# 13yof knee to the jaw



## Connor (Nov 7, 2013)

Hey guys, I had a weird one today and I want to know what the physiology of what was happening could've been. MFR's get taught next to nothing in terms of physiology. :/

approx. 13 y/o female, hit square in the jaw by opponent's knee while wrestling. She presented with only jaw pain, nothing else. no LOC, mild dizziness, no N/V, PEARL, no midline pain, no paresthesia, CMSx4 and AOx4. No prior concussions, no meds, no Hx. She was seriously shaken up and "shivering" as if she was cold, so I wanted her to stay with me for a while. She didn't seem in distress, just "shaken up" - her words.

She continued to shake continually after me trying to calm her down, so at that point I got her to lay down and took some vitals. This was all about 10 mins after she came to me. BP 130/105, HR ~130 and SpO2 94%. I assessed CMS again and suddenly she had very, very reduced grip strength and next to no movement in her feet. Pulses and sensory all intact. She started to complain of neck pain, midline. She continued to shake, not like a seizure or anything, just tremors. She had full awareness of what was going on and what happened this whole time, still not in any panic or kind of distress.

Called EMS since I can't board or transport, and I wanted them to do a more in-depth assessment. I was thinking neurogenic shock because apparently one of our other medics had a pt. like that a few days ago, but I thought s/s was hypotension and bradycardia?

I'm just confused as to why she was shaking like that, was it shock and if so, what kind?


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## Av8or007 (Nov 8, 2013)

Not sure as to the answer, but on another note, since when can an emr not apply spinal motion restriction/board the pt?

 I'm not going to get into the great backboard debate here...


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## Connor (Nov 8, 2013)

Av8or007 said:


> Not sure as to the answer, but on another note, since when can an emr not apply spinal motion restriction/board the pt?
> 
> I'm not going to get into the great backboard debate here...



I can "assist" 911 medics w/ SMR, just can't do it on my own. Which basically means wait until they arrive then do everything. & I wasn't working under the EMR scope, just a little bit below. It's a private volunteer thing, I suspect they don't want to risk getting sued.


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## Ewok Jerky (Nov 8, 2013)

Based your location, was she cold?  Was she still in her onesy or was she in warmups?  

Neurogenic shock in unlikely as she would be hypotensive and TACHYcardic, bradycardic would be a late finding in shock and would imply decompensation.  What was her skin like?  How was her mental status?  Was she able to describe her pain at all? Was it muscular? Was it localized or did it radiate anywhere?

With a shot to the jaw, loss of motor control to the feet doesn't make much sense if she was still able to move her upper extremities.


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## teedubbyaw (Nov 8, 2013)

Sounds like anxiety. I'd lean toward thinking the loss of motor was more psychogenic than not. I'd do a more in depth neuro assessment, blanket, o2 NC, and transport. I would not have immobilized her.


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## mycrofft (Nov 8, 2013)

Low systolic for that pulse rate and a sort of narrowed systolic/diastolic ratio.

Many possibilities. Was she on meds, or did she use anything going onto the mat (inhalers, pills)?  History of previous head or neck injury? Capillary refill time each extremity (one or two digits each). Gooseflesh? Tremors? 

As for spinal precautions, lying down quietly is adequate at your level (given adequate airway) if you are not moving them, the arriving squad will do their thing. The floor and gravity will be your board and straps.

"Shot to the jaw", if it included dorsiflexing the cervical or thoracic spine, could affect any motor a cervical or thoracic spine insult would. 

http://www.apparelyzed.com/support/functionality/t1-t4.html

And, of course the psychological possibilities.


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## Carlos Danger (Nov 8, 2013)

Anxiety.


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## TheLocalMedic (Nov 8, 2013)

Halothane said:


> Anxiety.



Ditto

13 year old female + hit to the face =  Anxiety.  

Probably the best thing would be to quit making a big deal out of it.  Tell her to sit with her team, relax and throw and ice pack on it.


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## Quin (Nov 8, 2013)

Does it help to know that she was probably massively dehydrated / wacky electrolytes? Betcha her K was almost nonexistent. 

Wrestlers try to compete in the lowest weight class possible. 

To do so, for about 24- 48 hours before a competition the stop eating, run in garbage bags to make themselves sweat, only drink diuretics, and spit constantly. You can lose about 12lbs of water weight per day doing this. 

Then right after weigh in (minutes before the match) they carb load. 

In highschool & college wrestling some of the shadier coaches keep banana bags  in the locker room for after match.


