# 22 y/o SOB



## LACoGurneyjockey (Aug 11, 2014)

You're dispatched for difficulty breathing, and arrive to find a 22 year old female CAOx4, lethargic and slow to respond. She is slumped over in her seat saying she can't breath, with 2-3 word dyspnea and apparent distress. Your patient appears to fall asleep several times in her seat and is easily awoken with verbal stimuli. She states she feels like her shirt is constricting on her chest and has a tightness in her chest. 
Vitals: BP 128/90, Sinus tach at 140 on the monitor, Respirations are at 30 and shallow, SPO2 92%. Lungs are clear, pupils are PERRL, skin is warm, dry, and normal in color. 
Let me know what else you want. 

This can be a really easy one, but it opened up my eyes to look at calls a little differently and I thought it was worth posting.


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## chaz90 (Aug 11, 2014)

OD is high on my initial list. EtCO2, medical history, admission of drug use would make it really easy. See if you're able to coax her to take a couple big deep breaths on room air to get the sats up. If she's unable or it doesn't work, let's try some supplemental O2.

History of smoking, birth control usage? Encourage her to stay awake to avoid having to trial Narcan if she becomes less responsive and her breathing slows. When did these problems start, have they ever happened before, and what was she doing before it?

Kinda wondering about the possibility of speedball usage with that heart rate and dilated pupils.

If nothing definitive from the previous assessment findings, get a 12 lead EKG. Monitor respiratory effort and response to titrated O2 administration, start an IV, draw labs, and transport non-emergent to nearest ED.


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## PotatoMedic (Aug 11, 2014)

What was she doing prior to sob?  Did she inhale anything?  Medical history?  Environmental hazards?


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## DesertMedic66 (Aug 11, 2014)

Medical history, allergies, Medications, capo waveform and value, 12-lead. 

First thing that pops in my head is PE.


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## STXmedic (Aug 11, 2014)

12 lead? EtCO2? 

Is she on birth control? 

History/meds/allergies. 

My initial suspicion is leaning towards PE, but you may change my mind with more info.

Edit: Or exactly what desert said...


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## DesertMedic66 (Aug 11, 2014)

STXmedic said:


> 12 lead? EtCO2?
> 
> Is she on birth control?
> 
> ...



It's a shame I can't "Like" my own posts hahaha


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## chaz90 (Aug 11, 2014)

The lethargy would be a bit surprising for this level of fairly mild sounding hypoxia, but the rest fits pretty darn well with a PE!


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## STXmedic (Aug 11, 2014)

I got you, Desert 

Yeah, that's the only thing that was keeping me from being certain, Chaz. Thinking maybe he misremembered the actual initial number. Speedballing isn't on my list because her respirations are too fast, so the depressant wouldn't be causing hypoxia. So she either has something interfering with her hemoglobin, or she has a VQ mismatch, and lungs are clear, so it must be on the perfusion side. That, or her respirations are _very_ shallow and she's not moving any air at all. Possible fracture preventing inspiration? But that wouldn't likely be described as tightness.


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## LACoGurneyjockey (Aug 11, 2014)

Tries but can't take a deep breath, tightness turns into pain when she tries. O2 brings the spo2 up to 97% within a few minutes. I don't have etco2 for you unfortunately.
Started about 30 minutes ago sitting on the couch when she passed out for several minutes, was woken up and began complaining of the difficulty breathing. She's had anxiety attacks and says this feels "kind of the same but different."
12 lead confirms sinus tach.
Only history is anxiety, and she has anxiety attacks once every couple weeks. Meds include xanax, flexeril, birth control, Prozac, and she admits to drinking lightly but does not appear intoxicated. Denies any drug use. No allergies. No pain on palpation or any signs of trauma/fracture.


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## teedubbyaw (Aug 11, 2014)

PE or an extreme anxiety attack. See if we can coach her breathing while we work on getting more info/vitals.


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## PotatoMedic (Aug 11, 2014)

Hyperventilating?


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## STXmedic (Aug 11, 2014)

Numbness/tingling to hands and feet, or carpal pedal spasms? How was she feeling just before passing out? Does she have a history of syncopal episodes? BGL? Was it witnessed? If so, how did the witnesses describe the episode?


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## STXmedic (Aug 11, 2014)

FireWA1 said:


> Hyperventilating?


30 and shallow.


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## LACoGurneyjockey (Aug 11, 2014)

She doesn't remember passing out but says her hands were numb when she woke up. No previous syncopals. BGL is 160. 
Witness described her sitting on the couch very much awake, then suddenly seeming very tired for 5-10 minutes before "falling asleep".


