‘I can’t feel or move my legs': MCHD critical case report

By Travis Clay, EMT-P; Johna Gilson, EMT-P; Eric Berlehner, EMT-P; Robert Dickson, MD, FAEMS; and Casey Patrick, MD, FAEMS

At approximately 1100 hours, our ground-based, dual paramedic EMS ambulance was dispatched to a rural community for a 71-year-old male reporting a sudden loss of feeling/motor function in his legs. Upon our arrival, we discovered the patient laying supine in the entryway to his home, tearful and writhing on the floor in obvious pain. The patient stated he was working in his attic when he suddenly felt numbness in his lower extremities. Being fearful he would fall out of the attic, he retreated down and summoned his neighbors to call 911.

History and physical assessment

The patient was alert and oriented appropriately. He spoke with clear speech, had strong bilateral grips and no facial asymmetry. He denied any trauma to his head, neck, back or lower extremities. The patient’s abdomen was soft, non-tender in all quadrants with no palpable masses. Pelvis was stable. Upper extremities were atraumatic with intact distal pulses. Lower extremities were atraumatic; however, there were no dorsalis pedis pulses, and only the right leg had a palpable popliteal pulse. The patient had no sensation or motor function distal to the right patella and no sensation or motor function distal to the left mid-shaft femur, respectively. There was no erythema or edema present in any extremity.

The patient’s history was significant for hypertension, COPD and a recent diagnosis of a small aortic arch aneurism which cardiology was following. There was no prior history of CVA, thromboembolic events, or neurological deficits or diseases. The patient further reported to have felt fine in the preceding days, absent any headaches, fevers, nausea, vomiting, or flu-like symptoms.

Vital signs

• Blood pressure. ~150/100 mmHg for the duration of patient contact
• Pulse. 140-150 BPM
• Respirations. 20-30
• Temp. Afebrile

Treatment

Immediately, our crew obtained complete, initial vital signs and moved the patient rapidly to the EMS cot. Transport to a comprehensive stroke center with readily available interventional radiology was initiated. The total scene time was approximately nine minutes.

A 12-lead ECG revealed sinus tachycardia with a rate between 140-150 BPM without ST segment changes, ectopy or evidence of bundle branch block. Capillary blood glucose was within normal limits.

Photos/MCHD

Early on, it became apparent that the patient was in an intense amount of pain. He was tearful, restless and often repeated, “it feels like my legs are swelling,” so the patient was administered fentanyl (1 mcg/kg) early on, repeated as needed. The patient reported significant relief of his discomfort following pain medication administration.

The receiving hospital was notified via radio of the complicated case and provided needed information. The total transport time was approximately 20 minutes. Upon arrival at the ER, patient care and report were given to the resident and attending physicians. EMS accompanied the patient with hospital staff to radiology for emergent CT angiography.

Photo/MCHD

Differential diagnosis: Non-traumatic acute bilateral lower extremity paralysis

• Acute vascular event
  • Vascular dissection
  • Acute thromboembolic event
• Guillain Barre syndrome
• Transverse myelitis
• Acute spinal cord compression
  • Epidural abscess
  • Epidural hematoma
  • Acute disc rupture

EMS critical interventions

• Recognition of acute vascular event
• Pain control
• Assessment of LE pulses, color and temperature
• Transport to a facility with interventional radiology/vascular surgery capabilities

ED diagnosis/imaging

• 10 cm abdominal aortic thrombus with extension into the bilateral iliac vessels

Hospital course

• The patient was taken emergently for vascular stenting.
• Initially successful but continued loss of LE vascular flow during hospitalization despite heparin drip
• Multiple trips to the OR with attempted unsuccessful revascularization
• LLE BKA eventually required

Takeaways from this critical case report

Here are 5 learning points from this case that can guide future patient assessment:

1. “I can’t move/feel my legs” – think compromised spinal cord. Paraplegia can be a result of cord compression, cord hypoxia or neuronal dysfunction.
2. Everyone deserves a complete exam!
3. Pulses, capillary refill, skin temperature to assess vascular supply are all key
4. Motor and sensory assessment also with consideration to reflexes and tone
5. Neurologic and compressive pathology should not cause compromised pulses and color changes in the lower extremities

This patient presented with a unique set of symptoms that multiple EMS providers with over 30-plus years of collective experience had not previously encountered. However, by taking a complete history and performing a thorough physical exam, they created a comprehensive differential and recognized the potential for an acute vascular event. While en route to the receiving emergency department, the differential diagnoses were well charted and included aortic dissection, acute vascular/embolic event, epidural abscess, disc-related spinal cord compression or Guillain Barre Syndrome.

Ultimately, clear and concise communication with the receiving emergency room staff and strong patient advocacy proved invaluable in the overall care of this patient.

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References

1. Lin M. “Paucis Verbis card: Acute limb ischemia.” ALiEM
2. Purcell D, Salzberg M, Kan V. “Acute Limb Ischemia: Pearls and Pitfalls.” www.emdocs.net
3. Nickson C. “Acute Non-Traumatic Weakness.” Life in the Fast Lane

Contributing authors

Travis Clay, EMT-P, is a Captain with MCHD. He has been in EMS since 2003 and a paramedic with MCHD since 2007.

Johna Gilson, EMT-P, has been in EMS since 2015 and has been a paramedic with MCHD since 2020.

Eric Berlehner, EMT-P, is an in-charge paramedic with MCHD where he has been since 1996.

Robert L. Dickson, MD, FACEP, FAEMS, is an assistant professor of emergency medicine at Baylor College of Medicine in Houston Texas. He serves as EMS medical director of Montgomery County Hospital District EMS and is board certified in emergency medicine. His academic interests include stroke, acute care coordination and resuscitation.