medicv83 Posted October 7, 2009 Share Posted October 7, 2009 Greetings all. Haven't posted in a while, but I have a question that could be debated. Sounds very simple and basic, however I was "yelled" at by a triage nurse yesterday, and it baffled me slightly as to her statement..... Let me run the scenario through first. Pulled up on scene of a 24 y/o male pt found sitting upright on the porch steps, in care of the local FD. Pt is conscious and alert, however unable to identify to what level his alertness actually was at the time. This individual was noted to be breathing at appx 40x/min. Very shallow. Lungs were clear to auscultation in the apices of the lungs anteriorly and posteriorly, and diminished in the bilateral bases. We immediately placed the pt on the pulse ox and it showed o2 sats of 89% room air. I was crouched in front of the pt, attempting to calm his respirations by requesting that he look at me and breath with me and normally. The pt family member stated that he walked outside after an argument and began breathing in this manner. The pt is not able to answer questions, however when asked if he has any pain the pt does point to the center of his chest. The pt was then guided in an upright manner and placed on our stretcher. He was sat in an upright position of comfort, and I had my partner place a NRB on at 10 lpm. The pt was beginning to get aggitated at this point, and was attempting to climb off the stretcher. I was continuosly talking to the pt and attempting to calm him down verbally and reassure him that I was there with him and for him, and told him every single movement we were going to make. Once in the truck, the cardiac monitor was placed on showing a sinus tach rhythm w/o ectopy at 132 bpm. Bp of 165/113. Respirations continued at appx 40 - 45 bpm. Pulse ox of 91% w/ nrb in place. We then began transport. As we began to drive, the pt then began to bob his head up and down and side to side, and w/in maybe 10 seconds of this became unresponsive, as I figured he would at somepoint. I think moved the monitor off of the back of the stretcher, and layed the pt supine, opened his airway utilizing the head/tilt chil/lift method. Pt respirations were appx 10/min at this time, and he was completely flaccid and unresponsive to sternal rub. I placed a nasal airway, and provided bvm respirations at 12/min, w/ high flow o2 @ 15lpm. This lasted appx 4 min, and upon arrival at the hospital the pt opened his eyes and was looking up at me providing ventilations. I immediately welcomed the pt back to a responsive state and explained to him where he was and who I was and what I was doing. I removed the bvm, and the pt gently reached up and removed the nasal airway. The pt now had regained control of his respirations and was breathing appx 16/min, w/ adequate air movement into the bases, clear throughout auscultation. I then replaced the NRB and maintained it at 10lpm. o2 sat of 99% on room air. Pt w/ complaint of slight chest tightness upon arrival. Pt states he does remember me coming to the scene, however nothing from then on. Phew......Now, we enter the hospital, and are in the "line" waiting to see the triage nurse, and she comes out and says she needs to know what every unit is here for. She asks my, and I begin to give her a bit of the situation. She then stops me in my sentence and says "I need two words, thats it, two words so that I can make a disposition". I tell her --"hyperventilation". She then says, "well why is he on oxygen then? Get the oxygen off of him". I said, "Well can I explain what had happened?" and she proceeded to tell me that I need to get the oxygen off of him if he was hyperventilating as this will continue to cause him to hyperventilate. From this point on she would not allow me to describe to her the scenario as I saw it, and stated that If I continue to maltreat pt's then she will continue to not listen to what I have to say about the scene, and she will form her own conclusions!!!!! I was utterly shocked. Not a single indiviual providing care for this pt from this point on asked me a thing about the scene! After all that, my question is.............Is there something I do not know about o2 administration during possible hyperventilation syndrome? Link to comment Share on other sites More sharing options...
Kiwiology Posted October 7, 2009 Share Posted October 7, 2009 My thinking is that if oxygen therapy continues to drive hyperventilation the patient will become (or become more) hypercapnic and alkalotic. That would explain why he passed out. Link to comment Share on other sites More sharing options...
Lone Star Posted October 7, 2009 Share Posted October 7, 2009 Since the patient's SPO2 reading was initially 89 on room air, one would think that the hypoxia was the primary 'drive' behind the hyperventilation. Why was the NRB only set at 10lpm? Even Basics are taught that in cases like this, that the application of 15lpm is appropriate. With the rise in SPO2 readings (which by the way wouldn't be on 'room air' if they're on a NRB), is that what caused the drop in the respiration rate? What was the patients past medical hx? SAMPLE? Don't get me wrong, I'm not trying to 'call anyone out', I'm just trying to figure out the logic behind these treatments. Wouldn't the chest pain be secondary to the respiratory distress? Obviously, with the patient breathing 40/bpm, the respirations will be shallow and tidal volume/minute volume will be inadequate. Even though the patient was hyperventilating, wouldn't a better description be 'respiratory distress'? Once the respiration rate dropped back to 16, what values were found in the reassessment of the vx? Couldn't the hypoxia explain the agitation, chest pain and syncopal episode? Link to comment Share on other sites More sharing options...
