# Unusual presentation



## Chris EMT J (Sep 22, 2022)

Hey so had this call that was really a unusual presentation so I am going to give some important information to the case and have some information private for patient confidentiality. 

Teenage male CC of jittery feeling

Visual cues:
Tripod position
Obviously involuntary shaking of legs and hands
 2-3 word sentences 
Holding chest 
And some gasping occasionally

Vitals:
HR 130s occasionally spiking to 160s (remains sinus tachycardia) 
BP 104/49 
O2 89% on RA 
RR 36 and irregular breathing patterns
Temp 98.7 BGL 92 

SAMPLE:
Heart palps/ involuntary shaking
No allergies
Only med is albeterol for mild occasional asthma
History just asthma and depression (in therapy)
Last oral intake was a few hours prior 
Events leading was resting after homework

ECG showed sinus tachycardia (medic interpretation) 
IV access obtained
Started some normal saline
Tried to coach him through deep breathing
Started 10lpm NRB 
Listened to lungs : clear breath sounds
Listened to heart : murmur present but otherwise normal 

Medic gave a medication can't remember exactly what to help calm him down 
Patient ended up going semi alert and unresponsive right as we were arriving. 

Anyone seen anything like this? Any clue what this was?


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## luke_31 (Sep 22, 2022)

First off you can’t go semi alert and unresponsive. Two different things. Second it sounds like an anxiety attack. Did the patient complain of any numbness or tingling to their extremities?


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## mgr22 (Sep 22, 2022)

The shaking and jittery feeling could have been from multiple self-administered albuterol doses.

Whatever sedative the patient was given could have made him less responsive. Also, who checked the lung sounds? Was it done in a moving ambulance or other noisy setting?


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## E tank (Sep 22, 2022)

Were there Redbull or Monster empties laying around?


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## Chris EMT J (Sep 22, 2022)

luke_31 said:


> First off you can’t go semi alert and unresponsive. Two different things. Second it sounds like an anxiety attack. Did the patient complain of any numbness or tingling to their extremities?


No I meant first went semi alert then fully unresponsive. And no numbness or tingling


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## Chris EMT J (Sep 22, 2022)

mgr22 said:


> The shaking and jittery feeling could have been from multiple self-administered albuterol doses.
> 
> Whatever sedative the patient was given could have made him less responsive. Also, who checked the lung sounds? Was it done in a moving ambulance or other noisy setting?


Lung sounds obtained in his bedroom we had the room quite


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## Chris EMT J (Sep 22, 2022)

E tank said:


> Were there Redbull or Monster empties laying around?


There was a couple redbulls in the crash but am not sure when they were drunk.


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## Chris EMT J (Sep 22, 2022)

mgr22 said:


> Also, who checked the lung sounds?


To answer that part I was checking lung sounds while medic was doing a 12lead


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## mgr22 (Sep 22, 2022)

ChrisEMTA said:


> To answer that part I was checking lung sounds while medic was doing a 12lead


I see you're an AEMT. No offense, not looking to assign blame, just wondering if you've had experience assessing asthmatics and can distinguish "clear" but minimal air movement.

The RA SpO2 is concerning. Assuming that number is accurate and not normal for the patient, there seems to be a mismatch between ventilation and perfusion. I'm suspicious of a ventilation problem, given the asthma history, but another possibility is a perfusion problem, such as a PE.


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## akflightmedic (Sep 22, 2022)

Def spontaneous pneumothorax!! 

Anyways, I felt like my Delorean malfunctioned because while reading this, it reminded me of a very similar scenario we have discussed here before. I mean very similar, down to the Red Bull in trash. Wish I had time to find it and compare.


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## Chris EMT J (Sep 23, 2022)

mgr22 said:


> I see you're an AEMT. No offense, not looking to assign blame, just wondering if you've had experience assessing asthmatics and can distinguish "clear" but minimal air movement.
> 
> The RA SpO2 is concerning. Assuming that number is accurate and not normal for the patient, there seems to be a mismatch between ventilation and perfusion. I'm suspicious of a ventilation problem, given the asthma history, but another possibility is a perfusion problem, such as a PE.


No offense taken. I listened right next to the bronchus then under the armpit about 5 intercoastal space heard the same breaths a little louder near bronchus but not much at all.
I think I can distinguish it but I mean I guess I could have misinterpreted what I was hearing.


