22 y/o SOB

[LACoGurneyjockey]

You're dispatched for difficulty breathing, and arrive to find a 22 year old female CAOx4, lethargic and slow to respond. She is slumped over in her seat saying she can't breath, with 2-3 word dyspnea and apparent distress. Your patient appears to fall asleep several times in her seat and is easily awoken with verbal stimuli. She states she feels like her shirt is constricting on her chest and has a tightness in her chest.
Vitals: BP 128/90, Sinus tach at 140 on the monitor, Respirations are at 30 and shallow, SPO2 92%. Lungs are clear, pupils are PERRL, skin is warm, dry, and normal in color.
Let me know what else you want.

This can be a really easy one, but it opened up my eyes to look at calls a little differently and I thought it was worth posting.

 

[chaz90]

OD is high on my initial list. EtCO2, medical history, admission of drug use would make it really easy. See if you're able to coax her to take a couple big deep breaths on room air to get the sats up. If she's unable or it doesn't work, let's try some supplemental O2.

History of smoking, birth control usage? Encourage her to stay awake to avoid having to trial Narcan if she becomes less responsive and her breathing slows. When did these problems start, have they ever happened before, and what was she doing before it?

Kinda wondering about the possibility of speedball usage with that heart rate and dilated pupils.

If nothing definitive from the previous assessment findings, get a 12 lead EKG. Monitor respiratory effort and response to titrated O2 administration, start an IV, draw labs, and transport non-emergent to nearest ED.

 

[PotatoMedic]

What was she doing prior to sob? Did she inhale anything? Medical history? Environmental hazards?

 

[DesertMedic66]

Medical history, allergies, Medications, capo waveform and value, 12-lead.

First thing that pops in my head is PE.

 

[STXmedic]

12 lead? EtCO2?

Is she on birth control?

History/meds/allergies.

My initial suspicion is leaning towards PE, but you may change my mind with more info.

Edit: Or exactly what desert said...

 

[DesertMedic66]

12 lead? EtCO2?

Is she on birth control?

History/meds/allergies.

My initial suspicion is leaning towards PE, but you may change my mind with more info.

Edit: Or exactly what desert said...

It's a shame I can't "Like" my own posts hahaha

 

[chaz90]

The lethargy would be a bit surprising for this level of fairly mild sounding hypoxia, but the rest fits pretty darn well with a PE!

 

[STXmedic]

I got you, Desert

Yeah, that's the only thing that was keeping me from being certain, Chaz. Thinking maybe he misremembered the actual initial number. Speedballing isn't on my list because her respirations are too fast, so the depressant wouldn't be causing hypoxia. So she either has something interfering with her hemoglobin, or she has a VQ mismatch, and lungs are clear, so it must be on the perfusion side. That, or her respirations are very shallow and she's not moving any air at all. Possible fracture preventing inspiration? But that wouldn't likely be described as tightness.

 

[LACoGurneyjockey]

Tries but can't take a deep breath, tightness turns into pain when she tries. O2 brings the spo2 up to 97% within a few minutes. I don't have etco2 for you unfortunately.
Started about 30 minutes ago sitting on the couch when she passed out for several minutes, was woken up and began complaining of the difficulty breathing. She's had anxiety attacks and says this feels "kind of the same but different."
12 lead confirms sinus tach.
Only history is anxiety, and she has anxiety attacks once every couple weeks. Meds include xanax, flexeril, birth control, Prozac, and she admits to drinking lightly but does not appear intoxicated. Denies any drug use. No allergies. No pain on palpation or any signs of trauma/fracture.

 

[teedubbyaw]

PE or an extreme anxiety attack. See if we can coach her breathing while we work on getting more info/vitals.

 

[PotatoMedic]

Hyperventilating?

 

[STXmedic]

Numbness/tingling to hands and feet, or carpal pedal spasms? How was she feeling just before passing out? Does she have a history of syncopal episodes? BGL? Was it witnessed? If so, how did the witnesses describe the episode?

 

[STXmedic]

Hyperventilating?

30 and shallow.

 

[LACoGurneyjockey]

She doesn't remember passing out but says her hands were numb when she woke up. No previous syncopals. BGL is 160.
Witness described her sitting on the couch very much awake, then suddenly seeming very tired for 5-10 minutes before "falling asleep".

 

[Clare]

?PE

DDx asthma with silent chest or FBAO (perhaps below the carina)

When you listen to her chest is she actually moving air?

Treatment I can provide would be oxygen at a very high flow rate, much higher than normal (15 lpm) on a non-rebreathing mask +/- "bootleg CPAP" (ensuring a good, tight seal with a bag mask and PEEP of 10 cmH2O).

For those who say this might be drugs - which? We have a very low rate of drug abuse in NZ (and virtually no narcotics or opiate type drugs) so it's something I know little about.

 

[chaz90]

For those who say this might be drugs - which? We have a very low rate of drug abuse in NZ (and virtually no narcotics or opiate type drugs) so it's something I know little about.

Leaning away from that differential now with the inability to take a deep breath, continued pain, and vitals inconsistent with what I would have expected for drug use.

 

[chaz90]

This onset is weird. Suddenly increased drowsiness, syncopal episode, then difficulty breathing when awoken? Not to mention the pain/tightness.

First time absence seizure with anxiety attack after the seizure ended?

 

[STXmedic]

Does she respond to bring coached? And if so, does she still need oxygen to maintain O2 saturations? I agree with Chaz- it's a strange presentation. It seems like something is missing...

Are the number of pills in her bottles appropriate for the amount of time prescribed? Does she admit to attempting to overdose? As a stretch, I'm wondering if she overdosed on her Xanax, was awoken after she started hypoventilating (thus the hypoxia), and then began having an anxiety attack... Definitely a stretch, though.

 

[kal0220]

Maybe an interaction between ETOH and the benzodiazapine. The mixture of Xanax and alcohol can lead to severe anxiety attacks. Drowsiness is a SE of alcohol and the Xanax.

EDIT: The high respiration can be a cause of the anxiety, along with the chest pain. The drowsiness as a result of the drugs interacting.

 

[LACoGurneyjockey]

No empty bottles, no signs of an OD.
As you're running all these possibilities thru your head the patient begins to feel less difficulty breathing, and is in significantly less distress. She states maybe this was just anxiety, and that she doesn't feel she needs to go by ambulance. She is alert and oriented, no longer complaining of anything but a mild sense of shortness of breath.
Are you comfortable having her sign AMA or are you going to push a little further for a transport, and why?