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## Akulahawk (Nov 8, 2013)

Connor said:


> Hey guys, I had a weird one today and I want to know what the physiology of what was happening could've been. MFR's get taught next to nothing in terms of physiology. :/
> 
> approx. 13 y/o female, hit square in the jaw by opponent's knee while wrestling. She presented with only jaw pain, nothing else. no LOC, mild dizziness, no N/V, PEARL, no midline pain, no paresthesia, CMSx4 and AOx4. No prior concussions, no meds, no Hx. She was seriously shaken up and "shivering" as if she was cold, so I wanted her to stay with me for a while. She didn't seem in distress, just "shaken up" - her words.
> 
> ...


With all that, how fast was she breathing? Shallow or deep?


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## TheLocalMedic (Nov 8, 2013)

Quin said:


> Does it help to know that she was probably massively dehydrated / wacky electrolytes? Betcha her K was almost nonexistent.
> 
> Wrestlers try to compete in the lowest weight class possible.
> 
> ...



Highly doubtful, especially considering the age.


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## Connor (Nov 8, 2013)

@Akulahawk, her breathing was normal.

@Quin, this was junior high wrestling. I doubt the coaches would do that, but low BGL or mild dehydration is definitely possible because I know some kids go all day without eating/drinking very much.

@TheLocalMedic, I was trying to make as little a deal as I could. I had a gut feeling and wanted her to stay w/ me, in the meantime I just chatted about her team and school and small talk stuff about family, friends, etc. Tried to make a connection.

@mycrofft, no known Hx. No meds, nothing. Skin was cool/clammy, and maybe I'm crazy but I think her cheeks were a little red/purple while we were putting her on a board, but up until then it was normal. Didn't check cap refill, just pulses. I put her on my stretcher semi-fowlers.

@teedubbyaw, The medics that arrived on scene decided to SMR. Would have put her on O2 if they were more than 5-10 mins out.

@beano, I made an effort to keep her comfortable. Her skin was unremarkable until 15-20 minutes after the injury, cool/clammy, and maybe I'm crazy but I think her cheeks were a little purple whilst we were putting her on a board. Mental status was perfect throughout. GCS15, AOx4. She could describe pain in her jaw and neck, and she could localize. Pain was too great for me to feel, hard to say weather or not it was muscular. No radiation. She could still grossly move all extremities, but when I asked her to squeeze my fingers, she could barely move her fingers. Same thing when I tested dorsi/plantar flexion in the feet.


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## Carlos Danger (Nov 8, 2013)

Quin said:


> Does it help to know that she was probably massively dehydrated / wacky electrolytes? Betcha her K was almost nonexistent.
> 
> Wrestlers try to compete in the lowest weight class possible.
> 
> ...



If her K was "almost nonexistent" then why did symptoms not start until she got kneed in the jaw?


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## Akulahawk (Nov 8, 2013)

Quin said:


> Does it help to know that she was probably massively dehydrated / wacky electrolytes? Betcha her K was almost nonexistent.
> 
> Wrestlers try to compete in the lowest weight class possible.
> 
> ...


Though I'm not a wrestler, I think I'm pretty well versed in what wrestlers do to "make weight." (See my sig. lines.) Catching a knee with a jaw normally doesn't trigger electrolyte abnormality symptoms. It just doesn't happen. 

I have a couple ideas in mind as to what happened... and the scenario you've outlined does not fit the story that we've all read.


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## CFal (Nov 8, 2013)

Quin said:


> Does it help to know that she was probably massively dehydrated / wacky electrolytes? Betcha her K was almost nonexistent.
> 
> Wrestlers try to compete in the lowest weight class possible.
> 
> ...



I did that while wrestling in HS


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## Tigger (Nov 8, 2013)

Connor said:


> @teedubbyaw, The medics that arrived on scene decided to SMR. Would have put her on O2 if they were more than 5-10 mins out.




The medics choosing to use SMR does make their call correct, just by the way.

Also, why the O2? Probably just going to freak her out and does appear to be indicated for respiratory distress.


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## chaz90 (Nov 8, 2013)

Tigger said:


> The medics choosing to use SMR *doesn't* make their call correct, just by the way.



Fixed what I believe was a typo on your part


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## Connor (Nov 8, 2013)

Tigger said:


> The medics choosing to use SMR does make their call correct, just by the way.
> 
> Also, why the O2? Probably just going to freak her out and does appear to be indicated for respiratory distress.



Because her spo2 dropped from 99% to 94% in about 10 mins, and if they were longer than 10 mins away, I don't want it to drop any more. Would have done nasal cannula at 4lpm. If it freaked her out, off it goes. She was pretty calm the whole time and in no type of apparent distress. Also, if it didn't freak her out, why not?

And, I'm not here asking when/where/why to apply SMR. Just wondering what the physiology or psychology of her response could have been.


