22 y/o SOB

[chaz90]

I don't care if she goes by ambulance or POV, but I'd like her to go to the ED for an evaluation. This sudden and dramatic lessening of symptoms leads me more towards a spontaneous resolution of a PE with risk of reoccurence. Either that, or hoofbeats could mean horses and it's an anxiety attack. Still doesn't quite explain the acute onset somnolence and lethargy though.

 

[Underoath87]

Spontaneous pneumo with the lethargy and other symptoms secondary to hypoxia/hypercapnea?

 

[LACoGurneyjockey]

It was a PE, most likely from the birth control that resolved itself.
As the EMT on an ALS truck there's a lot of times where my opinion is irrelevant, and this was one of them. I had PE in my head from early on, but the medic brushed it off as anxiety and BLSd her in. No O2, no IV, no 12 lead.
Just was a frustrating experience and I wanted to see how many others had PE on their mind from early on.

 

[teedubbyaw]

It was a PE, most likely from the birth control that resolved itself.
As the EMT on an ALS truck there's a lot of times where my opinion is irrelevant, and this was one of them. I had PE in my head from early on, but the medic brushed it off as anxiety and BLSd her in. No O2, no IV, no 12 lead.
Just was a frustrating experience and I wanted to see how many others had PE on their mind from early on.

Becoming complacent is a stupid thing to do. I've seen many ill-minded medics assume SOB is automatically anxiety.

If you can't rule it out, assume the worse.

 

[Carlos Danger]

It was a PE, most likely from the birth control that resolved itself.
As the EMT on an ALS truck there's a lot of times where my opinion is irrelevant, and this was one of them. I had PE in my head from early on, but the medic brushed it off as anxiety and BLSd her in. No O2, no IV, no 12 lead.
Just was a frustrating experience and I wanted to see how many others had PE on their mind from early on.

In all honesty, anxiety would have been at the top of my list of differentials given the presentation and history.

PE is always a possibility and would have been been in the back of my mind, but I would have though it unlikely.

I would have preferred she be seen at the ED, but would not have made a big issue of it if she didn't want to.

 

[Handsome Robb]

PE would be up on the list. Does she smoked that'd make it even more suspicious for PE although it seems pretty clear cut.

Kinda a zebra but ASA OD would fit. Tachypneic, tachycardic, lethargy. No N/V or abdominal pain though.

I wouldn't be super stoked AMAing her but I can't force her to go. We'd have a very long conversation about possibilities though.

Remi, why would anxiety be your top differential rather than PE? Not trying to get after you just wondering your thought process. I thought the same thing until I saw the SpO2. That piece of the puzzle doesn't fit anxiety.

 

[DesertMedic66]

My guess (could be completely wrong) is that the PE caused her to become very hypoxic very quickly which caused her to pass out. The PE possibly moved to a different position allowing her saturation to slowly rise a little bit which is when she came to and started to have her C/C until the PE moved once again to a different position or completely out of the lung.

I would like to transport her by ambulance. If she refused I would be on the phone with medical direction and have the doctor talk to her as well. If she still refused then go down all the AMA information, advise her of the risks, and then have her sign out AMA.

 

[Carlos Danger]

Remi, why would anxiety be your top differential rather than PE? Not trying to get after you just wondering your thought process. I thought the same thing until I saw the SpO2. That piece of the puzzle doesn't fit anxiety.

The mental picture I formed when reading the scenario just looked like anxiety to me. Almost any presentation *could be* a PE, but overall that's much less likely than anxiety.
I missed the Sp02 of 92 in the original post.

That said, the top differentials in my head for any complaints involving SOB and/or chest discomfort of any type are cardiac, PE, PTX, a major vascular etiology, GI problems, and anxiety. You just never know; the diagnostic tools we have in the field aren't very good at ruling out any of these problems. So at the end of the day, the best thing to do very often is just take them to the ED.

 

[Rialaigh]

Honestly, if you take away the sinus tach on the monitor this very much sounds like possible short spells of Vtach to me. I have seen multiple young healthy patients with no cardiac history present with "anxiety", weakness, SOB, chest pain, and spells of passing out and dizziness from runs of Vtach that are occur frequently. Always...always something to consider when the patient appears anxious and tachicardiac upon palpating a pulse.

 

[J B]

My guess (could be completely wrong) is that the PE caused her to become very hypoxic very quickly which caused her to pass out. The PE possibly moved to a different position allowing her saturation to slowly rise a little bit which is when she came to and started to have her C/C until the PE moved once again to a different position or completely out of the lung.

I would like to transport her by ambulance. If she refused I would be on the phone with medical direction and have the doctor talk to her as well. If she still refused then go down all the AMA information, advise her of the risks, and then have her sign out AMA.

Agree 100%.