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## Chris EMT J (Sep 23, 2022)

akflightmedic said:


> Def spontaneous pneumothorax!!
> 
> Anyways, I felt like my Delorean malfunctioned because while reading this, it reminded me of a very similar scenario we have discussed here before. I mean very similar, down to the Red Bull in trash. Wish I had time to find it and compare.


I thought this was a possibility until I heard air moving through all my points on the chest.


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## luke_31 (Sep 23, 2022)

ChrisEMTA said:


> No I meant first went semi alert then fully unresponsive. And no numbness or tingling


Ok makes sense. I’ll admit I missed the pulse ox reading so that would definitely have changed what the possible Dx would have been. PE or some other VQ mismatch would make sense


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## akflightmedic (Sep 23, 2022)

ChrisEMTA said:


> I thought this was a possibility until I heard air moving through all my points on the chest.



I did NOT say tension pneumothorax with diminished or absent breath sounds. If you think breath sounds will be absent during a pneumothorax, then you may want to go back and review this topic.


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## E tank (Sep 23, 2022)

akflightmedic said:


> ...if you think breath sounds will be absent during a pneumothorax, then you may want to go back and review this topic.


what am I missing here?


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## akflightmedic (Sep 23, 2022)

Just a side tangent, the comment by the poster indicated that pneumo was ruled out due to being able to hear breath sounds. I countered with, breath sounds are indeed possible with a pneumo, whether it be small or early. Am I wrong? My education, experience, and some googling to fact check what I think I know, says I am right. As always, I am open to counter opinion or facts to set me straight.


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## E tank (Sep 23, 2022)

akflightmedic said:


> I did NOT say tension pneumothorax with diminished or absent breath sounds. If you think breath sounds *must* be absent (to suspect) a pneumothorax, then you may want to go back and review this topic.


FTFY


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## akflightmedic (Sep 23, 2022)

Redacted


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## Chris EMT J (Sep 24, 2022)

akflightmedic said:


> I did NOT say tension pneumothorax with diminished or absent breath sounds. If you think breath sounds will be absent during a pneumothorax, then you may want to go back and review this topic.


Okay I am a advance EMT and I still do like learning. Spontaneous meaning no trauma pneumothorax meaning collapsed lung or lung lobe. So I thought that there would be a least a part of the lungs not getting inflated. So yes I did think that it was unlikely with that and that the patient wasn't tall and skinny but rather tall but buff. I haven't in my experience seen any pneumothoraxs that have had clear breath sounds heard all over both sides of the chest. I mean I will definitely research it more and take your experience in a count.


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## mgr22 (Sep 24, 2022)

What was the hospital dx?


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## Chris EMT J (Sep 24, 2022)

mgr22 said:


> What was the hospital dx?


Not sure he didn't get discharged within my shift so I don't get updates.


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## mgr22 (Sep 24, 2022)

ChrisEMTA said:


> Not sure he didn't get discharged within my shift so I don't get updates.


Too bad. Closing that loop is a good way to learn.


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## Chris EMT J (Sep 26, 2022)

mgr22 said:


> Too bad. Closing that loop is a good way to learn.


Yeah it's hard in my area to get updates. I wish I had the opportunity


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## akflightmedic (Sep 26, 2022)

Nice side topic for sure. I was always curious my entire career, so I used to inquire when I returned to the ER, or I would try and speak to the RNs I knew to get updates. Some made it easy, and some made it far more difficult than it should have been. I always tried to convey that it was great for ME, to become a better provider. Was I chasing the right diagnosis, could I have done anything differently? Was anything else found? It used to irk the hell out of me when they would stonewall and treat me as if I were not part of the treatment team.

As an ER nurse now, when crews come back, I always try to give them updates on their patients. I cannot even begin to tell you how many times they were absolutely shocked at the updates. This is not a dis on the EMS crew, however so many times they under present a complaint or concern.

I enjoy giving them updates as an educational adventure as opposed to shaming them for missing things or not understanding exactly what they were seeing. Most have been very receptive everywhere I have gone, and I find they start to seek me out to ask more questions on their own. I strongly feel this loop closure is vital and it is something both the service and facility are missing out on.

I know most facilities could not fund a full time EMS liaison nurse or medic; however, I do wish it eventually becomes a standard.


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## mgr22 (Sep 26, 2022)

I've worked with some people and systems over the years that provided hospital diagnoses and dispositions to EMS. It can be tricky to compare that data to prehospital care, but there were certainly opportunities for QA/QI.


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## Luno (Oct 20, 2022)

mgr22 said:


> What was the hospital dx?


?


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