9 y/o M Diff Breathing and Chest Pain

[LACoGurneyjockey]

Beauty, dude. Excellent, especially the deal of matching palpable pulse to pulse-ox!. The gum thing was a zebra I saw once, only the right bronchus, of course.

Wheeze is auscible high pitched noise on EXhalation; not heard nearly as well on inhalation, if at all. Exhalatory effort increased markedly. You can mimic it by exhaling all your air forcefully, then continue forcing; that last squeaking rasp is a forced end-expiratory wheeze. Do that one sitting down.
h34r:

Stridor: trouble INhaling. Can also be troubling on exhalation, but since air isn't getting in, effort and noise are more on inhalation. You can mimic it by constricting your throat as you inhale, as most actors do on training films for "wheezing".

Now you're making me think, may very well have been stridor, if I remember correctly he had high pitched noise on inhale and exhale, but I can't say for sure. He did seem to have more trouble getting air IN than out. I want to believe ALS would have recognized the difference (they said wheezing) but that's just the world I want to live in...
But that said, what difference in treatment or possible causes would early recognition of wheezing or stridor make?

 

[mycrofft]

Wheeze=constriction of bronchioles on down possibly without significant fluid involvement if rales/rhonchii are not heard. Suspect asthma, anaphylaxis. Treat with meds and O2.
Stridor= embarassment of airway probably from the oropharynx to the bronchus, although a small blocker can wedge in the broncus, usually the right. Suspect foreign object or soft tissue. Address pen (especially when lung sounds stop).
(SNORE: above larynx, usually soft tissue).

After a short while, they can be harder to tell apart. Oxygen, pt position/airway, hospital tout suite.

 

[Jambi]

Mycroft already mentioned it, but I don't want the thread to go on without saying I think you did well, and as well as you could have done. I can also understand the vacuum of frustration caused by the big disconnect between you and the 911 ALS response. It a bummer not having follow up.

Keep up the strong assessment skills!

 

[Akulahawk]

Maybe I'm not painting a clear enough picture, but when I first arrived it looked like heat exhaustion, maybe exercise induced asthma, but as soon as I sat him down, started the cannula, and coached him on slow deep breaths his wheezing subsided and he was sitting comfortably without distress. I only gave O2 to calm him down, not to treat such mild hypoxia.

Chances are pretty good that he was experiencing heat distress. However that usually doesn't present with any abnormal lung sounds. The wheezing should be a clue that something else is going on. Late in exercise, his lungs should be well bronchodilated, not constricted. In other words he shouldn't be wheezing. I'm prone to EIA. Mine's mild, but even in the more severe cases that require a neb to get the athlete through, the lungs will eventually dilate because that's part of the body's natural response to exercise stress. Incidentally, albuterol is considered a performance enhancing drug, so be careful about using it on athletes in certain sports. If that athlete isn't going to be competing any more that day, it's probably OK... of course by then, you're likely considering sending that athlete to the ED.

 

[LACoGurneyjockey]

Yeah its times like this that remind me I need to go to paramedic school sooner than later. My stand by company seems to do a good job of following up with the receiving facility for liability and just curiosity, so if/when I hear anymore ill be sure to update.
Mycroft, jambi, I appreciate the encouragement.

 

[Akulahawk]

Yeah its times like this that remind me I need to go to paramedic school sooner than later. My stand by company seems to do a good job of following up with the receiving facility for liability and just curiosity, so if/when I hear anymore ill be sure to update.
Mycroft, jambi, I appreciate the encouragement.

Before you go to Medic school, take a college level A&P course, the full-bore thing, not a survey course that covers the body in 1 semester. This is at the minimum. Check your local colleges for what prerequisites they require for nursing school and take those courses. It's not that I necessarily want you to become a nurse, rather I want you to have as solid a science foundation as they have. Then go to Medic School. You'll find it a whole lot easier to manage after that.

 

[LACoGurneyjockey]

I totally agree, A&P, EKG, pharmacology, PHTLS, and anything else I can find that is even slightly relevant. I want to be as prepared as possible.
That said, I'm really tired of "high flow O2 and position of comfort, call ALS".

 

[morbusstrangularis]

I totally agree, A&P, EKG, pharmacology, PHTLS, and anything else I can find that is even slightly relevant. I want to be as prepared as possible.
That said, I'm really tired of "high flow O2 and position of comfort, call ALS".

Good to hear you're taking the foundation seriously! In most medic schools the foundation isn't well taught or emphasized. If I were you, though, I'd stay away from any course that's algorithm based. Never taken PHTLS, so if I'm wrong, could someone please correct me, but that sounds a lot like ACLS or ATLS - emphasis of blind algorithms and cookbook medicine over understanding of underlying pathophysiology and mechanism of action for treatments. Best of luck to you!

 

[Akulahawk]

Good to hear you're taking the foundation seriously! In most medic schools the foundation isn't well taught or emphasized. If I were you, though, I'd stay away from any course that's algorithm based. Never taken PHTLS, so if I'm wrong, could someone please correct me, but that sounds a lot like ACLS or ATLS - emphasis of blind algorithms and cookbook medicine over understanding of underlying pathophysiology and mechanism of action for treatments. Best of luck to you!

PHTLS takes its cues from ATLS. That being said, I found ITLS (BTLS) to be more algorithm-oriented than PHTLS... at least when I last took BTLS, as it was titled then. Unfortunately, a lot of organizations won't accept a statement from you to the effect that you know how to treat ACS, strokes, and trauma because you've studied the material in-depth. The certificates just verify that you've been presented with, and tested on, some specified level of knowledge. Get the cert, get the job because it requires the cert, and go on to actually study the material and become an expert at it.

 

[morbusstrangularis]

PHTLS takes its cues from ATLS. That being said, I found ITLS (BTLS) to be more algorithm-oriented than PHTLS... at least when I last took BTLS, as it was titled then. Unfortunately, a lot of organizations won't accept a statement from you to the effect that you know how to treat ACS, strokes, and trauma because you've studied the material in-depth. The certificates just verify that you've been presented with, and tested on, some specified level of knowledge. Get the cert, get the job because it requires the cert, and go on to actually study the material and become an expert at it.

Agreed, my feelings on ACLS as well. My point to the OP was more of not focusing on or taking those courses until you understand the reasoning behind the treatments outlined. My feeling is you will get more out of the class if you already have a working (or better) knowledge of the foundational material.

 

[mycrofft]

And why not aim for RN? You can be an RN for life, but most techs (EMT or paramedic) leave due to low pay, injury or damage to personal life.


I'm not against algorithms, just know why they exist. The biggest reason is that it makes teaching easier, but don'tr tell any teachers I said that.h34r:

 

[Wheel]

And why not aim for RN? You can be an RN for life, but most techs (EMT or paramedic) leave due to low pay, injury or damage to personal life.

This isn't true everywhere. If you're passionate about EMS and are willing to move, it's not impossible to find a job that will allow you to use critical thinking and pay you well. Yes, some leave due to injury, but I'm pretty sure with the power stretcher and decent stair chair that there are RNs that lift as much or more than I do in a 12 hour shift.

Being a nurse is a good, respectable career, but it's not for everyone. I for one would love to see motivated individuals stay with EMS and move into education, supervision, lobbying, etc, similar to the progression that nursing has taken throughout the years.

 

[LACoGurneyjockey]

I know its been a while but I thought I'd post a follow up since I've got some new information. Two weeks after this first incident, someone else at the same company had the same kid, same symptoms at another soccer event. After two trips to trips to the ER finally diagnosed as exercise induced asthma. Anticlimactic at best...