Relevant from wikipedia:

As smaller PE's tend to lodge in more peripheral areas without collateral circulation they are more likely to cause lung infarction and small effusions, both of which are painful, but not hypoxia, dyspnea or hemodynamic instability such as tachycardia. Larger PE's, which tend to lodge more centrally, typically cause dyspnea, hypoxia, hypotension, tachycardia and syncope, but are often painless because there is no lung infarction due to collateral circulation. The classic presentation for PE with pleuritic pain, dyspnea and tachycardia is most likely to be caused by a large embolism that fragments and thus causes both large and small PEs. Thus small PEs are often missed because they cause pleuritic pain alone without any other findings and large PEs are often missed because they are painless and mimic other conditions often causing EKG changes and small rises in troponin and BNP levels.

 

[medicsb]

It was a PE, most likely from the birth control that resolved itself.
As the EMT on an ALS truck there's a lot of times where my opinion is irrelevant, and this was one of them. I had PE in my head from early on, but the medic brushed it off as anxiety and BLSd her in. No O2, no IV, no 12 lead.
Just was a frustrating experience and I wanted to see how many others had PE on their mind from early on.

So... wait. If the PE resolved itself then how do you know it was a PE? What tests would show that you recently had a PE, but do not anymore? How would the body so quickly breakdown a PE that is big enough to be symptomatic when patients on warfarin can take months to break down a PE?

 

[DesertMedic66]

So... wait. If the PE resolved itself then how do you know it was a PE? What tests would show that you recently had a PE, but do not anymore? How would the body so quickly breakdown a PE that is big enough to be symptomatic when patients on warfarin can take months to break down a PE?

Maybe not confirm that there was a PE but give a very high probability. Sudden onset of SOB, low O2 sats, birth control, d dimer blood test, and id imagine other blood tests.

Who said the clot was broken down? The clot may have just moved to another location in the body (generally from smaller to larger vessels).

 

[Handsome Robb]

Maybe not confirm that there was a PE but give a very high probability. Sudden onset of SOB, low O2 sats, birth control, d dimer blood test, and id imagine other blood tests.

Who said the clot was broken down? The clot may have just moved to another location in the body (generally from smaller to larger vessels).

Only problem with the moving to another part of the body theory is PEs are on the PA side and would have to travel through the capillary beds of the alveoli then back out into the circulatory system. If it's big enough to create an obstruction and make the patient symptomatic there's no way it'll make it through those capillary beds.

 

[Ewok Jerky]

So... wait. If the PE resolved itself then how do you know it was a PE?

Because that's what the ED said: slightly elevated d dimer, + risks factors, but a negative scan and resolution of symptoms = GOMER (at least around here anyways)

 

[LACoGurneyjockey]

Because that's what the ED said: slightly elevated d dimer, + risks factors, but a negative scan and resolution of symptoms = GOMER (at least around here anyways)

This

 

[Underoath87]

Only problem with the moving to another part of the body theory is PEs are on the PA side and would have to travel through the capillary beds of the alveoli then back out into the circulatory system. If it's big enough to create an obstruction and make the patient symptomatic there's no way it'll make it through those capillary beds.

Exactly. Capillaries are only wide enough for RBCs to pass through in single file.

 

[Ewok Jerky]

Exactly. Capillaries are only wide enough for RBCs to pass through in single file.

I think the confusion was more about venous clots vs arterial clots. Venous clots tend to originate in deep veins of the leg (or sometimes upper extremity) and when they thrombose they travel through progressively bigger veins, through the right side of the heart and get stuck in the small capillaries of the lungs, ie Pulmonary Embolis.

When a clot forms on the arterial side, lets say in the L atria secondary to AFib, and it gets dislodged it travels through a big artery to a smaller artery and so on until it gets stuck in a capillary bed somewhere, usually a toe or in the brain somewhere ie Stroke or Ischemic Foot.

 

[medicsb]

LACoGUrneyJockey, how do you "know" or were led to believe this was resolved PE (or was Beano on the call with you?).

Again, any clot big enough to cause symptoms is extremely unlikely to just disintegrate (even directly applying TPA to the clot directly does not usually completely dissolve it). If it did occur resolve, I don't know how you would prove it reliably.

 

[Ewok Jerky]

Again, any clot big enough to cause symptoms is extremely unlikely to just disintegrate (even directly applying TPA to the clot directly does not usually completely dissolve it). If it did occur resolve, I don't know how you would prove it reliably.

I wasn't there, just playing devil's advocate. The role of the ED is not to provide a diffinitive Dx but rather to exclude life threatening ones.

As for clots disintegrating...what about TIAs?

 

[LACoGurneyjockey]

LACoGUrneyJockey, how do you "know" or were led to believe this was resolved PE (or was Beano on the call with you?).

Again, any clot big enough to cause symptoms is extremely unlikely to just disintegrate (even directly applying TPA to the clot directly does not usually completely dissolve it). If it did occur resolve, I don't know how you would prove it reliably.

Me and beano are permanent partners, don't ever doubt it.
I don't have a CT machine in my truck, but I have an ED that I tend to trust.
Presentation, risk factors, an elevated d dimer test all point towards a PE. Do I have the clot on a tray in my bedroom, no, do I believe the ED when their diagnosis confirms my initial suspicion, yes.