# Pt had been on the computer



## shiroun (Jul 29, 2012)

Pt was around 170 lb, 6' male, athletic body, around 20 y/o. Pt was sitting on computer in room air conditioned at 70 degrees farenheit, He had apparently gotten up "every so often" to stretch, walk, grab food, etc. Approximately spent 12 hours on computer that day. No medications taken, no allergies, no injuries during the day (and no head trauma especially), A&Ox3

Upon arrival, Pt complained of tingling in toes, coldness in feet, a sort of hollowness in chest accompained with slight pain, slight SOB, and light-headedness, as well as nausea. PMH was a history of concussions, unknown number, over a period of 5-6 years. BP unavailable, respirations were somewhat shallow and mildly rapid. HR was extremely tachy, around 130-150 BPM. After 1-2 minutes on scene, HR was brady, at around 40-50 BPM with no interventions. PT felt lethargic, breaths returned to normal and regular, nausea persisted but no vomiting occured, and the "hollow feeling" remained aswell.

Transported to hospital, PT said he felt good enough to walk in, but was brought in on the stretcher.
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Okay. What the H:censored::censored::censored: happened with him. I'm completely lost as to how his HR went from ridiculously rapid, at OVER 120, to being brady so quickly. When I told the nurse this she was stumped as well, they hooked up an EKG and his QRS complex looked normal. 

So I'm bringing it here, thoughts? Patient was released later that day with no complications.


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## dewey (Jul 29, 2012)

What did his pupils look like, and who called 911?


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## dewey (Jul 30, 2012)

I would think TIA, or maybe a vicodin addict that was waiting for his fix to kick in when you showed up.  Take my opinion with a grain of salt as I'm still pretty new to this.


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## Aidey (Jul 30, 2012)

How was his heart rate assessed?


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## bahnrokt (Jul 30, 2012)

Sounds possible that he developed a clot in his lower extremities that broke lose and caused a pulmanry embolism.

Sat for a long time, tingling in legs and feet, upper chest/lung pain, some signs of hypoxia. 

Why was BP unavailable? SP02?


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## shiroun (Jul 30, 2012)

Aidey said:


> How was his heart rate assessed?



By palpation w/ a watch. I say 130-150 because I could feel a slight variation in the heart rate, I came up with 140 for his HR, but I could tell at certain points it was slower, and some it was faster, so I say 130-150 to be safe. He said he couldn't "hear his heart" anymore, so I took it again right when he said that, and it was insanely brady.



dewey said:


> I would think TIA, or maybe a vicodin addict that was waiting for his fix to kick in when you showed up.  Take my opinion with a grain of salt as I'm still pretty new to this.
> What did his pupils look like, and who called 911?



PT had no history of drug abuse, and no was on no medications. Potentially a TIA but he was A&Ox3, and was talking to us the entire time, albeit slightly out of breath. Don't TIAs usually present with unresponsiveness, or only responding to pain?

Pupils were regular before light was shined in them, and were bi-lateral reactive. He called 9-11, which is another reason I'm against the drug theory. Had he been feigning for the drug, he would have tried to get his fix, not called for an ambulance. 



bahnrokt said:


> Sounds possible that he developed a clot in his lower extremities that broke lose and caused a pulmanry embolism.
> 
> Sat for a long time, tingling in legs and feet, upper chest/lung pain, some signs of hypoxia.
> 
> Why was BP unavailable? SP02?



BP was unavailable because of a leak in the BP cuff pump, which I realized when I went to put it on him. It was the only one we had. No 02 Sensor was put on him because there were no signs of cyanosis present in the fingernails, under the eyelids, or on the gum.

With a pulmonary embolism, can it pass through and simply disappear, or does it need to be removed? He didn't have an MI, and as I said was released from the hospital that day with no surgery, or complications.

I've got an idea about what it was, but I want to see what everyone else can come up with. I feel like my answer is inadequite.

As another note, the PT mentioned in passing he'd recently been laid off, and his girlfriend had left him. 

But again, I would like to stress, he did not have a history of drugs, nor do I believe drugs were involved.