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## Clare (Aug 12, 2014)

?PE 

DDx asthma with silent chest or FBAO (perhaps below the carina)

When you listen to her chest is she actually moving air?

Treatment I can provide would be oxygen at a very high flow rate, much higher than normal (15 lpm) on a non-rebreathing mask +/- "bootleg CPAP" (ensuring a good, tight seal with a bag mask and PEEP of 10 cmH2O).

For those who say this might be drugs - which? We have a very low rate of drug abuse in NZ (and virtually no narcotics or opiate type drugs) so it's something I know little about.


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## chaz90 (Aug 12, 2014)

Clare said:


> For those who say this might be drugs - which? We have a very low rate of drug abuse in NZ (and virtually no narcotics or opiate type drugs) so it's something I know little about.



Leaning away from that differential now with the inability to take a deep breath, continued pain, and vitals inconsistent with what I would have expected for drug use.


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## chaz90 (Aug 12, 2014)

This onset is weird. Suddenly increased drowsiness, syncopal episode, then difficulty breathing when awoken? Not to mention the pain/tightness.

First time absence seizure with anxiety attack after the seizure ended?


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## STXmedic (Aug 12, 2014)

Does she respond to bring coached? And if so, does she still need oxygen to maintain O2 saturations? I agree with Chaz- it's a strange presentation. It seems like something is missing...

Are the number of pills in her bottles appropriate for the amount of time prescribed? Does she admit to attempting to overdose? As a stretch, I'm wondering if she overdosed on her Xanax, was awoken after she started hypoventilating (thus the hypoxia), and then began having an anxiety attack... Definitely a stretch, though.


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## kal0220 (Aug 12, 2014)

Maybe an interaction between ETOH and the benzodiazapine.  The mixture of Xanax and alcohol can lead to severe anxiety attacks.  Drowsiness is a SE of alcohol and the Xanax.

EDIT: The high respiration can be a cause of the anxiety, along with the chest pain.  The drowsiness as a result of the drugs interacting.


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## LACoGurneyjockey (Aug 12, 2014)

No empty bottles, no signs of an OD. 
As you're running all these possibilities thru your head the patient begins to feel less difficulty breathing, and is in significantly less distress. She states maybe this was just anxiety, and that she doesn't feel she needs to go by ambulance. She is alert and oriented, no longer complaining of anything but a mild sense of shortness of breath. 
Are you comfortable having her sign AMA or are you going to push a little further for a transport, and why?


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## chaz90 (Aug 12, 2014)

I don't care if she goes by ambulance or POV, but I'd like her to go to the ED for an evaluation. This sudden and dramatic lessening of symptoms leads me more towards a spontaneous resolution of a PE with risk of reoccurence. Either that, or hoofbeats could mean horses and it's an anxiety attack. Still doesn't quite explain the acute onset somnolence and lethargy though.


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## Underoath87 (Aug 12, 2014)

Spontaneous pneumo with the lethargy and other symptoms secondary to hypoxia/hypercapnea?


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## LACoGurneyjockey (Aug 12, 2014)

It was a PE, most likely from the birth control that resolved itself.
As the EMT on an ALS truck there's a lot of times where my opinion is irrelevant, and this was one of them. I had PE in my head from early on, but the medic brushed it off as anxiety and BLSd her in. No O2, no IV, no 12 lead.
Just was a frustrating experience and I wanted to see how many others had PE on their mind from early on.


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## teedubbyaw (Aug 12, 2014)

LACoGurneyjockey said:


> It was a PE, most likely from the birth control that resolved itself.
> As the EMT on an ALS truck there's a lot of times where my opinion is irrelevant, and this was one of them. I had PE in my head from early on, but the medic brushed it off as anxiety and BLSd her in. No O2, no IV, no 12 lead.
> Just was a frustrating experience and I wanted to see how many others had PE on their mind from early on.



Becoming complacent is a stupid thing to do. I've seen many ill-minded medics assume SOB is automatically anxiety. 

If you can't rule it out, assume the worse.


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## Carlos Danger (Aug 12, 2014)

LACoGurneyjockey said:


> It was a PE, most likely from the birth control that resolved itself.
> As the EMT on an ALS truck there's a lot of times where my opinion is irrelevant, and this was one of them. I had PE in my head from early on, but the medic brushed it off as anxiety and BLSd her in. No O2, no IV, no 12 lead.
> Just was a frustrating experience and I wanted to see how many others had PE on their mind from early on.



In all honesty, anxiety would have been at the top of my list of differentials given the presentation and history. 

