# passing out from overexertion?



## addictedforever (Dec 18, 2011)

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?


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## phideux (Dec 18, 2011)

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.


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## truetiger (Dec 18, 2011)

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


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## addictedforever (Dec 18, 2011)

pupils nonreactive


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## 18G (Dec 18, 2011)

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?


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## addictedforever (Dec 18, 2011)

18G said:


> 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?
> 
> ...



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.


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## addictedforever (Dec 18, 2011)

18G said:


> What do her lungs sound like? SpO2?  PMH?



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


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## 18G (Dec 18, 2011)

addictedforever said:


> Lungs-slight crackles all regions
> SpO2-84%
> I'm not familiar with what PMH means



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?


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## addictedforever (Dec 18, 2011)

18G said:


> PMH = Past Medical History.



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)


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## 18G (Dec 18, 2011)

12-lead?


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## addictedforever (Dec 18, 2011)

18G said:


> 12-lead?



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


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## truetiger (Dec 18, 2011)

What kind of monitor do you all use?


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## addictedforever (Dec 18, 2011)

truetiger said:


> What kind of monitor do you all use?



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.


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## 18G (Dec 18, 2011)

What was the outcome of the patient?


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## systemet (Dec 18, 2011)

addictedforever said:


> Okay here's the situation... You get called out for a 20 y/o female who has passed out they think from overexertion.



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.



> You arrive and there is a person administring first aid, trying to get the pt. to respond.



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".



> 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.



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.



> 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



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.



> 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.



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.



> Action plan? What are your tho'ts?



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.


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## addictedforever (Dec 18, 2011)

18G said:


> What was the outcome of the patient?



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%


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## usalsfyre (Dec 18, 2011)

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.


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## exodus (Dec 18, 2011)

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?


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## mycrofft (Dec 18, 2011)

*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?


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## firetender (Dec 18, 2011)

"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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## Smash (Dec 18, 2011)

addictedforever said:


> 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.



Funny, that was exactly what I was thinking.  HOCM is high on the list of badness for exercise induced syncope in the young, and there is obviously some faulty genes floating around the family.  I'd love to know the rhythm she was in, and what the murmur was.


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## 18G (Dec 18, 2011)

I had a very similar episode happen to me during some exercise which was only moderate at best. 

The preceding week I had been under a ton of stress and was very worn down. Immediately after the exertion, I became weak, dizzy, nauseated, pale and cool, hypotensive with 80's systolic, weak pulses, and the Medic onscene said I was bradycardic (don't know what rate). 

The EMS crew didn't feel the need to do a 12-lead. They gave me a NRB and I was fine after about 15mins. It was a first time event and never experienced that before so not totally sure what happened. I suspect that the high level of stress and body being completely worn down for the past week was a factor. 

So yeah, exertional states can produce presentations like the patient's in this scenario.


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## Handsome Robb (Dec 18, 2011)

At the point I'm at in my education and experience level I think I would have been quick to  pace this patient after ruling out something easily reversible and correcting the hypoxia unless, like someone else said, my partner could have gotten a line faster than we got the pacing set up. Drawing the atropine will take 2 seconds, we use prefills.


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## 18G (Dec 18, 2011)

NVRob said:


> At the point I'm at in my education and experience level I think I would have been quick to  pace this patient after ruling out something easily reversible and correcting the hypoxia unless, like someone else said, my partner could have gotten a line faster than we got the pacing set up. Drawing the atropine will take 2 seconds, we use prefills.



Honestly, I think this patient was extremely lucky that the body was able to correct what was wrong without intervention. Any patient with a HR of 34, crackles, hypotension, altered mental status, cool and pale skin, isn't gonna get a, "let's see if this is transient approach". 

A 12-lead was absolutely necessary in this patient's care. It's sad EMS didn't have it available.


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## Handsome Robb (Dec 18, 2011)

18G said:


> Honestly, I think this patient was extremely lucky that the body was able to correct what was wrong without intervention. Any patient with a HR of 34, crackles, hypotension, altered mental status, cool and pale skin, isn't gonna get a, "let's see if this is transient approach".
> 
> A 12-lead was absolutely necessary in this patient's care. It's sad EMS didn't have it available.



Alright, I don't feel so green now.  Thanks  I wouldn't be comfortable trying to "wait this one out" based on what was given. Even if the pt was hypothermic I'd start active rewarming and pacing provided they aren't too cold for electricity. 

Agreed on the 12 lead. When I first learned about them they seemed like it would take forever to get it setup. Now that I have placed my fair share while working I have realized how quick and easy they are.

So my thoughts are after initiating ACLS on this PT I would want to listen to lung sounds again as well as a bp. Provided the lungs cleared up a bit I would be leaning towards a bolus of warm saline, but maybe that's me being all giddy about our new NS bag warmers h34r: I don't see a pressor being high on my list unless fluids + pacing aren't doing the trick. If fixing her perfusion problem hasn't fixed the level of consciousness I'd be headed towards an ETT.