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## DesertMedic66 (Jul 30, 2012)

shiroun said:


> Don't TIAs usually present with unresponsiveness, or only responding to pain?
> 
> With a pulmonary embolism, can it pass through and simply disappear, or does it need to be removed?



TIAs can have symptoms from just tingling in the fingers all the way up to unresponsive. (from what I have seen TIAs normally wont be unconscious. Normally it's just weakness/numbness. 

If the embolism passes through the lungs where are some other places it could end up? (aka where does blood flow)


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## fast65 (Jul 30, 2012)

I'm not exactly sure what could have caused the rapid change in heart  rate, my best guess would have been some sort of vagal influence that  caused it. 

Despite there being any physical signs of hypoxia present, I would have still used the pulse ox, especially since he was complaining of SOB. Even though he may not have been showing any immediate signs of hypoxia, the pulse ox will allow you to complete a little more thorough of an assessment, as well as assist you in verifying your calculated pulse rate.



shiroun said:


> PT had no history of drug abuse, and no was on no medications.  Potentially a TIA but he was A&Ox3, and was talking to us the entire  time, albeit slightly out of breath. Don't TIAs usually present with  unresponsiveness, or only responding to pain?



No, TIA's will have the same signs and symptoms as a stroke, but should resolve themselves within 24 hours. So while those signs and symptoms can include unresponsiveness, that is by no means the only thing that defines a TIA.

My best guess would have been some sort of an embolus. Especially with the complaint of cold feet, chest pain, and SOB, in conjunction with the prolonged use of the computer. Depending on the size of the embolus, I believe the body can eventually absorb it, however, I don't know how long that would take.


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## bigbaldguy (Jul 30, 2012)

bahnrokt said:


> Sounds possible that he developed a clot in his lower extremities that broke lose and caused a pulmanry embolism.
> 
> Sat for a long time, tingling in legs and feet, upper chest/lung pain, some signs of hypoxia.
> 
> Why was BP unavailable? SP02?



Ths would be my guess as well.


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## heatherabel3 (Jul 30, 2012)

You mentioned laid off and his girlfriend leaving. 
Is it possible he was having a severe anxiety attack?

I ask because almost the exact same thing happened to me years ago the first time my husband deployed. I was hanging out watching TV one minute and the next I was struggling to breath, I thought my heart was gonna explode, and all 4 extremeties felt like they were asleep. My friend called 911 and once medics arrived and started helping me calm down I overcompensated and my HR went so low I passed out. ER doc said acute anxiety attack. Get out of the house and stop watching the news.


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## shiroun (Jul 30, 2012)

fast65 said:


> I'm not exactly sure what could have caused the rapid change in heart  rate, my best guess would have been some sort of vagal influence that  caused it.



Only vagal influence I could think of would have been SEVERE hypertension, causing intercranial pressure which would press on the vagus nerve. But again, no head trauma.




heatherabel3 said:


> You mentioned laid off and his girlfriend leaving.
> Is it possible he was having a severe anxiety attack?
> 
> I ask because almost the exact same thing happened to me years ago the first time my husband deployed. I was hanging out watching TV one minute and the next I was struggling to breath, I thought my heart was gonna explode, and all 4 extremeties felt like they were asleep. My friend called 911 and once medics arrived and started helping me calm down I overcompensated and my HR went so low I passed out. ER doc said acute anxiety attack. Get out of the house and stop watching the news.



This was what I brainstormed, and had an RN think of aswell. An embolism would fit, but whats throwing me was the tachycardia -> bradycardia in SUCH a short period of time. So I'm still not sure.


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## firetender (Jul 30, 2012)

*My crystal ball says...*

venous stasis

(now explain it to me!)


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## shiroun (Jul 30, 2012)

firetender said:


> venous stasis
> 
> (now explain it to me!)



Synonomous with Deep Vein Thrombosis. Its basically caused by sitting or being inactive for a really long time. Its the reasaon why every time a new game comes out, about 3-4 days later you hear about someone dieing by a pulmonary embolism.


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## mycrofft (Jul 30, 2012)

Undiagnosed arrythmia (a-fib?) and extremities asleep from Nintendosis.


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## shiroun (Jul 30, 2012)

mycrofft said:


> Undiagnosed arrythmia (a-fib?) and extremities asleep from Nintendosis.



