Uncontrollable Cramps - First Call - What's up?

[IvanD]

Hey guys,

I'm a freshman in a lib arts college and have just started working as a first responder for club sports. I'm a trained WFR and have been on the job for less than a month.

Today our school had a frisbee conference for which my partner and I had to be on call all day (my partner couldn't be reached, he's a EMT-B, so I responded alone). So I got a call late afternoon, was told that they had a guy "going in shock". It's also worth noting that it's 40 degrees outside today.

I booked it and got there 5 mins later, someone there thought he was going into shock and laid him down, raised his legs and wrapped him up with lots of blankets and jackets. Security got there (our security aren't trained medically) and called the medics in.

Since he was lying there all wrapped up already, I started with taking a history and vitals. His HR was 92, skin was relatively P/C/C never got around to others. But the history taking revealed that he had no allergies, took a vicodin, no past history of illnesses (though before I arrived, he told others he took a vicodin for a broken clavicle, but when I asked he said he hasn't broken anything for 4 years), also found out that for food he's only had a bagel and a banana since 8:30am and also claimed to have had a sip of alcohol, he's also been pushing gatorade pretty regularly all day.

Patient's chief complaint was uncontrollable cramping, legs, chest, arms. I was told that the cramps got better as he lied there. But when the medics tried sitting him up he had major cramps in his quads and hamstrings. He also complained of difficulty breathing at times. He was shaking through the entire time.

In the end the medics took him into the truck.

So my question is, what's up?

With my limited knowledge, I am suspecting hypoglycemia which caused all the symptoms like cramping, I'm thinking that the difficulty breathing was caused by chest cramps? Can someone speculate what happened?

Also something I wanna note, a medic and another women (I couldn't see her credentials, she had no patches) arrived on scene and when I handed her my history that I took, she dismissed it pretty quick. Was it because she didn't trust some college kid's history taking? But the paramedic seemed much more willing to listen to me and I managed to tell him that the patient consumed alcohol and popped a pill earlier. He seemed appreciative.

Just something to note, but how would you guys diagnose this patient? Also is there anything I did wrong/what could I have done better?

Thanks guys! Sorry for the mad long post.

 

[MrBrown]

Hypoglycaemia is something that only diabetics get. If you are a non diabetic you will never become clinically hypoglycaemic enough to the point where it is symptomatic from not eating alone.

Brown is wondering how much gatoraid this bloke chugged down, it is relatively heavy in electrolytes so Brown cannot help but wonder if its an imbalance of calcium or magnesium. Now Brown is the first to say that is unlikely.

"Cramping" means different things to different people, when Brown got cramp in Browns leg the other night Brown was moving round in 6/10 pain saying foul words, or it could have meant some discomfort or heat tinglies to this guy. True skeletal muscle cramp is caused by lack of cellular ATP within the myosin so basically somebody has been in a position which allows for the muscle cells to become hypoxic.

There is also a very high chance this is thermoregulatory.

From the way you describe it this guy was what we could call minor and stable, it could be 200 different things.

Patches mean nothing, this lady could have been a Consultant Physician for all you know. Any good clinical professional will re-check and ask the same questions that you just did, it mitigates clinical risk and its nothing personal against you.

 

[IvanD]

I was also curious to what the paramedics will then do to figure out what's wrong? Since they loaded him into the truck and didn't seem like they were going anywhere for awhile.

 

[MrBrown]

I was also curious to what the paramedics will then do to figure out what's wrong? Since they loaded him into the truck and didn't seem like they were going anywhere for awhile.

Brown would have a look at this blokes ECG, do a BGL, ask some more questions about his "cramps" and assoc symptoms e.g. vomiting, diarrhoea, pain, take a temperature, do an abdo exam... differential is hypoglycaemia (just because he says no I am not diabetic doesn't mean jack), a massive MI, gastroenteritis/abdo or heat related illness.

There is a careful balance between "diagnosis" and "management" in the context of ambulance praxis. While Brown is a huge proponent of thorough assessment and diagnoses, it is sometimes impossible for Ambulance Officers to make a confident diagnosis so fall back on treating symptoms as they present. This is not an excuse for useless loser cookbook ambo's to feel comfortable being technicians.

If this bloke presented to Brown like this and lacking any significant symptoms, we would not transport him.

 

[IvanD]

Ooh, he also told someone that he's had an abnormal heart rhythm since he was a child and he didn't know anymore about that.

 

[emsstudent4life]

I was also curious to what the paramedics will then do to figure out what's wrong? Since they loaded him into the truck and didn't seem like they were going anywhere for awhile.

Detailed Focus physical

 

[LucidResq]

Ooh, he also told someone that he's had an abnormal heart rhythm since he was a child and he didn't know anymore about that.

Definitely something worth investigating, as Brown mentions getting that EKG. However, I wonder if he was really referring to an innocent heart murmur in this case.

 

[Aidey]

Hypoglycaemia is something that only diabetics get. If you are a non diabetic you will never become clinically hypoglycaemic enough to the point where it is symptomatic from not eating alone.

