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passing out from overexertion?

Discussion in 'Scenarios' started by addictedforever, Dec 18, 2011.

  1. addictedforever

    addictedforever New Member

    Okay here's the situation... You get called out for a 20 y/o female who has passed out they think from overexertion. You arrive and there is a person administring first aid, trying to get the pt. to respond. She has squeezed his hand, he reports to you, but that has been the extent of her response.

    She was playing broomball, felt tired, then when they tried to move her to get her inside, she went limp. They moved her inside and laid her on the floor which is where she is now. She is soaking wet, and freezing cold. (It is -10C/10F outside.) Whole body is rigid. They have people rubbing her extremeties, and have warmed blankets covering her.

    Just after you get there, she goes limp, completely, 100% limp. Breathing goes to almost nothing, very shallow breaths every 10-20 seconds. Radial pulse-nonexistent. Carotid pulse-very weak, irregular 35 bpm. B/P-86/44

    They are able to tell you that she has suspected heart murmur and that she has passed out from overexertion about three months ago, but it wasn't the same as this time.

    Action plan? What are your tho'ts?
  2. phideux

    phideux Member

    Location:
    South Carolina
    EMS Training:
    EMT-Paramedic
    Airway, OPA or NPA to start and assist ventilations.
    Put her on the monitor and see what you got.
    Follow ACLS Guidelines, Rule out the Hs+Ts, prepare to pace, Epi, Dopamine, etc.
  3. truetiger

    truetiger New Member

    OPA,BVM,12 lead, ACLS guidelines, IVx2, BGL off of sharp, pupils?
    If no change after treatment of bradycardia, intubate.
  4. addictedforever

    addictedforever New Member

    pupils nonreactive
  5. 18G

    18G Active Member

    It's definitely possible to have near or actual syncope due to over exertion. Syncope is self-limiting so if it is true syncope the patient usually rebounds pretty quickly. If the patient remains unresponsive than its not syncope.

    What is a suspected heart murmur? Either you have one or you don't?

    When I hear heart murmur and past episode of a similar nature, I would be asking if anyone knows how long the patient has had the heart murmur (congenital & getting worse?, normally asymptomatic?, see's a cardiologist?) and what is causing the heart murmur. A patient with a valve problem has a murmur and depending on which valve (usually mitral in younger person) can have decreased cardiac output and decreased exercise tolerance.

    There can be an autonomic response during exertional states which can lead to presentations like you describe. The breathing problem isn't typical though.

    As far as treatment, a 12-lead would be nice.. Blood glucose check. IV access. Fluid bolus. Oxygen. Airway management as needed. Assist breathing as needed. Get the wet clothes off and continue to passively warm. Atropine as indicated. Consider pacing.

    What do her lungs sound like? SpO2? PMH?
    Last edited by a moderator: Dec 18, 2011
  6. addictedforever

    addictedforever New Member

    The pt. was tested for HOCM, but they did not know the results of the test as it had just been a couple days ago that she'd been tested. The drs were suspecting that she might have HOCM because her brother has it. At this point she was not seeing a cardiologist and did not have a family dr.
  7. addictedforever

    addictedforever New Member

    Lungs-slight crackles all regions
    SpO2-84%
    I'm not familiar with what PMH means
  8. 18G

    18G Active Member

    PMH = Past Medical History.

    A patient in this condition with altered LOC, bradycardia, hypotension, change of resp status, and crackles, is going to get immediate pacing unless I have a Medic partner who can get atropine on board before I'm ready to pace.

    Was a 12-lead acquired?
    Last edited by a moderator: Dec 18, 2011
  9. addictedforever

    addictedforever New Member

    Okay, thanks...

    PMH--non-outstanding besides her episode where she passed out three months ago, except during that episode she hyperventilated

    12 lead was not acquired. We do not have that ability on our unit. (a very small volunteer unit in rural northwestern ontario, canada)
    Last edited by a moderator: Dec 18, 2011
  10. 18G

    18G Active Member

    12-lead?
  11. addictedforever

    addictedforever New Member

    12 lead was not acquired. We do not have that ability on our unit (a very small volunteer unit in rural northwestern ontario.)
  12. truetiger

    truetiger New Member

    What kind of monitor do you all use?
  13. addictedforever

    addictedforever New Member

    It sucks, but currently we have no heart monitor of any kind, unless the pulse oximeter with rythm counts, we're waiting for a grant to get one.
  14. 18G

    18G Active Member

    What was the outcome of the patient?
  15. systemet

    systemet Member

    Chances are they're wrong. I can see a Navy SEAL passing out from exhausation, or an elite athlete. The average person person passing out from a little bit of broomball = something else going on.