Be gentle


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## systemet (Dec 19, 2011)

18G said:


> I had a very similar episode happen to me during some exercise which was only moderate at best.



Then, with respect, I'd suggest you might want to chat with your family MD, and get an ECG.  Seriously.

If you do VO2max tests on people, and they get their heart rate up to 200/min, and then pass out, this makes some sort of sense.  But becoming unconscious and bradycardic to 35/min, bradypneic, as described by OP, quite possible after having some sort of seizure episode (Stoke-Adams syndrome anyone?), is not a normal response to moderate exercise.



> The preceding week I had been under a ton of stress and was very worn down. Immediately after the exertion, I became weak, dizzy, nauseated, pale and cool, hypotensive with 80's systolic, weak pulses, and the Medic onscene said I was bradycardic (don't know what rate).



Then you have something else happening.  Maybe you're sick, maybe there's an electrolyte issue, maybe you've just discovered some cardiac pathology, and the exertion is unmasking all of this.  But this is not a normal response to exercise.

The body is adept at preventing us from overexerting ourselves.  We maintain normal pH and PCO2 until we reach our lactate threshold, and even for a fair while beyond.  Even with maximal exercise normally healthy people don't even approach the beginning of cardiac ischemia, despite cardiac output being the limiting factor.

People shouldn't just pass out because they're exercising.  When this occurs it's because of something else.  It should be taken seriously, it should be evaluated, and doing otherwise is lazy and incompetent.  There is something else happening here, ranging from the benign anxiety syndrome precipitated by getting a mild sense of dyspnea while exercise to something more severe.




> The EMS crew didn't feel the need to do a 12-lead. They gave me a NRB and I was fine after about 15mins. It was a first time event and never experienced that before so not totally sure what happened. I suspect that the high level of stress and body being completely worn down for the past week was a factor.



Those probably were, but dude, you should go talk to your doctor.  Are you sure you don't have a high risk ECG?



> So yeah, exertional states can produce presentations like the patient's in this scenario.



Only in that exertional states can unmask underlying pathology.  The healthy human body doesn't decide to throw you unconscious and desaturate you because you played a little broomball.  This is not normal physiology.


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## systemet (Dec 19, 2011)

18G said:


> Honestly, I think this patient was extremely lucky that the body was able to correct what was wrong without intervention. Any patient with a HR of 34, crackles, hypotension, altered mental status, cool and pale skin, isn't gonna get a, "let's see if this is transient approach".



It's amazing how many things get fixed by the time it takes to move the patient to a decent environment and gain IV access though.

It's hard to make these judgments without being there, but given how many syncopal events are self-limiting, I wouldn't be jumping on pacing until I have any hypoxia corrected.  

If you believe that the altered mental status is caused by hypotension from the bradycardia, then pacing is appropriate.  This is a definite possibility in this patient, with a familial cardiac hx.  



> A 12-lead was absolutely necessary in this patient's care. It's sad EMS didn't have it available.



Agreed.  It would be nice to see if there was any signs of infarction, Brugada syndrome, HOCM, etc.  Even a 3-lead would be nice to see if this is just sinus bradycardia, or if we have some sort of AV block occurring (which would bias us right towards pacing).


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## 18G (Dec 19, 2011)

systemet said:


> Then, with respect, I'd suggest you might want to chat with your family MD, and get an ECG.  Seriously.
> 
> If you do VO2max tests on people, and they get their heart rate up to 200/min, and then pass out, this makes some sort of sense.  But becoming unconscious and bradycardic to 35/min, bradypneic, as described by OP, quite possible after having some sort of seizure episode (Stoke-Adams syndrome anyone?), is not a normal response to moderate exercise.
> 
> ...




Actually, I have felt similar to this episode many, many years ago when I experienced heat exhaustion which is why I am summing it up to over exertion in the presence of being really worn down. 

I had an echocardiogram done a few weeks prior to this because I asked my PCP for it based on a 12-lead finding I noted on myself. The echo was normal.


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## systemet (Dec 19, 2011)

18G said:


> Actually, I have felt similar to this episode many, many years ago when I experienced heat exhaustion which is why I am summing it up to over exertion in the presence of being really worn down.
> 
> I had an echocardiogram done a few weeks prior to this because I asked my PCP for it based on a 12-lead finding I noted on myself. The echo was normal.



I'm glad you've had this evaluated, at least partially.  I think I'm starting to stick my nose a little too far into what's your business and not mine.

Let me apologise if I came across as too dogmatic about this.  I just want to make sure it's clear for any basic providers reading this thread that passing out during exercise = pathology until proven otherwise.


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## 18G (Dec 19, 2011)

systemet said:


> I'm glad you've had this evaluated, at least partially.  I think I'm starting to stick my nose a little too far into what's your business and not mine.
> 
> Let me apologise if I came across as too dogmatic about this.  I just want to make sure it's clear for any basic providers reading this thread that passing out during exercise = pathology until proven otherwise.



No need to apologize. I certainly welcome your insight and appreciate your input on my little episode and the OP's scenario.


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