Unusual presentation

ChrisEMTA

Forum Lieutenant
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Hey so had this call that was really a unusual presentation so I am going to give some important information to the case and have some information private for patient confidentiality.

Teenage male CC of jittery feeling

Visual cues:
Tripod position
Obviously involuntary shaking of legs and hands
2-3 word sentences
Holding chest
And some gasping occasionally

Vitals:
HR 130s occasionally spiking to 160s (remains sinus tachycardia)
BP 104/49
O2 89% on RA
RR 36 and irregular breathing patterns
Temp 98.7 BGL 92

SAMPLE:
Heart palps/ involuntary shaking
No allergies
Only med is albeterol for mild occasional asthma
History just asthma and depression (in therapy)
Last oral intake was a few hours prior
Events leading was resting after homework

ECG showed sinus tachycardia (medic interpretation)
IV access obtained
Started some normal saline
Tried to coach him through deep breathing
Started 10lpm NRB
Listened to lungs : clear breath sounds
Listened to heart : murmur present but otherwise normal

Medic gave a medication can't remember exactly what to help calm him down
Patient ended up going semi alert and unresponsive right as we were arriving.

Anyone seen anything like this? Any clue what this was?
 

luke_31

Forum Asst. Chief
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First off you can’t go semi alert and unresponsive. Two different things. Second it sounds like an anxiety attack. Did the patient complain of any numbness or tingling to their extremities?
 

mgr22

Forum Deputy Chief
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The shaking and jittery feeling could have been from multiple self-administered albuterol doses.

Whatever sedative the patient was given could have made him less responsive. Also, who checked the lung sounds? Was it done in a moving ambulance or other noisy setting?
 
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ChrisEMTA

ChrisEMTA

Forum Lieutenant
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First off you can’t go semi alert and unresponsive. Two different things. Second it sounds like an anxiety attack. Did the patient complain of any numbness or tingling to their extremities?
No I meant first went semi alert then fully unresponsive. And no numbness or tingling
 
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ChrisEMTA

ChrisEMTA

Forum Lieutenant
111
10
18
The shaking and jittery feeling could have been from multiple self-administered albuterol doses.

Whatever sedative the patient was given could have made him less responsive. Also, who checked the lung sounds? Was it done in a moving ambulance or other noisy setting?
Lung sounds obtained in his bedroom we had the room quite
 

mgr22

Forum Deputy Chief
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To answer that part I was checking lung sounds while medic was doing a 12lead
I see you're an AEMT. No offense, not looking to assign blame, just wondering if you've had experience assessing asthmatics and can distinguish "clear" but minimal air movement.

The RA SpO2 is concerning. Assuming that number is accurate and not normal for the patient, there seems to be a mismatch between ventilation and perfusion. I'm suspicious of a ventilation problem, given the asthma history, but another possibility is a perfusion problem, such as a PE.
 

akflightmedic

Forum Deputy Chief
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Def spontaneous pneumothorax!! :)

Anyways, I felt like my Delorean malfunctioned because while reading this, it reminded me of a very similar scenario we have discussed here before. I mean very similar, down to the Red Bull in trash. Wish I had time to find it and compare.
 
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ChrisEMTA

ChrisEMTA

Forum Lieutenant
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I see you're an AEMT. No offense, not looking to assign blame, just wondering if you've had experience assessing asthmatics and can distinguish "clear" but minimal air movement.

The RA SpO2 is concerning. Assuming that number is accurate and not normal for the patient, there seems to be a mismatch between ventilation and perfusion. I'm suspicious of a ventilation problem, given the asthma history, but another possibility is a perfusion problem, such as a PE.
No offense taken. I listened right next to the bronchus then under the armpit about 5 intercoastal space heard the same breaths a little louder near bronchus but not much at all.
I think I can distinguish it but I mean I guess I could have misinterpreted what I was hearing.
 
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ChrisEMTA

ChrisEMTA

Forum Lieutenant
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Def spontaneous pneumothorax!! :)

Anyways, I felt like my Delorean malfunctioned because while reading this, it reminded me of a very similar scenario we have discussed here before. I mean very similar, down to the Red Bull in trash. Wish I had time to find it and compare.
I thought this was a possibility until I heard air moving through all my points on the chest.
 

luke_31

Forum Asst. Chief
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No I meant first went semi alert then fully unresponsive. And no numbness or tingling
Ok makes sense. I’ll admit I missed the pulse ox reading so that would definitely have changed what the possible Dx would have been. PE or some other VQ mismatch would make sense
 

akflightmedic

Forum Deputy Chief
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I thought this was a possibility until I heard air moving through all my points on the chest.

I did NOT say tension pneumothorax with diminished or absent breath sounds. If you think breath sounds will be absent during a pneumothorax, then you may want to go back and review this topic.
 

akflightmedic

Forum Deputy Chief
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Just a side tangent, the comment by the poster indicated that pneumo was ruled out due to being able to hear breath sounds. I countered with, breath sounds are indeed possible with a pneumo, whether it be small or early. Am I wrong? My education, experience, and some googling to fact check what I think I know, says I am right. As always, I am open to counter opinion or facts to set me straight.
 

akflightmedic

Forum Deputy Chief
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Redacted
 
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ChrisEMTA

ChrisEMTA

Forum Lieutenant
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I did NOT say tension pneumothorax with diminished or absent breath sounds. If you think breath sounds will be absent during a pneumothorax, then you may want to go back and review this topic.
Okay I am a advance EMT and I still do like learning. Spontaneous meaning no trauma pneumothorax meaning collapsed lung or lung lobe. So I thought that there would be a least a part of the lungs not getting inflated. So yes I did think that it was unlikely with that and that the patient wasn't tall and skinny but rather tall but buff. I haven't in my experience seen any pneumothoraxs that have had clear breath sounds heard all over both sides of the chest. I mean I will definitely research it more and take your experience in a count.
 
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