Verced In Anxiety-Induced Hyperventilation

[RocketMedic]

19 y/o F c/o recurrent hyperventilation x2 days with multiple ER visits (1 discharge after coaching, 1 discharge after sedation). Med Hx of pediatric febrile seizures (stopped at 2 y/o), no current or relevent medical history, not pregnant, medications Xanax (out x 1 week) and depo shot, allergic to PCN. Complaining of severe pain, hyperventilation, SOB, carpopedal spasms of hands and feet, spasms to arms and legs as well, onset while lying in bedroom (same onset multiple times, home heater is off, rest of family is asymptomatic, no index of suspicion for hypoxia or CO poisoning). Initially encountered supine in back seat of car, very anxious, CAOx4, RR30/normal volume/normal effort, SpO2 100%, EtCO2 26 mmHg, P100, BP 130/90. Carpopedal spasms were evident, x30 minutes, pain 10/10. Anyways, I assessed this as anxiety-induced hyperventilation. Seeing as how the whole "NRB at 4L/min" is dangerously close to malpractice and this is a problem caused by hyperoxygenation, I decided on a slightly different course of treatment- 2mg of Verced initially followed up with another 3mg slow push to a total of 5mg to relieve the spasms, along with coaching. Patient's carpopedal spasms rapidly resolved after verced administration, pain was entirely resolved, patient remained CAOx4 throughout the transport (and much calmer!), coached RR to 20/normal, pulse remained around 90, EtCO2 increased to 32 over approximately 20 minutes with complete resolution of symptoms and a transient headache that resolved, O2 sats remained at 98-100%. A few of my coworkers opined that I should have done the low-flow NRB or a paper bag and withheld the verced. I'm pretty sure that I've done right by my patient and stayed within protocol, and I was able to justify it, but I'd like your take on this.

My thoughts: coaching has failed, and although sound, it's not going to relieve the spasms or pain in a realistic amount of time. This patient's follow-on care is going to be anxiety management, which is outside of my scope. For my role, the concern is her pain (caused by muscle spasms), which are being caused by hyperoxygenation and hypocarbia. Increasing the concentration of CO2 in rebreathed air would eventually "help" her by relieving presumed respiratory alkalosis/hypocarbia, but she's still going to hyperventilate and has proven to simply continue to do so with discontinuation of "paper-bag therapy". I learned in school that it's not appropriate to paper-bag our patients, especially those who are in pain, and that pain is likely going to render coaching a futile exercise. Verced (with protocols for sedating an anxious patient) nicely gift-wraps spasm relief and sedation for us, allowing the patient to relax and titrate her CO2 levels back towards normal, relieves pain, and makes her feel better. Thus, it's a better treatment modality than induced hypercarbia until the spasm breaks or "she'll live with it", which are the alternates proposed.

Your thoughts? (I'm still pretty new, and this is the first time I've run across this, trying to do right by my patients).

 

[VFlutter]

Just to clarify...you mean versed, as in Midazolam, correct?

 

[RocketMedic]

Touche, I do indeed. Shows why I should double-check Swype.

 

[Merck]

A couple things. First I probably wouldn't treat this patient but rather she would go with a BLS crew to the hospital. Midaz can be funny sometimes. 5mg in one can be quite different than 5 in another pt. This girl is likely going to be fine.

That said, the paper bag thing is a no-no. The problem is that you are trying to correct her gasses based on a presumption. While it likely is anxiety that isn't always the case. I would say anecdotally that a pt with a psych hx of some sort is more likely to have a possibility of suicide attempt so be sure to rule out other things (ASA OD comes to mind). Also, anxiety is in my opinion a diagnosis of exclusion. So just be careful.

Use you Midaz as you see fit but just my personal idea is that I likely wouldn't. Also, just to be clear, the problem is not caused by hyperoxygenation.

 

[VFlutter]

That said, the paper bag thing is a no-no. The problem is that you are trying to correct her gasses based on a presumption. While it likely is anxiety that isn't always the case. I would say anecdotally that a pt with a psych hx of some sort is more likely to have a possibility of suicide attempt so be sure to rule out other things (ASA OD comes to mind). Also, anxiety is in my opinion a diagnosis of exclusion.

Hypocalcemia is another zebra to consider. Does not neccesarily fit with the hyperventilation but could cause the spasms. What if the spasms happened first causing her to get anxious and hyperventilate?

 

[Doczilla]

Out of xanax for a week, huh? How long was she on it previously? Benzo withdrawal causes anxiety, and if it was the case a "rescue" dose is not unreasonable.

A lot of times they give out "blanket" meds for anxiety, then tapering does not occur due to poor compliance or provider complacency.

 

[RocketMedic]

A couple things. First I probably wouldn't treat this patient but rather she would go with a BLS crew to the hospital. Midaz can be funny sometimes. 5mg in one can be quite different than 5 in another pt. This girl is likely going to be fine.

