did it cause her to have a siezure? If she siezed, did she become apnic? And did that apnea cause her to enter some sort of arrhythmia? What is the original problem, and how do I fix that? 
Everything else will fall into place after that.

Good comments from everyone. I'll try to get another case posted in a week or so. Anyone have parting thoughts on this case?

Regards,

Jeff Brosius
B.S., NREMTP, CCT-P
"Medicine is the only profession that
labors incessantly to destroy the reason
for its own existence." -- James Bryce

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