30 minutes
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 Concurrent chemotherapyOther Risk increases with age >60 years of age Previous proven deep vein thrombosis (DVT)/PE Immobility Thrombotic disorder Neurological disease with extremity paresis Thrombophilia Hormone replacement therapy and oral contraception Prolonged bed rest >3 days Other recent trauma
1 What validated assessment tool could assist you with assessing the probability of PE in this patient? See Table 1.3.Table 1.3 Wells’ criteria for PESource: JRCALC (2019), p. 368.CriteriaScoreClinical signs and symptoms of DVT (leg swelling and pain with palpation of the deep veins)3An alternative diagnosis is PE is less likely3Pulse rate >100 bpm1.5Immobilisation or surgery in the previous 4 weeks1.5Previous DVT/PE1.5Haemoptysis1Malignancy (treatment ongoing or within the last 6 months or palliative)1Clinical probabilityHigh>6 pointsModerate2–6 pointsLow<2 pointsNote: When using the Wells’ criteria, a low probability does not rule out PE.
Case Progression
You decide to move your patient to the back of the ambulance to continue the examination in a warm and private environment. On standing, the patient complains of feeling dizzy and faint and is unable to walk even a couple of steps. You instruct your crewmate to fetch the carry chair as you can’t get the stretcher close enough to the patient.
Patient assessment triangle
General appearance
Patient feels better when lying flat.
Circulation to the skin
Normal.
Work of breathing
Increased. Patient
