13yof knee to the jaw

[chaz90]

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?

 

[Quin]

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.

 

[Connor]

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.

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.

 

[Aidey]

Hypokalemia causes muscle weakness.

 

[ZombieEMT]

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.

 

[EMT B]

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.

 

[Tigger]

Fixed what I believe was a typo on your part

Thank you.

Also, sigh.

 

[mycrofft]

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.

 

[emtdansby]

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

 

[NomadicMedic]

I'm not a minimizer, but...

 

[Akulahawk]

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.

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...

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.

 

[teedubbyaw]

^well said.


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

 

[Connor]

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

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?

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: