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Anxiety

29 posts in this topic

Posted · Report post

You are working on a dual paramedic truck when you are dispatched to a patient complaining of anxiety. You are about 15 miles out from the nearest hospital in a suburban/semi-rural part of your response area.

When you arrive on scene you are led inside a large, newer house to the living room where you find your patient, an approximately 35 year old man sitting on the couch appearing to be in moderate distress.

Go.

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Posted · Report post

Who called 911? If someone else did, are they present?

How long ago did he/they call 911? Any distress before that?

Pain level?

Ability to breathe? Breath sounds?

Any allergies? Specifically, food ones?

Is he hot/cold? Pale, sweaty, clammy?

Is he in shape?

Any clues that you can see?

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Posted · Report post

Who called 911? If someone else did, are they present?

Family called for the patient.

How long ago did he/they call 911? Any distress before that?

About thirty seconds before you were dispatched. They've been feeling shitty for the last fifteen minutes.

Pain level?

10/10.

Ability to breathe? Breath sounds?

Patient reports shortness of breath, lung sounds are clear bilaterally.

Any allergies? Specifically, food ones?

Penicillin.

Is he hot/cold? Pale, sweaty, clammy?

A little cool, pale, clammy.

Is he in shape?

Looks to be on the thin side. 140lbs, 5'10".

Any clues that you can see?

Nothing that stands out.

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Posted · Report post

I ask this with the utmost seriousness. How does the wife look? Describe her and her interaction with the hubby...

Ok, maybe not the utmost seriousness, but I still ask it as a valid question.

Otherwise,

Vitals with temp

EKG

Medical history

Medicines

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Posted (edited) · Report post

I ask this with the utmost seriousness. How does the wife look? Describe her and her interaction with the hubby...

Ok, maybe not the utmost seriousness, but I still ask it as a valid question.

Otherwise,

Haha... wife looks normal. Not an obvious druggie or alcoholic, looks genuinely concerned, all of that good stuff. These folks are obviously upper middle-class.

Vitals with temp

HR: 280

BP: 138/88

RR: 20 non-labored

BGL: 78

Temp: 98.5

EKG

11ay9s4.jpg

Medical history

ADHD, anxiety.

Medicines

Xanax, Adderall.

Edited by Bieber
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Posted · Report post

pain level 10/10.........where?

PQRST?

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Posted (edited) · Report post

Sweet !

Damn fast.

12 lead?

When has he taken his medicines, how many?

Any drug use?

What was he doing at the onset of symptoms?

Surprise butt sex? Are you sure about that wife?

Any similar symptoms (maybe less severity) in recent days?

Recent illness?

Any recent symptoms he may have though as innocuous?

Edited by Mateo_1387
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Posted · Report post

No hx of SVT?

Has this ever happened before? If so, how was it relieved?

10/10 pain where, describe pain, did pain start suddenly, did it start at the same time he started feeling his anxiety?

Do his anxiety attacks usually present this way, how does he relieve them when they occure?

Any drug use, alcohol? What were they doing when it started? Any signs if dehydration?

If no to drugs or physical activity or dehydration: O2 if indicated (what are his sats?), vagal, adenosine 6mg, 12mg.

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Posted · Report post

pain level 10/10.........where?

PQRST?

In her chest.

P - No worsening on palpation, hasn't moved from her seat since it started.

Q - Like an elephant is sitting on her chest and a swarm of bees is flying around inside as well.

R - None.

S - 10/10

T - Constant and worsening for the last fifteen minutes.

12 lead?

Shows a narrow complex tachycardia rate of 180 with normal axis deviation and no ST-elevation/depression, T-wave inversion or other conduction abnormalities.

When has he taken his medicines, how many?

Took his Xanax about an hour ago, usual dose.

Any drug use?

None!

Surprise butt sex?

None... so far!

Are you sure about that wife?

Pretty sure. =)

What was he doing at the onset of symptoms?

Watching TV.

Any similar symptoms (maybe less severity) in recent days?

No attacks for about the last week or so, but he states that his panic attacks have been getting worse over the last 3-4 months.

Recent illness?

Nada.

Any recent symptoms he may have though as innocuous?

Worsened panic attacks over the last few months, but none as bad as today. The wife insisted on calling today because she noticed a vessel in his neck "pounding".

No hx of SVT?

Nope!

Has this ever happened before? If so, how was it relieved?

Yes. Relieved with time.

10/10 pain where, describe pain, did pain start suddenly, did it start at the same time he started feeling his anxiety?

Chest, yes, yes.

Do his anxiety attacks usually present this way, how does he relieve them when they occure?

Yes but not as severe though worsening over the last few months.

Any drug use, alcohol? What were they doing when it started? Any signs if dehydration?

Mucous membranes are pretty dry. No alcohol. Sitting watching TV.

