# Posturing and short of breath.



## mycrofft (Mar 28, 2010)

A skinny disheveled woman is sitting on a bus bench with a few buddies as you drive up one evening. Her wrists are cocked towards the palm (volar), her fingers are all bent with normal ROM but hooked at different angles to one another. One elbow is bent so the hand is near her face, she is staring uncomprehendingly at the hand which is slowly writhing.
BP: 126/84, P:126/reg/strong, Resp: 30/rapid/unlabored, lungs CTA, able to speak during exhalations. Established she and her friends were sitting and drinking beer, when she said she was a little short of breath during an arguement, it got worse, then she started complaining of arm cramps.
Although mildly inebriated, she is AOX3 and eyes are PERL, although darting around in panic. No meds, no allergies.

1. What's up?
2. What would you do?

Oh, yeah, scene is safe.


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## MS Medic (Mar 28, 2010)

get Hx, including respritory or psych (mainly anxiety),
asses for any possible CHF findings, peripheral edema/JVD/etc., 
asses for asthma/COPD, productive cough/capno waveform

My inital assumption would be hyperventilating due to an anxiety attack


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## Aprz (Mar 28, 2010)

What are her skin signs? In my area, we use AOx4 (person, place, time, and event). I am assuming you used just up to AOx3 (person, place, and time).

Assuming she's pink, warm, and dry (maybe a little moist/diaphoretic -> I would expect her skin to be slightly cooler if that's the case especially since it's the evening and if she's not wearing a jacket, but still pink), I agree w/ MS Medic that she's probably having an anxiety attack/hyperventilating which is causing spasms in her arms. I would treat by administering her O2 via a NC @ 2 L/m, direct her to purse her lips when exhaling, direct her to take deep breaths, and mainly try to calm her down (hopefully the O2, being there, doing something in front of her like giving directions, talking to her, being a good looking guy in uniform  (for some people it would worsen their condition though, haha, being too nervous, yeh? ), and having a nice smile  would do the trick). Transport code 2 (No LNS, especially wouldn't want to make her more anxious) to facility of choice in the fowler's position (for comfort).

Gosh, I hope I don't brutalize this, but to make this more fun and thinking ahead.. if the NC wasn't showing signs of improvement, and attempts to calm her down fail, and her resp. became more rapid than it is (I consider 30 to be borderline), I would be evasive and bump up to a BVM @ 15 L/m and try to pace + track her breathing w/ PPV (start off w/ waiting 3s and give her a breath when she inhales, and I would try to lower that to waiting 5s and giving her a breath when she inhales). If her breathing didn't get any more rapid, but either/or if cyanosis became present (I'd keep an eye on her fingers and lips) or NC wasn't showing signs of improvement after appx. 5m on route (but she hasn't gotten any worse/faster breathing), I would flood her w/ more O2 by bumping up to an NRM @ 15 L/m. I would continue attempts to comfort/emotionally support her.

Complications I think that can most likely occur is that she either lose consciousness from lack of O2, or she won't tolerate a NC and NRM while she's conscious because she's too anxious (I would attempt to do a blow by w/ a NRM @ 15 L/m), and I would expect her to become light headed and be nauseous.

I would doubt asthma, COPD, and CHF since lungs were CTA and while resp. is rapid, you didn't mention any sounds (particularly wheezing if she had asthma), but I assume that would be inherent since lungs are CTA anyway,  and it also sounds like mycrofft gave us his findings from a full assessment (he mentioned no Rx + NKA).

Hopefully I didn't go too crazy with this, but I really wanted to have a good attempt at this. B) Rip away!


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## Veneficus (Mar 28, 2010)

*giving the younger guys a chance*

Lack of O2?



Aprz said:


> Complications I think that can most likely occur is that she either lose consciousness from lack of O2, or she won't tolerate a NC and NRM while she's conscious because she's too anxious (I would have airway adjuncts and a BVM ready expecting her to lose consciousness, but I would also expect that after she lose consciousness that her breathing would reset so we won't really need a BVM + airway adjuncts (just in case though)), and I would expect her to become light headed and be nauseous.!



could I just make reference to:


http://www.turner-white.com/pdf/hp_mar00_hypocal.pdf


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## Aprz (Mar 28, 2010)

Hey, that was an interesting read. Thanks. I had no knowledge on that. Unfortunately, I am gonna pull the lack of training card out and say that I watched it on tv (not really, I am really only cert. First Responder and currently an EMT-b student). With my level of training so far, I would still go with what I have (thoughts and treatment), but with that lovely article you just provided me and I quickly read it, I would also test for Chvostek sign and Trousseau sign, but of course once I learn more about this because...

*[scratch this]*Doing a quick search on the Internet to go into more detail on on Trousseau sign, I looked at http://en.wikipedia.org/wiki/Trousseau_sign_of_latent_tetany. What I don't exactly understand with this is that if carpopedal spasm is present (like what I would expect with somebody who is hyperventilating) after inflating the BP cuff for 3 minutes (would you do it for that long?) above their systolic, would that be signs against or for hypocalcemia.*[/scratch this]* Just because it sounds so painful too, even though it's not a treatment, I am wondering if I am allowed to do that.

Thanks for giving me a chance and help educating me more. 

