An ALS crew was dispatched to a woman at a nursing home who was unresponsive.  Staff reported that she was last seen well 5 hours before and normally is completely alert and oriented.  When the crew assessed the patient, she did not respond to a sternal rub but noted to have normal ventilations, cool and pale skin and a weak radial pulse.  They quickly obtained vitals and found the following:

Vitals: BP 65/41,  HR 79,  RR 16,  Sat 98%

The crew immediately placed an IV and started giving fluids as well as frequent doses of push dose epinephrine (PDE).  The patients’ blood pressure improved to 95/57 and the patient became responsive and was able to communicate with the crew.  It was at this point that the crew started working on extrication and monitored the patient’s hemodynamics very closely while in route to the receiving facility.  The patients’ blood pressure remained stable while in route to the hospital. 

Highlights of the case:

Start treating shock prior to extrication.

This patient was very hypotensive and was in shock.  Shock is defined as a state where not enough oxygen is being delivered to the tissues to meet the oxygen demands of those tissues.  This can lead to irreversible organ damage.  In the case of this patient, she was not perfusing her brain enough for her to remain conscious and this was the most likely reason for her minimal responsiveness when the crew first arrived since it improved when the crew treated her blood pressure.  Addressing vital sign derangements in critically ill medical patients should almost always happen on scene prior to extrication since treating these vital sign derangements decreases the likelihood of further vital organ injury and cardiovascular collapse.  This crew aggressively treated the patient’s hypotension and stabilized the patient as much as possible prior to extrication, which was fantastic prehospital care.