PE is always a possibility and would have been been in the back of my mind, but I would have though it unlikely. 

I would have preferred she be seen at the ED, but would not have made a big issue of it if she didn't want to.


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## Handsome Robb (Aug 12, 2014)

PE would be up on the list. Does she smoked that'd make it even more suspicious for PE although it seems pretty clear cut. 

Kinda a zebra but ASA OD would fit. Tachypneic, tachycardic, lethargy. No N/V or abdominal pain though.

I wouldn't be super stoked AMAing her but I can't force her to go. We'd have a very long conversation about possibilities though.

Remi, why would anxiety be your top differential rather than PE? Not trying to get after you just wondering your thought process. I thought the same thing until I saw the SpO2. That piece of the puzzle doesn't fit anxiety.


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## DesertMedic66 (Aug 12, 2014)

My guess (could be completely wrong) is that the PE caused her to become very hypoxic very quickly which caused her to pass out. The PE possibly moved to a different position allowing her saturation to slowly rise a little bit which is when she came to and started to have her C/C until the PE moved once again to a different position or completely out of the lung. 

I would like to transport her by ambulance. If she refused I would be on the phone with medical direction and have the doctor talk to her as well. If she still refused then go down all the AMA information, advise her of the risks, and then have her sign out AMA.


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## Carlos Danger (Aug 13, 2014)

Handsome Robb said:


> Remi, why would anxiety be your top differential rather than PE? Not trying to get after you just wondering your thought process. I thought the same thing until I saw the SpO2. That piece of the puzzle doesn't fit anxiety.



The mental picture I formed when reading the scenario just looked like anxiety to me. Almost any presentation *could be* a PE, but overall that's much less likely than anxiety. 
I missed the Sp02 of 92 in the original post.

That said, the top differentials in my head for any complaints involving SOB and/or chest discomfort of any type are cardiac, PE, PTX, a major vascular etiology, GI problems, and anxiety. You just never know; the diagnostic tools we have in the field aren't very good at ruling out any of these problems. So at the end of the day, the best thing to do very often is just take them to the ED.


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## Rialaigh (Aug 14, 2014)

Honestly, if you take away the sinus tach on the monitor this very much sounds like possible short spells of Vtach to me. I have seen multiple young healthy patients with no cardiac history present with "anxiety", weakness, SOB, chest pain, and spells of passing out and dizziness from runs of Vtach that are occur frequently. Always...always something to consider when the patient appears anxious and tachicardiac upon palpating a pulse.


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## J B (Aug 15, 2014)

DesertEMT66 said:


> My guess (could be completely wrong) is that the PE caused her to become very hypoxic very quickly which caused her to pass out. The PE possibly moved to a different position allowing her saturation to slowly rise a little bit which is when she came to and started to have her C/C until the PE moved once again to a different position or completely out of the lung.
> 
> I would like to transport her by ambulance. If she refused I would be on the phone with medical direction and have the doctor talk to her as well. If she still refused then go down all the AMA information, advise her of the risks, and then have her sign out AMA.



Agree 100%.

Relevant from wikipedia:



> As smaller PE's tend to lodge in more peripheral areas without collateral circulation they are more likely to cause lung infarction and small effusions, both of which are painful, but not hypoxia, dyspnea or hemodynamic instability such as tachycardia. Larger PE's, which tend to lodge more centrally, typically cause dyspnea, hypoxia, hypotension, tachycardia and syncope, but are often painless because there is no lung infarction due to collateral circulation. The classic presentation for PE with pleuritic pain, dyspnea and tachycardia is most likely to be caused by a large embolism that fragments and thus causes both large and small PEs. Thus small PEs are often missed because they cause pleuritic pain alone without any other findings and large PEs are often missed because they are painless and mimic other conditions often causing EKG changes and small rises in troponin and BNP levels.


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## medicsb (Aug 17, 2014)

LACoGurneyjockey said:


> It was a PE, most likely from the birth control that resolved itself.
> As the EMT on an ALS truck there's a lot of times where my opinion is irrelevant, and this was one of them. I had PE in my head from early on, but the medic brushed it off as anxiety and BLSd her in. No O2, no IV, no 12 lead.
> Just was a frustrating experience and I wanted to see how many others had PE on their mind from early on.



So... wait.  If the PE resolved itself then how do you know it was a PE?  What tests would show that you recently had a PE, but do not anymore?  How would the body so quickly breakdown a PE that is big enough to be symptomatic when patients on warfarin can take months to break down a PE?