Pt hadn't been eneregized any time in the last month. That was one of my thoughts too.

What the hell is nintendosis?


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## Sublime (Jul 30, 2012)

shiroun said:


> Only vagal influence I could think of would have been SEVERE hypertension, causing intercranial pressure which would press on the vagus nerve. But again, no head trauma.
> 
> 
> 
> ...



What signs and symptoms did he have that would lead you to the conclusion of ICP or sever hypertension? Doesn't sound like he had either of those. 

Sounds to me like a panic attack. Change in heart rate due probably due to vagal response caused by pt. freaking himself out or possibly the person taking it was incorrect the first or second time?


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## shiroun (Jul 30, 2012)

Sublime said:


> What signs and symptoms did he have that would lead you to the conclusion of ICP or sever hypertension? Doesn't sound like he had either of those.
> 
> Sounds to me like a panic attack. Change in heart rate due probably due to vagal response caused by pt. freaking himself out or possibly the person taking it was incorrect the first or second time?



Sorry, I mis-wrote that. I meant to say that hypertension would be the only thing that could cause a serious vagal influence, not that he was hypertensive, or had ICP.

Any other ideas besides embolus and panic attack?


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## dewey (Jul 30, 2012)

mycrofft said:


> Undiagnosed arrythmia (a-fib?) and extremities asleep from Nintendosis.



Nintendosis :rofl:

I'm stealing that one.


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## mycrofft (Jul 30, 2012)

Nintendosis:sit in one place for hours, often leaning forwards, often accelerating pulse and breathing. Yields repetitive motion injuries, lower extremity numbness and potential to go vagal when standing up.


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## EMT91 (Jul 31, 2012)

Did you get an EKG on him at all? Did you happen to exam his feet? Did they appear purple or anything?


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## Doczilla (Jul 31, 2012)

Young male. Symptomatic tachycardia, resolved on its own. 

He fits the epidemiologic profile for WPW or a similar accessory pathway. Could have had a brief bout of SVT. Only an EP study will tell though.


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## Maine iac (Jul 31, 2012)

I had a guy, right in front of me brady down to 23. I caught it with a 12 lead at 27bpm then it went right back up to the mid 70s.

He was talking right the way through it like nothing had happened.

This guy almost sounds like a panic attack/hyperventilation.


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## shiroun (Aug 1, 2012)

EMT91 said:


> Did you get an EKG on him at all? Did you happen to exam his feet? Did they appear purple or anything?



No cyanosis, anywhere.





Maine iac said:


> I had a guy, right in front of me brady down to 23. I caught it with a 12 lead at 27bpm then it went right back up to the mid 70s.
> 
> He was talking right the way through it like nothing had happened.
> 
> This guy almost sounds like a panic attack/hyperventilation.



At 23? Holy :censored::censored::censored::censored:. And if anything he'd been hypoventilating, he wasnt taking quick breaths, they were deep, strong, breaths. But he felt them to be shallow.


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## Tedmonds2 (Aug 1, 2012)

shiroun said:


> Synonomous with Deep Vein Thrombosis. Its basically caused by sitting or being inactive for a really long time. Its the reasaon why every time a new game comes out, about 3-4 days later you hear about someone dieing by a pulmonary embolism.



Haha that explains 90% of private ambulance people who post for 12+ hours a day and sit in a small space and don't move.


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## Lil Medic (Aug 7, 2012)

I'd say it was a clot that broke and settled into a PE then re-broke and settled elsewhere that allowed adequate blood flow, with a bad pulse reading? possible drugs but the hospital would find that out later. Otherwise I'd bank on human or device error for the pulse fluctuation. If you think about it that type of rapid change would require massive stimulation from some source that simply wasn't present. but clots seem like the most likely cause to me at least.


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## Aidey (Aug 7, 2012)

Where would the clot have settled the second time?


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## mycrofft (Aug 8, 2012)

His left hip pocket?