That said, the paper bag thing is a no-no. The problem is that you are trying to correct her gasses based on a presumption. While it likely is anxiety that isn't always the case. I would say anecdotally that a pt with a psych hx of some sort is more likely to have a possibility of suicide attempt so be sure to rule out other things (ASA OD comes to mind). Also, anxiety is in my opinion a diagnosis of exclusion. So just be careful.
Use you Midaz as you see fit but just my personal idea is that I likely wouldn't. Also, just to be clear, the problem is not caused by hyperoxygenation.

I was thinking somewhat along those lines. ASA OD and chronic hypocalcemica,were both screened for by the last er, and the fathers story didn't point to it either, but it is something I did worry about. Versed for either recurrant anxiety or hypocalcemia,or ASA OD would still be appropriate though?

 

[RocketMedic]

Out of xanax for a week, huh? How long was she on it previously? Benzo withdrawal causes anxiety, and if it was the case a "rescue" dose is not unreasonable.

A lot of times they give out "blanket" meds for anxiety, then tapering does not occur due to poor compliance or provider complacency.

"Since high school" and "sometimes I skip doses when I don't need it, but I haven't needed it lately."

 

[Doczilla]

Case closed in my book. Obviously there would be underlying issues that need figuring out for her, but xanax is handed out like Motrin is in the army. Now she's Benzo dependent (maybe not aware of it) and thus the magnitude of her anxiety attacks are increased.

By the way, go do PT! Its almost six.

 

[RocketMedic]

Im almost out, brother. 4 days left.

 

[bigbaldguy]

Sounds like you did the right thing to me. Anxiety was causing physical symptoms. You removed the symptoms by treating the anxiety (kinda). I wish more providers would understand that anxiety is a very real issue that needs to be addressed. It's no different than pain and should be treated when it's safe to do so. Of course there are a fair number of providers who don't really believe in pain either so there is that.

 

[clearblueskies]

I would have to agree with you here. Versed would by NO MEANS be my first choice here! I would be far more likely to give 1-2 mg of ativan for this if I DID give anything. The neat thing about anxiety induced hyperventilation is that eventually they will blow off all of their CO2, they will get slightly alkalotic and will magically pass out, wake up shortly there after and will no longer be hyperventilating. I normally will try and talk someone down and if that doesn't work I will lay them down and let them fix their problem physiologically! The body does what it needs to fix its self and this is yet another example of it! If they do it a few times I will smoke them with 2 mg of ativan and let them sleep it off at the ER.

 

[RocketMedic]

I understand that they will eventually pass out, but that's still quite a bit of painful, spasmodic suffering. With an SpO2 of 100%, there's no real reason to start oxygen or anything, but an IV line and 2mg of Versed (I don't have Ativan) worked wonders.

 

[RocketMedic]

I would have to agree with you here. Versed would by NO MEANS be my first choice here! I would be far more likely to give 1-2 mg of ativan for this if I DID give anything. The neat thing about anxiety induced hyperventilation is that eventually they will blow off all of their CO2, they will get slightly alkalotic and will magically pass out, wake up shortly there after and will no longer be hyperventilating. I normally will try and talk someone down and if that doesn't work I will lay them down and let them fix their problem physiologically! The body does what it needs to fix its self and this is yet another example of it! If they do it a few times I will smoke them with 2 mg of ativan and let them sleep it off at the ER.

Why not Versed, if I may ask?

 

[clearblueskies]

Why not Versed, if I may ask?

There is a lot of literature that we have been tasked with reviewing at work (stupid accreditation review coming up) combined with personal experience, versed seems to further exacerbate a left shift on the oxyhemoglobin dissociation curve when it is given for the purposes of sedation. This is essentially what you are trying to accomplish when you are giving it for anxiety and the associated hyperventilation. While you are not trying to sedate them back to the stone age, in order for you to get the results you are looking for it often take a bit more then 2.5mg of versed in these cases where someone is really spun up. This is because they are already shifted to the left on the curve and this makes versed slower to react then ativan. The like I said for some reason it exacerbates the shift and causes more problems in the next few hours. Pretty interesting albeit confusing information at times, but I really limit versed use if I can get away with in when I am practicing. I know we may be spoiled, but we carry quite a few things that work better and are safer in my mind, especially in a patient that is already Ph compromised like the severe hyperventilation patient is. If I am going to give anything I try to stick to Ativan.