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## TheLocalMedic (Nov 8, 2013)

Connor said:


> Because her spo2 dropped from 99% to 94% in about 10 mins, and if they were longer than 10 mins away, I don't want it to drop any more. Would have done nasal cannula at 4lpm. If it freaked her out, off it goes. She was pretty calm the whole time and in no type of apparent distress. Also, if it didn't freak her out, why not?
> 
> And, I'm not here asking when/where/why to apply SMR. Just wondering what the physiology or psychology of her response could have been.



Must…  not… begin… SMR or oxygen debate…  again!  :deadhorse:


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## STXmedic (Nov 8, 2013)

TheLocalMedic said:


> Must…  not… begin… SMR or oxygen debate…  again!  :deadhorse:



Seriously? It's just oxygen. We breathe it in all day. Her sats are obviously dropping, so just put the patient on a NRB. It could only help.


/troll face


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## chaz90 (Nov 8, 2013)

Ok, I'll attempt to sum up the responses in this thread so far.

The general consensus from what we've been presented is that it was likely anxiety, it sounds like the OP did a good job of ensuring the patient was cared for, and we've all done an admirable job of keeping our thoughts on SMR and O2 in the background (if just only).


Sound about right?


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## Quin (Nov 9, 2013)

Halothane said:


> If her K was "almost nonexistent" then why did symptoms not start until she got kneed in the jaw?



I'm just a chick on the Internet who wasnt there...

But as an ex-athlete/ex-military... One comes across this all the time. 

Hence armchair theory: 
It wasnt the knee to the jaw.. except that it exacerbated a pre existing condition by adding adrenaline/norepi/etc. triggered by the nocioceptors to a persisting chemical stew... It was the sitting. 

Dehydration +
Depleted lytes +
Adrenaline hangover +
Pain response 
= mild hypoxia, tachy or bradycardia, etc. 

You see it in athletes and soldiers who over extend all the time. 
(And every time... The potassium is on the rocks, even though everything else is messed up, their K is toast. Here. Drink this super grainy, nasty tasting, sludge. You'll feel better! . No one thinks I'm serious. I can't imagine why?). 

In athletes it's just usually in the locker room. Meaning she'd have most likely gone through this in private, later. Pounding Gatorade Recovery, and sitting in a shower. 

Unless its severe (like marathon runners) it usually self resolves. 
Although fluids and lytes are magic wands.


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## Connor (Nov 9, 2013)

Quin said:


> I'm just a chick on the Internet who wasnt there...
> 
> But as an ex-athlete/ex-military... One comes across this all the time.
> 
> ...



That's an awesome explanation, thanks. She had never played any sports prior and this was her first wrestling match, and she was going against someone two years ahead of her. May or may not be relevant?

Where would the tremors and reduced/almost non-existent grip strength come from then? The potassium deficiency messing with the nervous system/motor neurons?

Seems like a bit much for a simple junior high wrestling practice match, but it makes a lot of sense.


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## Aidey (Nov 9, 2013)

Hypokalemia causes muscle weakness.


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## ZombieEMT (Nov 9, 2013)

If I had to take my best education guess (which is little because I am only and EMT) I would suggest anxiety also. Considering the symptoms and situation, thats what it sounds like, but I think you as an EMR did the right thing to contact more education ALS. As for oxygen an SaO2, I was tought it is not always reliable. I also ask, how accurate is the pulse oximeter you are using is. If you are functioning as less than an EMR and on volunteer basis, is it a good one, or a cheap one that just anyone can go purchase at CVS for 30 dollars. I do believe that allowing the patient to go back with her team would have been a better way to fix the anxiety. Even if you were talking to her and making small talk, it might be unvomfortable for her, especially if she does not know you and she/he is a teenager. 

I would love to know if there was something else going on, but I think this situation was over thought.


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## EMT B (Nov 9, 2013)

Connor said:


> That's an awesome explanation, thanks. She had never played any sports prior and this was her first wrestling match, and she was going against someone two years ahead of her. May or may not be relevant?
> 
> Where would the tremors and reduced/almost non-existent grip strength come from then? The potassium deficiency messing with the nervous system/motor neurons?
> 
> Seems like a bit much for a simple junior high wrestling practice match, but it makes a lot of sense.



You need potassium for muscle depolarization.


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## Tigger (Nov 9, 2013)

chaz90 said:


> Fixed what I believe was a typo on your part


Thank you. 

Also, sigh.


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## mycrofft (Nov 9, 2013)

Lack of grip and tremors can also be sheer fear, either acute or delayed reaction.

Quin, roger that. 

OP, I know, "PEARL" (PERL?) but were the pupils narrowed? Reading the comments I'm sort-of reminded of the case I posted about about endorphins.


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## emtdansby (Nov 9, 2013)

I see a lot of people on here saying anxiety over and over. The OP has repeated over and over that she was calm and showed no distress. I would lean toward the low K. I had a patient whose K was so low he was limp like a rag doll, nearly paralyzed.

