Zodiac
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It's a psychogenic seizure (previously referred to as pseudoseizures but there's nothing false about them). They're brought on by psychological problems...including anxiety.
Panic attack/PTSD/seizures
- Thread starter bigbaldguy
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It's a psychogenic seizure (previously referred to as pseudoseizures but there's nothing false about them). They're brought on by psychological problems...including anxiety.
Zodiac
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***In addition to my previous comment
Psychogenic non-epileptic seizures (previously referred to as pseudoseizures but there's nothing false about them) go a far step beyond a simple anxiety attack. Although they are brought on by psychological problems and have nothing to do with abnormal electrical discharges in the brain, they are just as dangerous, uncontrollable, and unpredictable and they don't always have a trigger. The OP stated that the patient would lose consciousness and seize, rinse and repeat. Assuming that a physiological explanation for these episodes did not exist (history of epilepsy, head trauma, etc.) and given the patient's history of PTSD then the only plausible conclusion that could be made would be that this patient was experiencing psychogenic seizures. To dismiss it as just an anxiety attack would be detrimental as people who with histories of psychogenic seizures have been known to cause motor vehicle accidents and severely sever their tongues/cheeks. For his safety and that of others, transporting for a psychological evaluation would be beneficial so that he could begin receiving proper treatment for his condition and perhaps evade injuring himself.
Psychogenic non-epileptic seizures (previously referred to as pseudoseizures but there's nothing false about them) go a far step beyond a simple anxiety attack. Although they are brought on by psychological problems and have nothing to do with abnormal electrical discharges in the brain, they are just as dangerous, uncontrollable, and unpredictable and they don't always have a trigger. The OP stated that the patient would lose consciousness and seize, rinse and repeat. Assuming that a physiological explanation for these episodes did not exist (history of epilepsy, head trauma, etc.) and given the patient's history of PTSD then the only plausible conclusion that could be made would be that this patient was experiencing psychogenic seizures. To dismiss it as just an anxiety attack would be detrimental as people who with histories of psychogenic seizures have been known to cause motor vehicle accidents and severely sever their tongues/cheeks. For his safety and that of others, transporting for a psychological evaluation would be beneficial so that he could begin receiving proper treatment for his condition and perhaps evade injuring himself.
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Ehhh, I see what your saying...but their presentation is more different than simply listing the symptoms suggest. I've yet to see an anxiety disorder that presented as being truly in extremis. Granted, there's probably a lot of PE's that don't present that way either, but how many of these deteriorate? Some understanding of risk stratification is important as well. I'd be much less concerned about PE in an otherwise healthy 14 year old than a 70 year old with cardiac history being treated for prostate cancer.
At some point these are the type of distinctions EMS is going to have to start making to advance and prove value in the healthcare system.
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mycrofft
Still crazy but elsewhere
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Trevor, of course. Good point
Having seen scores of all sorts of presentations in the field, we "understand". Get it, got it, good?
A "field diagnosis", however, is necessary, unless you are working strictly from a set of protocols which dictate treatment without an idea of the problem and based solely upon field assessment findings...i.e., "cook-booking".
Without some sort of field diagnosis, you either run like heck for the nearest faclity with every call because you cannot make a differenteial to guide you to start any particular treatment, or you start treating everything with the symptoms and signs you have elicited so far... which as you pointed out indirectly would result in a lot of very sick and anxious people being given benzos when they needed oxygen, or t-shirt rebreathing, or rapid tranport and a receiving facility equipped to handle a PE, or a psychiatric admit, or intravenous cardiac meds, or whatever.
I got good at spotting pseudoseizures, but I always had ACLS materials and
O2 on hand and called for suction JIC (just in case). The tough ones were those with a psych component. And just because they are exhibiting a clinically unlikely seizureform activity, doesn't mean there isn't something wrong with them anyway.
Having seen scores of all sorts of presentations in the field, we "understand". Get it, got it, good?
A "field diagnosis", however, is necessary, unless you are working strictly from a set of protocols which dictate treatment without an idea of the problem and based solely upon field assessment findings...i.e., "cook-booking".
Without some sort of field diagnosis, you either run like heck for the nearest faclity with every call because you cannot make a differenteial to guide you to start any particular treatment, or you start treating everything with the symptoms and signs you have elicited so far... which as you pointed out indirectly would result in a lot of very sick and anxious people being given benzos when they needed oxygen, or t-shirt rebreathing, or rapid tranport and a receiving facility equipped to handle a PE, or a psychiatric admit, or intravenous cardiac meds, or whatever.
I got good at spotting pseudoseizures, but I always had ACLS materials and
O2 on hand and called for suction JIC (just in case). The tough ones were those with a psych component. And just because they are exhibiting a clinically unlikely seizureform activity, doesn't mean there isn't something wrong with them anyway.
Absolutely, i just find it absurd that EMS providers THINK we can diagnosis Anxiety.
Aidey
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Do you honestly think that MDs order a d-dimer on every single patient that presents to the ER with anxiety?
Nope, i dont, especially since they have a really, really, REALLY low specificity....
Aidey
Community Leader Emeritus
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Sure it has a low specificity, but it has a high sensitivity, and a negative test is considered conclusive in proving there is no thrombus. So, if you don't think they are running d-dimers on everyone how do you think they are differentiating between anxiety and PE?
by getting a better history then what the OP posted... Look, all Im saying is that you CAN NOT absolutely differentiate this difference between PE/Anxiety everytime prehospitally... Can you sometimes? Sure. But most of the time you need more diagnostics... (d-dimer ,if you want. Spiral CT, etc.) But most of all, education is important. There's a reason Physicians have as much education as they do... They learn about things like the PERC rule (which i would be willing to bet the majority of pre hospital responders dont know about). They have better clinical Gestalt, and that knowledge and skills help guide their decision on whether or not to do something like a ddimer...
