Clinical Cases in Paramedicine. Группа авторов
Airway
Clear.
Breathing
RR: 30. Audible wheeze on auscultation.
Circulation
HR: 120. Palpable radial. Capillary refill time 2 seconds.
Disability
Moving all four limbs.
Exposure
Normal temperature in the ambulance.
Vital signs
RR: 30 bpm
HR: 120 bpm
BP: 148/78 mmHg
SpO2: 90%
Blood glucose: not repeated
Temperature: not repeated
GCS: 15/15
4 lead ECG: atrial fibrillation
Allergies: nil
1 When the nebuliser has finished, you notice that the patient’s SpO 2 is dropping so you decide to keep the patient on oxygen. What percentage of oxygen would you administer to this patient and why?28% oxygen through a nasal cannula. The patient is at risk of developing hypercapnia respiratory failure, so it is important the oxygen is titrated to maintain saturations between 88 and 92%. Research suggests that over‐oxygenation increases the mortality and morbidity of COPD patients and that titration of oxygen administration can reduce mortality.
2 What is meant by the term hypercapnia? ‘A condition of abnormally elevated carbon dioxide (CO2) levels in the blood, caused by hypoventilation, lung disease, or diminished consciousness’ (NAEMT, 2015, p. 92).‘Alveolar hypoventilation with increased alveolar carbon dioxide limits the amount of oxygen available for diffusion into the blood, leading to secondary hypoxemia’ (McCance et al., 2010, p. 1269).
LEVEL 2 CASE STUDY
Pulmonary embolism (PE)
| Information type | Data |
| Time of origin | 17:55 |
| Time of dispatch | 18:01 |
| On‐scene time | 18:10 |
| Day of the week | Friday |
| Nearest hospital | 30 minutes |
| Nearest backup | 15 minutes |
| Patient details | Name: Jasmine Wallis DOB: 27/12/2000 |
CASE
You have been called to a car park for a 20‐year‐old female who is complaining of feeling dizzy and faint.
Pre‐arrival information
She is conscious and breathing.
Windscreen report
The car park is behind a row of shops and is poorly lit. The patient is hard to spot at first, as she is sitting on the metal fire escape steps with her head in her hands at the back of a building. She is alone. The car park is full, which prevents you parking near to the patient.
Entering the location
You park your ambulance as near as possible and cross the car park to get to your patient.
On arrival with the patient
The patient is able to raise her head and make eye contact.
Patient assessment triangle
General appearance
The patient looks at you when you speak and is able to speak in full sentences.
Circulation to the skin
Mildly pale.
Work of breathing
Increased. The patients looks mildly short of breath.
SYSTEMATIC APPROACH
Danger
None at this time.
Response
Alert.
Airway
Clear.
Breathing
RR: 26. Mildly increased effort, no accessory muscle use. Auscultation – clear.
Circulation
HR: 120. Tachycardic, weak and regular pulse. Capillary refill time >2 seconds.
Disability
Pupils equal and reactive to light (PEARL).
Exposure
The patient is sitting on metal fire escape stairs, in a dark, cold car park in an undesirable part of town.
Vital signs
RR: 26 bpm
HR: 120 bpm
BP: 90/60 mmHg
SpO2: 90%
Blood glucose: 4.4 mmol/L
Temperature: 36.5 °C
ECG: sinus tachycardia
Allergies: nil
TASK
Look through the information provided in this case study and highlight all of the information that might concern you as a paramedic.
1 List your differential diagnoses for this patient. Musculoskeletal pain.Pericarditis.Hyperventilation.Chest infection.Syncope.Pneumothorax.
2 List as many predisposing factors associated with PE as you can. Which could assist you with working through your differential diagnosis and history taking? See Table 1.2.Table 1.2 Pulmonary embolism predisposing factorsSource: JRCALC (2019), p. 367.Surgery, especially recent Abdominal Pelvic Hip or knee Post‐operative intensive careObstetrics PregnancyCardiac Recent acute myocardial infarctionLimb problems Recent lower limb fractures Varicose veins Lower limb problems secondary to stroke or spinal cord injuryMalignancy Abdominal and /or pelvic, in particular advanced metastatic disease