If no to drugs or physical activity or dehydration: O2 if indicated (what are his sats?), vagal, adenosine 6mg, 12mg.

SpO2 is 98% on room air.

What do you guys wanna do? What are we thinking so far?

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Posted · Report post

250ml fluid challenge see if there's any change.

One post you said hr of 280, an other 180, and you keep switching between a him and a her, is it a transsexual who's having an anxiety attack because there are strangers around? :P

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Posted · Report post

250ml fluid challenge see if there's any change.

One post you said hr of 280, an other 180, and you keep switching between a him and a her, is it a transsexual who's having an anxiety attack because there are strangers around? :P

I did? My bad, rate's 280.

You got your IV, you're pumpin' fluid in. Waiting for that to go. =)

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Posted · Report post

At 280, I'm thinking less dehydration more SVT. Keep the 250 running anyways and try vagal manuver.

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Posted · Report post

Vagal maneuvers and fluid fail!

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Posted (edited) · Report post

pads/ electrodes.....DC shock for sync. cardio version...dont stuff around people..........

1st at 100j

2nd at 150j

3rd at 200j

unsuccessful then Amiodarone

50mg (1ml) IV undiluted bolus

repeat every 3 minutes whilst indication persist

Max dose; 300mg (6ml)

if that fails....urgent transport

Edited by craig
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Posted · Report post

I would give adenosine a try before shocking. Less invasive. He's awake/alert.

6mg/12mg

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Posted · Report post

I would definetely give Adenosine before attempting to cardiovert.

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Posted · Report post

Before we do anything, what rhythm are we calling it? And explain your interpretation if you would.

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Posted · Report post

Narrow complex tachy, regular rhythm, see some P waves in leads II and III, no delta waves. I'm calling it a SVT.

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Posted · Report post

Chest pain, Diaphoretic....

I'll go with 100 Fentanyl, 2.4 Midazolam and then cardiovert

If that dosent work we can try 12 of Adenosine.

If all else fails Amiodarone 150mg in 50ml minibag ran over 5min.

I do not support wasting time trying fluids of excessive vagals with that high of a heart rate, and chestpain WITH cardiac symptoms (nausea, clammy, sweaty).

Basically give them a 5ml syringe and ask them to blow the plunger out of it, if they don't slow thier rate they require further treatment.

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Posted · Report post

My fluid idea was based off the 180 hr. I agree, 280 is nothing to mess around with.

I'm curious why cardiovert before drugs? He's maintaining a pressure. It's a dual paramedic crew, one could administer drugs while the other preps for cardiovert in case the drugs don't work.

I've never seen cardioversion done at that high a rate, wouldn't it be difficult to sync? And aren't you risking a more lethal rhythm? I know if it needs to be done it needs to be done but wouldn't it be more prudent to try the drugs first?

I'm sorry if these are stupid questions, it's the way I understand this, if I'm wrong, please correct me.

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Posted · Report post

Narrow complex tachy, regular rhythm, see some P waves in leads II and III, no delta waves. I'm calling it a SVT.

good eye sight.....280 HR on ecg and you can pick out P waves....impressed

narrow, tachy, regular..........SVT..........no need for P waves on that....

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Posted (edited) · Report post

good eye sight.....280 HR on ecg and you can pick out P waves....impressed

I smell sarcasm

What the hell was I thinking. Sorry for being stupid.

Edited by Curiosity
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Posted · Report post

This is really fast for a 35 year old. I'm surprised that it's narrow and there's not some sort of rate-dependent bundle-branch block. I'd also be suspicious of any illicit drug use, or the presence of a concealed accessory pathway -- otherwise this guy's got an impressive AV node.

I think I'd get the 12-lead first if he's "stable"-ish. although the information provided didn't give us much.

Differentials:

AVNT, AVRT, atrial tach, a.fib,

I see where craig's coming from the cardioversion, and it's not a bad idea --- this is scenarioland, I bet the guy has WPW -- , but I think I'd go the vagals/adenosine (12mg) route, and see what we see. If he decompensates we can re-evaluate cardioversion,

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Posted (edited) · Report post

Hello,

I agree that he is stable-ish as well.

He has an anxiety disorder. I has been worse over the pat 3-4 months. These worsening episodes of anxiety could be cardiac in nature (as suggested by numerous posters) or their could be some other internal medicine type cause such as hyperthyroidism. It is hard to say.

This is my weak point. But, I though WPW had a shortened PR intervial? We can not see the PRI due to the rate. But, if we change the EKG speed we may be able to see if their is a P wave. I have seen Cardiology do this trick before.

I would load him on the cot, connect the monitor and get a line going. Give him some Ativan SL or IV and get the Adenosine ready.

Cheers

Edited by DartmouthDave
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Posted · Report post

It doesn't look like WPW to me. There is no slurring on the upstroke of the R wave.

Here's an example:

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