*Edit:* Ah, after I reread it the wiki and slower, I see that carpopedal spasm would be a sign for hypocalcemia. I thought that carpopedal spasm was also a sign of hyperventilation though?

..and yeh, to clarify my with lack of O2 statement, I meant from rapid breathing (too fast/probably poor TD), I would expect her to collapse/lose consciousness.


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## MS Medic (Mar 28, 2010)

Veneficus, you could very well be right. The hyperventilation was only my first impression based on the presentation and events prior. I would get a further Hx and assessment before any definative Rx. Although O2 by NC at 2LPM would not be a bad thing.


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## Veneficus (Mar 28, 2010)

MS Medic said:


> Veneficus, you could very well be right. The hyperventilation was only my first impression based on the presentation and events prior. I would get a further Hx and assessment before any definative Rx. Although O2 by NC at 2LPM would not be a bad thing.



Hypocalcemia is a presentation of hyperventilation syndrome. However, it is a Dx of exclusion. So you have to rule out all of the other neuro and endocrine possibilities first.


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## MS Medic (Mar 28, 2010)

Everything I am finding on hypocalcemia seems to mimic an anxiety attack. Hematology was one of those areas in school that was retained just long enough to pass the chapter test due to the lack of ability to Dx and Rx in the field and has not gotten much of my attention before now. 
I am at work and have a crappy internet connection so I appologize for being lazy, I will look this up more tomorrow when at home, but is there anything that can differentiate between it and an anxiety attack?


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## Veneficus (Mar 28, 2010)

MS Medic said:


> but is there anything that can differentiate between it and an anxiety attack?



Medscape (which you have to register for) has a very good article on hyperventilation syndrome that somebody sent me. 

Hypocalcemia is listed as an endocrine disorder, and hyperventilation syndrome has a strong psych component.

In the field the best you can do for it is try to reduce the respiratory rate, but by itself is not diagnostic. Generally the mechanism is respiratory alkalosis.


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## Veneficus (Mar 28, 2010)

a partial quote of the multipage article:

"Prehospital Care
Because respiratory distress or chest pain has many potentially serious causes, this diagnosis should never be made in the field. Even when a patient carries a prior diagnosis of hyperventilation syndrome (HVS), it is still necessary to transport patients with these complaints to a hospital for a more complete evaluation.

Rebreathing into a paper bag is not recommended in the field.
Deaths have occurred in patients with acute myocardial infarction (MI), pneumothorax, and pulmonary embolism who were initially misdiagnosed with HVS and treated with paper bag rebreathing."

You might also try some benzos.


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## Melclin (Mar 29, 2010)

http://emedicine.medscape.com/article/807277-overview  -- I assume that's the article you're talking about.

For Aprz, your understanding of those resp physiology issues seems a little skewed in the ways you would expect of the overly simplistic approach that seems common in those EMT-B programs. Not having a go at you, I just thought it might help you to understand some of those issues a bit better than maybe what is taught in class, so here's a few links.

http://people.eku.edu/ritchisong/301notes6.htm -- I just found this one the other day, haven't looked over it well yet, but it seems pretty good and its got embedded youtube videos which is always good.

http://www.ccmtutorials.com/rs/oxygen/index.htm  -- a Ventmedic classic. Bit complex at first, but if you make your way through it with a google window open, or keep coming back to it after various respiratory discussions - its a pretty good page. 

Hyperventilation syndrome: Important to realise that given the near impossible task of accurately diagnosing it in the field (as Vene says, its a diagnosis of exclusion), you shouldn't ever write a person off as "just hyperventilating" because they're a young woman or because there are possible signs of anxiety provoking stimuli. Anxious young women have heart attacks and PE's ect, as well. Also Hyperventilation syndrome itself shouldn't be written off either, there are some pretty nasty side affects in chronic hyperventilation, especially when combined with comorbities like CVD etc. Just some food for thought. It'd be pretty embarrassing if you left stressed out young girl X at home because she was anxious and got called back to her in arrest 2ndry to a PE - its happened here more than a few times.


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## mycrofft (Mar 29, 2010)

*OK, the actual case's Dx..........*

1. Drunk.
2. Somewhat dehydrated.
3. Hyperventilation.
4. "Probable" malnutrition.
I'd put a nickle in the little box that said "Mental illness", but you have to address the other stuff before you can assess that.


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## Aprz (Mar 29, 2010)

Hey Melclin, I read the first and second link, and that second link was the bomb. At the beginning it was review, but when it started talking about partial pressure and up to the medulla, that was new to me. I knew exchange happened, but didn't know how. Unfortunately, I haven't read the third link yet because it's 12:35 PM in my area and I am tired now. Hopefully I'll read it later today after I get some sleep. Thanks for the info.


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## Veneficus (Mar 29, 2010)

Melclin said:


> http://emedicine.medscape.com/article/807277-overview  -- I assume that's the article you're talking about.



It was thanks, everytime i send a link to my friends it asks them to log in? I don't get it.


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## Sam Adams (Mar 30, 2010)

Any recent use (recreational or otherwise) of: antipsychotics, antiemetics, or antidepressants?


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## mycrofft (Apr 1, 2010)

*Does alcohol count?*

The local cops recognized her too.


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