I would also like to throw this out there, there is a small possibility of a spinal hematoma. Its a small possibility, but the progression of her weakness makes it a possibility. As the swelling progresses, she would slowly lose use of her limbs. Just some food for thought


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## NomadicMedic (Nov 9, 2013)

I'm not a minimizer, but...


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## Akulahawk (Nov 9, 2013)

Connor said:


> That's an awesome explanation, thanks. She had *never played any sports prior and this was her first wrestling match*, and she was going against someone two years ahead of her. May or may not be relevant?
> 
> Where would the tremors and reduced/almost non-existent grip strength come from then? The potassium deficiency messing with the nervous system/motor neurons?
> 
> *Seems like a bit much for a simple junior high wrestling practice match*, but it makes a lot of sense.





EMT B said:


> You need potassium for muscle depolarization.





mycrofft said:


> Lack of grip and tremors can also be sheer fear, either acute or delayed reaction.
> 
> Quin, roger that.
> 
> OP, I know, "PEARL" (PERL?) but were the pupils narrowed? Reading the comments I'm sort-of reminded of the case I posted about about endorphins.


Also had weak push/pull at the feet... 


emtdansby said:


> I see a lot of people on here saying anxiety over and over. The OP has repeated over and over that she was calm and showed no distress. I would lean toward the low K. I had a patient whose K was so low he was limp like a rag doll, nearly paralyzed.
> 
> I would also like to throw this out there, there is a *small possibility of a spinal hematoma*. Its a small possibility, but the progression of her weakness makes it a possibility. As the swelling progresses, she would slowly lose use of her limbs. Just some food for thought


The thing about low K levels is that normally we see a progression of symptoms rather than something coming on acutely, like turning on a switch. That's one reason why I don't suspect an electrolyte problem, or at least not a severe one. Given the MOI, _and _the symptoms, this is what I worry about. I've seen 2 SCI's caused by this same mechanism, only the impact was severe enough that the cord was transected at about the C4-5 level. Given this was Jr High wrestling, I doubt the energy delivered to the jaw was sufficient to do anything more than stretch things a bit, possibly stretching the spinal artery a bit, not enough to cause outright problems, but a small, growing hematoma. 

You'll also have stretched cervical ligaments (essentially a grade 1 sprain) and lots of sore muscles that were forced to lengthen while contracted. This causes that "difficult to determine" if the pain/discomfort is muscular or skeletal, and since nothing is grossly misplaced or fractured, you won't feel any step-offs, and you won't have a significant change in amount of pain if you tap on the vertebrae. 

Having EMS transport the girl to the ED for further evaluation (and specifically to r/o hematoma/SCI) was the best course of action this MFR could have done. 

PS: Yes, I'm aware that MOI is a poor indicator of actual injury. I spout this myself. MOI tells me where to look.


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## teedubbyaw (Nov 10, 2013)

^well said. 


You can have a calm demeanor and still have over reaction of the sympathetic NS.


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## Connor (Nov 10, 2013)

mycrofft said:


> OP, I know, "PEARL" (PERL?) but were the pupils narrowed? Reading the comments I'm sort-of reminded of the case I posted about about endorphins.



About 4-5mm



emtdansby said:


> I see a lot of people on here saying anxiety over and over. The *OP has repeated over and over that she was calm and showed no distress*. I would lean toward the low K. I had a patient whose K was so low he was limp like a rag doll, nearly paralyzed.
> 
> I would also like to throw this out there, there is a small possibility of a spinal hematoma. Its a small possibility, but the progression of her weakness makes it a possibility. As the swelling progresses, she would slowly lose use of her limbs. Just some food for thought



I have stated that several times, thanks for acknowledging. A tiny spinal hematoma makes sense based on the progression of s/s, but damn. Hopefully it's reversible?



Akulahawk said:


> Also had weak push/pull at the feet...
> 
> *The thing about low K levels is that normally we see a progression of symptoms rather than something coming on acutely, like turning on a switch.* That's one reason why I don't suspect an electrolyte problem, or at least not a severe one. Given the MOI, _and _the symptoms, this is what I worry about. I've seen 2 SCI's caused by this same mechanism, only the impact was severe enough that the cord was transected at about the C4-5 level. Given this was Jr High wrestling, I doubt the energy delivered to the jaw was sufficient to do anything more than stretch things a bit, possibly stretching the spinal artery a bit, not enough to cause outright problems, but a small, growing hematoma.



Unless I'm missing something and 15+ mins after impact is like turning on a switch, symptoms were definitely delayed. I'd also be surprised if the impact had enough energy to cause SCI but I didn't see it, and wouldn't that be an instant onset and maybe even posturing? Or is that something totally different.

Also, DEmedic... I find this relevant:
http://en.wikipedia.org/wiki/KISS_principle

I can't help but feed my curiosity h34r:


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