13yof knee to the jaw

Connor

Connor

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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?
 
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...
 
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...
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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.
 
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.
 
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.
 
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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Anxiety.
 
Halothane said:
Anxiety.
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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.
 
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.
 
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.

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

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.
Click to expand...

Highly doubtful, especially considering the age.
 
@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.
 
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.

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.
Click to expand...

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

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 high school & college wrestling some of the shadier coaches keep banana bags in the locker room for after match.
Click to expand...
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.
 
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.

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.
Click to expand...

I did that while wrestling in HS
 
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.
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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.
 
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.
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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. :)
 
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. :)
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Must… not… begin… SMR or oxygen debate… again! :deadhorse:
 
TheLocalMedic said:
Must… not… begin… SMR or oxygen debate… again! :deadhorse:
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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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