Say what? There are plenty of people who become hypoglycemic for other reasons.

 

[medic417]

And lets not forget vicodin. Possible reaction/interaction.

 

[Bullets]

despite the weather, I would take his relative lack of nutritional intake into serious consideration. he's neb outside running around sweating for some time on a banana and a bagel, which while they provide some potassium and carbohydrates, not the level a person engaged in athletics needs. muscle cramps could be due to mineral imbalance. gatorade had some electrolytes, but its mostly sugar which is crap for your body. kids just needs to be bettet at eating the right way during games

 

[medichopeful]

despite the weather, I would take his relative lack of nutritional intake into serious consideration. he's neb outside running around sweating for some time on a banana and a bagel, which while they provide some potassium and carbohydrates, not the level a person engaged in athletics needs. muscle cramps could be due to mineral imbalance. gatorade had some electrolytes, but its mostly sugar which is crap for your body. kids just needs to be bettet at eating the right way during games

Agreed. My first thought on a quick read through was hypocalcemia, but I could be wrong!

 

[Outbac1]

I few things I'd like to know. How much Gatorade did he drink? How often did he urinate? If he was working hard in 40 degree heat I bet he lost a lot of water through sweating. If he wasn't urinating frequently he probably had a water/ sodium imbalance. He probably took in more sodium than he expelled as Gatorade is very high in sodium. That coupled with a high water loss could result in hypernatremia. That could easily cause the muscle cramps.
Fluids are in order as are labs to determine electolyte levels which will then guide which fluids.

 

[Aidey]

Unless gatorade is forumlated differently in Canada it doesn't hav THAT much sodium, especially considering the average American's diet.

 

[IvanD]

Just to clear up sorry, this was in Minnesota so 40 degrees would be in F

 

[Akulahawk]

The Gatorade you buy on the supermarket shelf is too concentrated. When you get the packet that you mix with 5 gallons of water, you get the proper dilution... and it tastes MUCH weaker. Properly done, Gatorade will be absorbed as fast as water is. While that guy had been taking Gatorade in all day, he's not had much in the way of actual food. He's been running around all day. He's probably used most of his stores of muscular glycogen and is dependent upon metabolism of fatty acids and whatever other carbs can be transported to his muscles for them to metabolize. In other words, he ran out of gas and his muscles are letting him know it. There's also a chance that he was suffering from an electrolyte imbalance... but I'd be thinking there'd be other symptoms too.

 

[Outbac1]

According to the gatorade site
http://www.gatorade.com/default.aspx#product?s=gatorade-g
there is 110mg sodium/240ml or about 450mg/liter. A person guzzeling 3 liters will max out their daily recommended intake. Since that is a "Daily" intake a person drinking alot in say 3 hours is going to overload on sodium. That with a water deficit equals what I said.

Recommended sodium intake

The Institute of Medicine (IOM)1 recommends the following “adequate intakes,” or AIs, per day:
1,000 milligrams (mg) for children aged 1 to 3
1,200 mg for children aged 4 to 8
1,500 mg for people aged 9 to 50
1,300 mg for adults aged 51 to 70
1,200 mg for seniors over 70 years of age.

The IOM has also established a “tolerable upper intake level,” or UL (see Definitions and Limitations), which ranges from 1,500 mg to 2,200 mg of sodium per day for children and adolescents aged 1 to 13, up to 2,300 mg per day for people aged 14 or older. Consumption exceeding these limits increases the risks of adverse health effects, especially those linked to hypertension.1
http://www.statcan.gc.ca/pub/82-003-x/2006004/article/sodium/4148995-eng.htm

I probably should have picked up on the 40F. I guess thats what I get for posting late at night when I'm tired.

 

[Shishkabob]

My first thought was cramps caused by improper hydrations / nutrition.


Reason why the ambulance stayed for a while was probably to start an IV and get some NS or LR in to see if it helped relieve the cramps.


Just because it's 40* doesn't mean you can't have heat cramps / other heat related illnesses.

 

[18G]

Say what? There are plenty of people who become hypoglycemic for other reasons.

While it is possible to become hypoglycemic for other reasons, it is extremely rare for a person to experience hypoglycemia outside the presence of diabetes.

In a non-diabetic person in a normal health state, the counter regulatory hormones maintain glucose level within a normal physiological limit.

Of course non-diabetics with say a pancreatic mass could become hypoglycemic but again, it's extremely rare.

Most non-diabetic people who have issues with blood glucose levels are HYPERglycemic as a result of the stress response during illness or injury.

I agree it sounds like an electrolyte issue given the HPI. Muscle cramping is the muscles way of saying slow down and replenish me with electrolytes lost through excessive sweating and metabolism.

 

[Shishkabob]

One quick correction:


Difference between hypoglycemia and clinical/ symptomatic hypoglycemia.

 

[EMTMama]

Say what? There are plenty of people who become hypoglycemic for other reasons.

I was getting ready to say the same thing. I'm not diabetic and I've had trouble with hypoglycemia for years (A1C is always normal).