    Copy. Standing there, possibly after having putting her in the recovery position and staring. Possibly gathering all his sense to provide the responding crew with a hearty "I think she's going into shock".

    Rigid sounds weird. Is she seizing?

    She shouldn't be hypothermic to the point of unconsciousness in that environment while active, with other people present. Not unless she's drunk out of her skull, and everyone else is ignoring her.

    Sounds sick. It would definitely be helpful to have an ECG here to see what we're dealing with. Is 35/min sinus bradycardia, IVR, some degree of AV block, ventricular bigeminy, etc? These questions are hard to answer without technology.

    What's happening now is probably the same thing that happened last time. But it's not the overexertion in isolation. It's something else on top of that.

    As others have said, ensure the airway is patent, i.e. OPA. Probably defer intubation for now. Sounds like BVM ventilation is necessary if the RR is 3-6/min, ECG, IV access, pulse oximetry, capnography, glucose (*not a chance this is DM, in my mind, but it's an outside possibility).

    Once I know the airway is patent, that the patient is well saturated, and not obscenely hypercapnic, then we've got to see if we have the same pressure / rate issues. Depending on the stability at that point, a 12-lead + atropine + fluids might be ok, but we could be going down the pacing route.
  16. addictedforever

    addictedforever New Member

    We transported ASAP and concentrated on respirations. She woke up during transport, but then became unresponsive again. But by the time we arrived at the ED, she was awake and alert. When she figured out who we were, she rolled her eyes and seemed to think she was fine. But she wouldn't talk. She was great and when they checked her vitals at the ED, they were T-37.3C, R-15, P-70bpm, B/P-104/58, O2-91%
  17. usalsfyre

    usalsfyre You have my stapler

    Arrhythmia. It's a shame you don't have 12 lead capabilities, that would have been useful to a cardiologist.

    Oxygen, protect the airway probably via maneuvers and suction only until I see how she responds. No BVM unless she's hypoxic on the O2, no intubation until I'm good and sure she's going to stay out and only consider cardiac measures until I'm reasonably sure it's not a transient issue.
  18. exodus

    exodus Active Member

    Location:
    Hemet, Ca
    First off, get some one bagging her, if her SPo2 was 84% then she's definetly hypoxic. How was the waveform on the SPo2? Was it a real reading? What was her temp on the field? 37 = 99f at the ER. If it was about that I'm not going to load her up with hot blankets, just one to insulate while in the back of the rig. Then bolus her with a big bag to see if the pressure comes up?
  19. mycrofft

    mycrofft Still crazy but elsewhere

    Location:
    Central California
    Pupils on scene nonreactive.....

    Equal or not, dilated or pinpoint or "normal"?

    With your initial data, suspect cardiac, support VS at ACLS level or best you can do, get her out of the cold, didi-mau (book out of there). Just the general gestalt makes me want to suspect some hypothermic component, but the cold, per se, doesn't kill you first, its the arrythmias and potential metabolic wastes, right?

    Not in my experience that "unresponsive pupil" people recover soon if at all.
    Rigidity....some sort of seizure form activity?

    BTW, isn't it disquieting to see people stacking blankets on a pt and they pt's back is directly on a 50 degree or lower concrete floor?
  20. firetender

    firetender Active Member

    Location:
    Maui, HI
    EMS Training:
    EMT-Paramedic
    "Passing out from overexertion" is not a diagnosis. It is the beginning of a medical inquiry.

    Yes, the patient passed out. And yes, it was during exertion. Now, it's all about "Why?"

    So a line of inquiry that keeps going back to the "exertion" part is not necessarily going to be fruitful. That just defines the circumstances under which the symptoms appeared and NOT the causative factor. As has been mentioned, the whole thing is about the underlying cause of which a heart murmer is likely to be a key element.

    But what's important to you in the back of the rig? How about what is the heart doing now?

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