And as a side note, high sensitivity doesnt mean that the test points to a certain (*read specific*) diagnosis. In order for a test to be valuable it should have a relatively high specificity as well...
And as a side note, high sensitivity doesnt mean that the test points to a certain (*read specific*) diagnosis. In order for a test to be valuable it should have a relatively high specificity as well...
Agreed - an ideal test is minimally invasive, inexpensive, with no risk to the patient, quick, and has 100% sensitivity and 100% specificity, but that's rarely the way it works.
Usually you end up in a situation where you have to trade sensitivity for specificity. If you want to catch every patient with condition X (100% sensitivity), you end up getting a few false positives (<100% specificity). If you want to be highly specific, you end up becoming less sensitive.
I don't have a source at hand, but I was under the impression that a d-dimer is 90-95% sensitive, and 50% specific for detecting PE.
Perc rule we covered that in a respiratory ed class I took a few years back, quick and to the point and if I'm not mistaken almost 100% correct at diagnosing PE.
Lets see I believe its eight criteria based on age, vitals, history, edema and I believe steroid use, but I'm not positive on that.
Time go find the book.
Lets see I believe its eight criteria based on age, vitals, history, edema and I believe steroid use, but I'm not positive on that.
Time go find the book.
OP
OP
bigbaldguy
Former medic seven years 911 service in houston
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I'm really digging the info you guys are providing on this topic. D dimer and perc are both new to me but I looked them up and applying what I know about patient to these tests says low probability of PE. Just to be clear we transported this patient priority and my ICP was able to stay with patient during initial patient evaluation at ER. We were also given patients paperwork regarding previous medical issues and psych evals at pickup.
Aidey
Community Leader Emeritus
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I understand the difference between sensitivity and specificity, and in the case of the d-dimer I believe the value is because it is accurate at ruling out a PE, not because it can rule in a PE. The test is ~95% accurate by itself, and if a patient has a negative d-dimer along with the absence of other clinical indications of a PE the chance of a patient having a PE gets about as close to zero as it can.
My point still stands that not every patient who goes to the ED with a complaint of anxiety gets a d-dimer, and they most definitely don't get a CT or a pulmonary angiogram. It is also entierly possible for the well educated provider to use and apply the various assessment tools to determine the probability of a PE.
Let me clean this up a little, sorry I was a bit rusty.
If they meet the criteria then they rule out for PE and I believe the percentages are near 100%
Ok, its hormones not steroids.
Aidey,
Youre absolutely correct, thats where clinical Gestalt comes in. The point Im trying to make (albeit, apparently not well) is that EMTs (as a whole, AND AT ALL LEVELS) have a habit of "not knowing what we dont know". WE have a habit of calling something the least dangerous thing it could be without knowing, or evaluating, for the more life threatening things first...
Youre absolutely correct, thats where clinical Gestalt comes in. The point Im trying to make (albeit, apparently not well) is that EMTs (as a whole, AND AT ALL LEVELS) have a habit of "not knowing what we dont know". WE have a habit of calling something the least dangerous thing it could be without knowing, or evaluating, for the more life threatening things first...
Patria O Muerte
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As far as I know, from personal experience, these can be very murky waters. I had an extremely bad anxiety attack last year (in my EMT class!) due to an anxiety disorder that was undiagnosed at the time, and because I wasn't even considering anxiety the medic and EMT who were treating me took my word for it that it was a heart problem. Fortunately, after a few minutes of my pulse jumping around and my breathing going out of control, they realized it could indeed be stress, and started calming me down. That did the trick.
Point is, at least in my experience on the road, we're used to looking at things from a very medical perspective in certain scenarios. Its cases like these that we should take a step back and try to view any psychological problems that may be contributing to it. I know that, as emergency providers, we're used to assessing patients in a humanistic and comforting way, but sometimes tunnel vision occurs, and we have to be sure that we are being rational. Unfortunately these days psychological problems and neuroses are more common than not.
For someone who has never actually personally experienced an anxiety/panic attack, it is very hard to describe. I'd imagine that on the outside looking in it seems like someone is being overdramatic and needs to calm themselves down. But to the person suffering through it, it is one of the most terrorizing feelings in the world. It is like that sinking feeling you get in your stomach when you realize you've done something wrong or have lost something- it's like that but about 10x worse, there is no identifiable cause to it in the moment, and it lasts longer than you can bear it. I implore any providers dealing with a patient in this state to realize how serious of a condition it really is.
Point is, at least in my experience on the road, we're used to looking at things from a very medical perspective in certain scenarios. Its cases like these that we should take a step back and try to view any psychological problems that may be contributing to it. I know that, as emergency providers, we're used to assessing patients in a humanistic and comforting way, but sometimes tunnel vision occurs, and we have to be sure that we are being rational. Unfortunately these days psychological problems and neuroses are more common than not.
For someone who has never actually personally experienced an anxiety/panic attack, it is very hard to describe. I'd imagine that on the outside looking in it seems like someone is being overdramatic and needs to calm themselves down. But to the person suffering through it, it is one of the most terrorizing feelings in the world. It is like that sinking feeling you get in your stomach when you realize you've done something wrong or have lost something- it's like that but about 10x worse, there is no identifiable cause to it in the moment, and it lasts longer than you can bear it. I implore any providers dealing with a patient in this state to realize how serious of a condition it really is.