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## shiroun (Aug 8, 2012)

Lil Medic said:


> I'd say it was a clot that broke and settled into a PE then re-broke and settled elsewhere that allowed adequate blood flow, with a bad pulse reading? possible drugs but the hospital would find that out later. Otherwise I'd bank on human or device error for the pulse fluctuation. If you think about it that type of rapid change would require massive stimulation from some source that simply wasn't present. but clots seem like the most likely cause to me at least.



I can assure you there was no human/device error in it. I'm anal about inital vitals, and theres no WAY I'd be able to screw up a pulse, besides on the stupidly high end when your head is like :wacko: trying to count.

Anyway, looks like the result is clots or an acute anxiety attack. Sounds good.


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## Doczilla (Aug 8, 2012)

Doczilla said:


> Young male. Symptomatic tachycardia, resolved on its own.
> 
> He fits the epidemiologic profile for WPW or a similar accessory pathway. Could have had a brief bout of SVT. Only an EP study will tell though.



Just curious, why am I the only one thinking this?


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## Aidey (Aug 8, 2012)

You're not. This really doesn't fit a PE very well.


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## Doczilla (Aug 8, 2012)

Was that what the followup revealed? Maybe I missed it...


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## VFlutter (Aug 8, 2012)

Doczilla said:


> Young male. Symptomatic tachycardia, resolved on its own.
> 
> He fits the epidemiologic profile for WPW or a similar accessory pathway. Could have had a brief bout of SVT. Only an EP study will tell though.



This was my first thought as well. SVT causing hemodynamic instability and then spontaneously converting back to SR. However, in a healthy 20 year old person I wouldnt think 150s would cause that much of a problem unless there was some other underlying problem. But that is just based off personal experience, I have seen many patients remain asymptomatic until closer to 200. Then again every patient is different. 

Was he by chance slamming red bulls all day? A sudden change in position can also cause SVT. Did the symptoms start when he was sitting down or after standing up? Sitting there all day causes venous stasis then he stands up all the sudden and does not get an adequate return of blood to the heart so the heart gets pissed off and goes into SVT


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## SnakeDocNC (Aug 10, 2012)

I am not judging the EMT that ran this call just trying to provide good advice.  From the description there is no way to rule out drug use because pt could fear getting in trouble so I would have reported to the nurse that pt possibly ETOH.  Second with no BP its hard to tell what the heart is really doing and prove SVT without a EKG.  As a general rule no matter what the pt looks like I always obtain an SPO2 reading.  There are a thousand things that come to mind that could be wrong with this pt but with the info provided I want to lean to some sort of shock.  Prolly would have called for ALS with the unstable vital signs.


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## Aidey (Aug 10, 2012)

Unless you have a reason beyond "the pt might be lying" to think they have alcohol on board DO NOT tell the nurse that. 

Seriously. 

Most nursing homes don't allow alcohol. If confused grandma tells you she hasn't been drinking are you still going to assume she might have been and is lying because she doesn't want to get trouble?


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## VFlutter (Aug 10, 2012)

Aidey said:


> Unless you have a reason beyond "the pt might be lying" to think they have alcohol on board DO NOT tell the nurse that.
> 
> Seriously.
> 
> Most nursing homes don't allow alcohol. If confused grandma tells you she hasn't been drinking are you still going to assume she might have been and is lying because she doesn't want to get trouble?



+1, you can also get yourself into legal trouble for assuming or reporting that without a probable cause not just "he is a young kid in college". What if you report that you think that patient is ETOH after a car accident just becase it is Friday night and the kid is younger? Then they pull those records for court and you are walking a fine line of getting sued if the patient was not. 

There is nothing wrong with reporting the patient has ETOH odor to breath or that bystanders repot patient was drinking but just assuming is a whole mother story.


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## Tigger (Aug 10, 2012)

At some point common sense seems to have been lost. Why would anyone bother to assume drug or alcohol use without some observations pointing towards it? Of course we can't rule anything out completely, but that doesn't mean that it is happening either.


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## SnakeDocNC (Aug 12, 2012)

Okay I should have worded it differently.  Just because the pt. or room mate said there was no drug use doesnt mean you should not look for evidence of it.  I was trying to point out that alot of times when young people are having an overdose or reaction to drugs they will not admit it due to fear of legal trouble.  Report to nurse what you saw.


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