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## DesertMedic66 (Aug 17, 2014)

medicsb said:


> So... wait.  If the PE resolved itself then how do you know it was a PE?  What tests would show that you recently had a PE, but do not anymore?  How would the body so quickly breakdown a PE that is big enough to be symptomatic when patients on warfarin can take months to break down a PE?



Maybe not confirm that there was a PE but give a very high probability. Sudden onset of SOB, low O2 sats, birth control, d dimer blood test, and id imagine other blood tests. 

Who said the clot was broken down? The clot may have just moved to another location in the body (generally from smaller to larger vessels).


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## Handsome Robb (Aug 17, 2014)

DesertEMT66 said:


> Maybe not confirm that there was a PE but give a very high probability. Sudden onset of SOB, low O2 sats, birth control, d dimer blood test, and id imagine other blood tests.
> 
> Who said the clot was broken down? The clot may have just moved to another location in the body (generally from smaller to larger vessels).



Only problem with the moving to another part of the body theory is PEs are on the PA side and would have to travel through the capillary beds of the alveoli then back out into the circulatory system. If it's big enough to create an obstruction and make the patient symptomatic there's no way it'll make it through those capillary beds.


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## Ewok Jerky (Aug 17, 2014)

medicsb said:


> So... wait.  If the PE resolved itself then how do you know it was a PE?



Because that's what the ED said: slightly elevated d dimer, + risks factors, but a negative scan and resolution of symptoms = GOMER (at least around  here anyways)


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## LACoGurneyjockey (Aug 17, 2014)

beano said:


> Because that's what the ED said: slightly elevated d dimer, + risks factors, but a negative scan and resolution of symptoms = GOMER (at least around  here anyways)


This


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## Underoath87 (Aug 17, 2014)

Handsome Robb said:


> Only problem with the moving to another part of the body theory is PEs are on the PA side and would have to travel through the capillary beds of the alveoli then back out into the circulatory system. I*f it's big enough to create an obstruction and make the patient symptomatic there's no way it'll make it through those capillary beds.*



Exactly.  Capillaries are only wide enough for RBCs to pass through in single file.


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## Ewok Jerky (Aug 17, 2014)

Underoath87 said:


> Exactly.  Capillaries are only wide enough for RBCs to pass through in single file.



I think the confusion was more about venous clots vs arterial clots.  Venous clots tend to originate in deep veins of the leg (or sometimes upper extremity) and when they thrombose they travel through progressively bigger veins, through the right side of the heart and get stuck in the small capillaries of the lungs, ie Pulmonary Embolis.  

When a clot forms on the arterial side, lets say in the L atria secondary to AFib, and it gets dislodged it travels through a big artery to a smaller artery and so on until it gets stuck in a capillary bed somewhere, usually a toe or in the brain somewhere ie Stroke or Ischemic Foot.


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## medicsb (Aug 17, 2014)

LACoGUrneyJockey, how do you "know" or were led to believe this was resolved PE (or was Beano on the call with you?).  

Again, any clot big enough to cause symptoms is extremely unlikely to just disintegrate (even directly applying TPA to the clot directly does not usually completely dissolve it).  If it did occur resolve, I don't know how you would prove it reliably.


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## Ewok Jerky (Aug 17, 2014)

medicsb said:


> Again, any clot big enough to cause symptoms is extremely unlikely to just disintegrate (even directly applying TPA to the clot directly does not usually completely dissolve it).  If it did occur resolve, I don't know how you would prove it reliably.



I wasn't there, just playing devil's advocate.  The role of the ED is not to provide a diffinitive Dx but rather to exclude life threatening ones.

As for clots disintegrating...what about TIAs?


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## LACoGurneyjockey (Aug 17, 2014)

medicsb said:


> LACoGUrneyJockey, how do you "know" or were led to believe this was resolved PE (or was Beano on the call with you?).
> 
> Again, any clot big enough to cause symptoms is extremely unlikely to just disintegrate (even directly applying TPA to the clot directly does not usually completely dissolve it).  If it did occur resolve, I don't know how you would prove it reliably.



Me and beano are permanent partners, don't ever doubt it. 
I don't have a CT machine in my truck, but I have an ED that I tend to trust. 
Presentation, risk factors, an elevated d dimer test all point towards a PE. Do I have the clot on a tray in my bedroom, no, do I believe the ED when their diagnosis confirms my initial suspicion, yes.


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## Nightmare (Oct 17, 2014)

So placing myself on the scene...given the presentation, history and then the resolution of symptoms I would have done my best to convince her to go by ambo but if she persisted I would have signed her off and then it would have come back to bite me in the *** lol


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