 

[jwk]

There is a lot of literature that we have been tasked with reviewing at work (stupid accreditation review coming up) combined with personal experience, versed seems to further exacerbate a left shift on the oxyhemoglobin dissociation curve when it is given for the purposes of sedation. This is essentially what you are trying to accomplish when you are giving it for anxiety and the associated hyperventilation. While you are not trying to sedate them back to the stone age, in order for you to get the results you are looking for it often take a bit more then 2.5mg of versed in these cases where someone is really spun up. This is because they are already shifted to the left on the curve and this makes versed slower to react then ativan. The like I said for some reason it exacerbates the shift and causes more problems in the next few hours. Pretty interesting albeit confusing information at times, but I really limit versed use if I can get away with in when I am practicing. I know we may be spoiled, but we carry quite a few things that work better and are safer in my mind, especially in a patient that is already Ph compromised like the severe hyperventilation patient is. If I am going to give anything I try to stick to Ativan.

Huh?

You have a left shift because they're alkalotic from hyperventilation. I'm not sure why you think giving something to sedate the patient and thus slowing down their respiratory rate somehow further shifts the curve to the left. That makes no sense to me, and it makes no sense that since these pharmacologically similar drugs depress respiration, that one would somehow make things worse and the other doesn't. Slowing the respiratory rate, regardless of if it's done with a brown bag or a drug, will bring the curve back to the right as the CO2 rises.

Also - Ativan has a much longer duration of action than Versed. Why use a longer acting drug that's harder to titrate to effect when you have a shorter acting easily titratable drug, which in most cases should be fine for a short-term problem?

 

[VFlutter]

eventually they will blow off all of their CO2, they will get slightly alkalotic and will magically pass out, wake up shortly there after and will no longer be hyperventilating.

Uh say what? Why would you let it get to that point?

 

[RocketMedic]

Uh say what? Why would you let it get to that point?

That was my other functional concern- carpopedal spasms are painful and agitating the patient to the point where coaching was totally ineffective (as evidenced by the ER's failed earlier efforts). It didn't seem right to wait for her to potentially pass out- were I to do that, I'd literally be just a ride.

The other concern I had was that there's no good way to document "brown bag" or "NRB at 3LPM", nor do I have protocols for those. All I have is "general supportive care, oxygen if needed, coaching, consider sedation if patient condition permits."

New Mexico's EMS protocols are fairly disorganized.

 

[clearblueskies]

it has absolutely nothing to do with slowing down of the patients respiratory rate causing the problem here. The problem is biochemical in nature and results from the confirmation change that the versed isomer goes through when introduced into an alcolotic environment. IE. the known alcolosis of a patient who is severly hyperventilating. It can (but does not always) precipitate a further deepening alcolosis by causing a further release of bicarb by the kidneys. This can cause a whole host of problems when trying to reverse it later on, not the least of which is the potassium suddenly becoming artificially low. This reaction doesnt occur with the other benzos. and no one is sure why. It has been detrimental enough that our facility and many i know have protocols against administration of versed to a known alcolotic patient unless there are no other options. It has also been taught to us in the classes im taking for my CRNA license. Ive had three different anastesiologists warn against this in school . One of them actually said it took a week to get his patient turned around in the ICU after giving it. I know i won't chance it after learning about it.

 

[clearblueskies]

You are right the spasms are uncomfortable, but none the less hyperventilation and carpopedal spasms have never killed anyone that I have ever seen in the literature. They will and do go away on their own, just as hyperventilation does. For me giving medication for this is like saying that no woman can possibly safely give birth today without modern medical intervention. What would someone have done previous to versed administration of they started hyperventilating?? If it got bad enough they passed out and the problem stopped. Believe me I'm all about helping people, however the more that I learn in CRNA school about the very same medications that I use every day as a medic, I begin to realize that medics are far more apt to give a drug for something just because they have it. I might not always be the best thing to do by we want to do SOMETHING, even if we really don't understand 100% of the problems that can be associated with a drug. It is really no different then a medic who goes on a call for a benzo overdose that they can prove. The want to do something so they haul out their faithful flumazinil, because "By God I Can Fix This"!! They give the drug and then the patient begins to seize uncontrollably, and it can only be stopped in the ER with Phenobarb. Yeah we fixed the overdose but almost killed the patient with the Romazicon. I have seen this happen with patient who were NOT previous seizure patients, and just OD on their buddies valium or ativan. I'm not telling you that you shouldn't give versed for this, by all means if your protocols provide it then the call is yours. I'm simply telling you what I have learned and now understand about the medication and this situation overall.

That was my other functional concern- carpopedal spasms are painful and agitating the patient to the point where coaching was totally ineffective (as evidenced by the ER's failed earlier efforts). It didn't seem right to wait for her to potentially pass out- were I to do that, I'd literally be just a ride.

The other concern I had was that there's no good way to document "brown bag" or "NRB at 3LPM", nor do I have protocols for those. All I have is "general supportive care, oxygen if needed, coaching, consider sedation if patient condition permits."

New Mexico's EMS protocols are fairly disorganized.