Street Scene Questions: Ventilation, Perfusion, and Shock: Understanding Pathophysiology

It is 2000 hours. Your unit is dispatched to a run-down home for a man complaining of diarrhea. When you arrive, you notice a foul, fecal smell. You meet the patient, a sixty-eight-year-old man, in the living room. He complains of nausea and diarrhea over the past three days. He notes his bowel movements have been “very dark, almost black.” He is awake, alert, and breathing at a rate of
24/min. His skin is slightly pale. You have a difficult time finding a radial pulse but feel a carotid pulse at 124.
Street Scene Questions
1. What additional patient history should you obtain?
2. What does your primary assessment reveal about this patient’s condition? How sick is he and why?
3. Why might this patient not have a palpable radial pulse? How is this related to his heart and respiratory rates? You place the patient on high-concentration oxygen and continue your assessment while your partner readies the stretcher for transport. You locate a very weak radial pulse and obtain a blood pressure of 82/62. You notice no injuries but find his abdomen to be slightly tender in the left quadrants. You load the patient on the stretcher and prepare to transfer him to the ambulance.

4. Was a low blood pressure predictable based on your primary assessment?
5. What is the cause of this patient’s low blood pressure?

6. Should you contact ALS (Advanced Life Support, Para-medic-level EMS) for this call or simply transport the patient to the hospital yourself?
When the patient stands to transfer from the chair to the stretcher he becomes very dizzy and “feels like he is going to passout.” Once he lies down on the stretcher, he feels better.
En route to the hospital, you obtain a SAMPLE history. He states that his biggest problem tonight is the diarrhea, but his stomach hurts too. He has no allergies. He tells you he has a history of

“drinking too much” and that he has had some “stomach problems because of it.” He can’t tell you what those problems are, but he “takes a pill for them.” He hasn’t been able to eat much over the
past couple of days. In fact, he tells you he has been feeling weak for a few days and now the diarrhea has really made him feel bad. You continue to transport him to the hospital. There he is
diagnosed with a severe gastrointestinal bleed and prepared for surgery.

Answers

Street Scene Questions
1. You will want to know how long his problem has been going on. Does he have any history of GI-related problems? Does he have any other medical problems or take any medications?
2. His fast heart rate and pale skin point to compensated shock. With the history he has presented, this person has the potential to be critically ill.
3. This person has no radial pulse because the pressure in the cardiovascular system is very low. His heart rate and respiratory rate have increased to compensate for poor perfusion.
4. The low blood pressure was predictable based on the weak radial pulse.

5. This person’s low blood pressure is likely caused by internal bleeding in the GI tract. Clues that indicate this diagnosis include the dark stools and the tender abdomen.

6. ALS should be contacted. Advanced personnel can administer intravenous fluid to help increase cardiovascular pressure and perfusion.