Sunday, February 14, 2010

Clinical Case 002: Neurological

Initial Emergency Call:
67yo M, Unresponsive, Hx Diabetes.

You are dispatched on a Priority 1 (lights & sirens), and arrive at the scene in 13min. A woman who identifies herself as the patient's sister-in-law meets you out the front and states she found him unresponsive after he failed to show up for an appointment and had given the patient "honey in his cheek-pouch" as per the Communication Officer's directions. She confirms the patient is a diabetic, and takes pills for the condition.

You find the patient in the lateral position on his bed, with the sticky honey leaking from his mouth.

On Examination:
A: Partially obstructed by the honey, with snores and gargling noises present.
B: Bradypnoeic, with periods of apnoea.
C: Pulse tachycardic and strong.
D: Unresponsive to voice.
E: Nil apparent injuries seen nor felt on patient.

Vital Signs:
GCS: 4/15 (extends to painful stimuli).
HR: 128BPM, regular and strong.
RR: 8/min irregular and varied depths, with apnoeic periods.
BP: 195/75mmHg
SpO2: 78% on room air.
BSL: 13.8mmol/L (or 249mg/dL).
ECG: Sinus bradycardia.
Pupils: R > L, sluggish.

PmHx: Diabetes Mellitus Type II, Angina, Hypertension.

GTN Sublingual spray PRN
Metformin 1000mg BD
Aspirin 150mg Daily
Metoprolol 100mg BD

Q1: What could be wrong with this patient? Provide a brief list of differential diagnoses.
Q2: Detail your pre-hospital interventions according to your service's guidelines and your scope of practice.
Q3: What other investigations would you - or could you - carry out?
Q4: Was the Communication Officer correct in instructing the sister-in-law to administer honey in this situation? If not, how could have he/she made a better judgement?

Please post your answers in the comments section. Please include where you work (Country, State) and your qualification (Eg. Paramedic, VAO, Student, EMT-B, etc.).

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