Tough call not sure what was going on.

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systemet

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1- Benzo's to control the agitation SL, or preferably IV.

2 - bG to r/o DKA / HHNC.

3 - Hopefully a 12-lead if benzos have rendered them compliant.

4 - A frank discussion about any drug use.

It could be many different things. Without benzodiazepines your ability to assess this patient is going to be limited. Differentials include hyperventilation syndome / anxiety / psych. issues, toxicology, PE, hyperglycemia, infarct, CVA, etc.

Best guess from available information: psych +/- drugs. But at the same time, while the least serious condition may be the most probable, you have to rule out the less probable but more serious conditions first.
 
Shishkabob

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rhan101277 said:
We don't have protocols for treating anxiety and I am not sure how appropriate it would be, if at all, to ask a physician for such an order. I was really leaning towards a panic attack, I did try a duoneb for the wheezing it didn't help so I stopped treatment. SpO2 was always 98%+.

I realize patients don't always tell the truth, this guy definitely had meth mouth.
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If SpO2 is within good ranges, I see no cyanosis and no real work of breathing besides the tachynpnea, my last thought is "Oh crap I need to control their airway".



Does your system allow benzos for agitation? At our agency, the ground EMS cannot treat 'anxiety' (again, for fear of thinking it's just a panic attack) but we're allowed to treat agitation, using the same dosages.

One of our QA/QI /education guys is fond of saying "EVERYONE is agitated!" if you catch his drift...
 
AlphaButch

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No meds? Aspirin usage? denies drug use - communicative between breaths? nodding? Was he able to slow down his breathing with coaching or just by exhaustion?

Dispatch sent as an AICD w/heart hx. Did he have an AICD? Any actual complaint of chest pain? smothering (lungs or chest)? Pulse rates ok, but how did it feel (weak, bounding,etc)? any BP on scene? Nausea, tremors, twitching or head angulation?

Given the info, I'd veer to overdose/poisoning. Would want to conduct tests to r/o PE or MI induced panic.
 
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rhan101277

rhan101277

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Linuss said:
If SpO2 is within good ranges, I see no cyanosis and no real work of breathing besides the tachynpnea, my last thought is "Oh crap I need to control their airway".



Does your system allow benzos for agitation? At our agency, the ground EMS cannot treat 'anxiety' (again, for fear of thinking it's just a panic attack) but we're allowed to treat agitation, using the same dosages.

One of our QA/QI /education guys is fond of saying "EVERYONE is agitated!" if you catch his drift...
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Well GCS was 9.
 
bigbaldguy

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rhan101277

rhan101277

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I might could have used the behavioral protocol, although it is geared towards uncooperative psych patients. It has 2mg midazolam.
 
epipusher

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If possible, attempt to coach the patient in slowing or controlling their resps. If not, they are going to pass out eventually. Monitor the patient, and enjoy the quiet ride to the ed.
 
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rhan101277

rhan101277

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epipusher said:
If possible, attempt to coach the patient in slowing or controlling their resps. If not, they are going to pass out eventually. Monitor the patient, and enjoy the quiet ride to the ed.
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Yeah I tried coaching, I was aware he would pass out eventually. I was just curious why the ER went with mag sulfate with no positive hx of asthma, maybe they were using it to relax muscles.

Doctors can do shotgun medicine and I cannot.
 
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Handsome Robb

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I was wondering why the mag as well. My thought was maybe trying to correct possible respiratory alkalosis since it has a pH of ~6.0 if it was adjusted? That seems like bringing a gun to a fist fight though especially without ABGs first.
 
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FFEMT427

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Using mag to relax the pt. seems like a poor method. Was the pt. still having a wheeze if so did the hospital start with first line treatments (Nebs ect.). As for the alkaliosis I did a little searching and didnt find mag as a treatment that doesnt mean they were not trying it(Im not being argumentitive just throughing out ideas
 
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Handsome Robb

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I agree with you. It doesn't seem like a common treatment for alkalosis. From what I found some solutions can contain sulfuric acid or sodium hydroxide to adjust pH levels. Haven't been able to find other sources to support this though.
 
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rhan101277

rhan101277

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FFEMT427 said:
Using mag to relax the pt. seems like a poor method. Was the pt. still having a wheeze if so did the hospital start with first line treatments (Nebs ect.). As for the alkaliosis I did a little searching and didnt find mag as a treatment that doesnt mean they were not trying it(Im not being argumentitive just throughing out ideas
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Yeah he was wheezing, they didn't try the nebs and went straight to mag. He was in distress but with no asthma hx, I tried one breathing tx and that was it. I didn't want to try anymore tx because he had no asthma hx and it would just cause more cardiac oxygen demand. They must have thought asthma when I came in but later said it was all in his head. It sounded like he was causing this wheezing from his upper airway alone (you can do it yourself). I verified he wasn't choking.
 
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FFEMT427

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NVRob said:
I agree with you. It doesn't seem like a common treatment for alkalosis. From what I found some solutions can contain sulfuric acid or sodium hydroxide to adjust pH levels. Haven't been able to find other sources to support this though.
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Yeah I found that they use sodium and potasium chloride hydorchloric acid IV (WOW) and dialisis but these treatments are all for severe metabolic alkaliosis which they would want to have labs back before they treated anyway.
I think this is a pretty valid question is the hospital staff of the hospital you went to pretty on the ball when it comes to treatment because just because just because some of the providers in hospital went to higher education than us doesnt mean they learned a d!@# thing
 
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BrushBunny91

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I was informed that the paper bag method was heavily outdated and should never be attempted on account of recent legal action.
 
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systemet

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NVRob said:
I was wondering why the mag as well. My thought was maybe trying to correct possible respiratory alkalosis since it has a pH of ~6.0 if it was adjusted? That seems like bringing a gun to a fist fight though especially without ABGs first.
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* The patient could be hypomagnesemic +/- hypokalemic. Any recent history of prolonged vomiting or diarrhea? However hyperventilation would be unlikely as a compensatory mechanism in this setting, as it produces metabolic alkalosis. Hypomagnesemia is also common in alcoholics, who can also develop ketoacidosis.

* Pure respiratory alkalosis is treated by controlling the minute volume. In the context of hyperventilation syndrome, this is usually by calming the patient +/- sedation. If they derrange their pH too badly, they'll pass out, go apneic for a while, and then start breathing again at a slower rate (If it's psychogenic).

* Outside of psychogenic causes, hyperventilation and respiratory alkalosis is often a compensation for metabolic acidosis. Alphabutch suggeted possible salicylate toxicity. Organic alcohols are another potential factor. A PE can also cause hyperventilation to maintain gas exchange, as part of the surface area for diffusion is potentially lost.

* The paper bag works. It's just not advised in EMS due to fears of litigation. You can't know (even if you can reasonably suspect) that this is some sort of anxiety syndrome. So if you take a patient with a large PE, and given them a paper bag, it might expose you to legal liability.

* I've run labs where we take ETCO2 on conscious volunteers, and get them to rebreath from a plastic bag containing 100% O2. It's impressive to see people get their ETCO2 up to 60 mmHg, and then watch the facial flushing, tachycardia, HTN that result. Hypercapnia is cool. None of the subjects desaturate. If you were to have a patient rebreathing CO2, then any fall in SpO2 should suggest the presence of another underlying pathology.
 
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