P_Instructor Posted October 7, 2009 Share Posted October 7, 2009 It's not so much about the oxygen but the CO2 blowoff. With the patient passing out, metabolism continues and CO2 slowly increases back to homeostatic levels, whereupon the patient comes to and breathes at more normal rate. Question, was there any spasms noted with the patient? The nurse would probably want to stick the patient's head in a paper sack with that attitude. Link to comment Share on other sites More sharing options...
JPINFV Posted October 7, 2009 Share Posted October 7, 2009 Why was the NRB only set at 10lpm? Even Basics are taught that in cases like this, that the application of 15lpm is appropriate. Unless the bag is collapsing, the only difference between 10 L/M and 15 L/M is going to be how fast you drain your oxygen tank. Link to comment Share on other sites More sharing options...
medicv83 Posted October 7, 2009 Author Share Posted October 7, 2009 Unless the bag is collapsing, the only difference between 10 L/M and 15 L/M is going to be how fast you drain your oxygen tank. Thank you JP, as I was just going to say this. The pt wasnt sucking this bag down at all. I am not curious as to why he had chest pain during a period of hyperventilation, of course his chest will be tight. Yes the agitation is from the hypoxia, well at least it can be assumed that way. Once the pt regained his consciousness, his bp thereafter was in the mid 130's systolic, and a pulse rate of 97, nsr w/o ectopy at all. Im just more curious in the administration of o2 in a pt who is hyperventilating. Why would this nurse be so adamant that o2 not be administered, and we can call this whatever we want, either respiratory distress, sob, diff breathing, or hyperventilation. However either way, isnt any of these an indication for o2? Link to comment Share on other sites More sharing options...
HERBIE1 Posted October 7, 2009 Share Posted October 7, 2009 Need more info. PMH? Similar past epiosode? Events leading up to EMS involvement? Argument? Stressful situation? Personal problems? Medications? ETOH or drugs? Psych history? Carpal/pedal spasms? Tingling fingers? I've had countless hyperventilation syndromes and have NEVER had a patient actually lose consciousness because they have completely screwed up their respiratory drive. Had a few come close, but that was after probably an hour of rapid, shallow breathing. Link to comment Share on other sites More sharing options...
VentMedic Posted October 7, 2009 Share Posted October 7, 2009 Phew......Now, we enter the hospital, and are in the "line" waiting to see the triage nurse, and she comes out and says she needs to know what every unit is here for. She asks my, and I begin to give her a bit of the situation. She then stops me in my sentence and says "I need two words, thats it, two words so that I can make a disposition". I tell her --"hyperventilation". She then says, "well why is he on oxygen then? Get the oxygen off of him". I said, "Well can I explain what had happened?" and she proceeded to tell me that I need to get the oxygen off of him if he was hyperventilating as this will continue to cause him to hyperventilate. From this point on she would not allow me to describe to her the scenario as I saw it, and stated that If I continue to maltreat pt's then she will continue to not listen to what I have to say about the scene, and she will form her own conclusions!!!!! I was utterly shocked. Not a single indiviual providing care for this pt from this point on asked me a thing about the scene! After all that, my question is.............Is there something I do not know about o2 administration during possible hyperventilation syndrome? You made the diagnosis of "hyperventilation" and stated that to the nurse. You actually had no idea if it was hyperventilation without knowing the PaCO2. You only knew the patient was tachyneic and has an SpO2 of 89% on RA. Sometimes it is best to just give the signs and symptoms without the diagnosis. Too many have put themselves in the BS state of mind when they hear or presume "hyperventilation". As well, there should be a distinction made with "hyperventilation" by physiological definition and "hyperventilation syndrome". The syndrome, can also be chronic and have physiological changes that may not always follows the rules of "hyperventilation" by definition. So, assuming "hyperventilation" can lead on down the wrong assessment pathway and that includes the nurse you said this to. This patient could also have a true diagnosis of "hyperventilation syndrome (HVS)" other than the one that is just associated with a momentary anxiety attack can become chronic which needs the assessment and treatment of a specialist. A good read on the subject: Overview http://emedicine.medscape.com/article/807277-overview Differiential diagnosis http://emedicine.medscape.com/article/807277-diagnosis Treatment and medication http://emedicine.medscape.com/article/807277-treatment Follow-up http://emedicine.medscape.com/article/807277-followup There can be many reasons for him to have a tachyneic episode. He may even have a RAD sensitivity that has yet to be determined. We see a lot of those in the PFT labs and try our best to recreate the symptoms. He might also have periods of SVT from something like LGL or WPW that might bring on a "panic like attack" and resolves. He might even have runs of VT that are transient but can be a strange feeling. Emotional states can exacerbate whatever underlying there might be and the etiology may yet to be determined. Also, the liter flow of the NRBM is set by the patient's minute volume or dept of each inspiration and one should not be thinking of regulating the FiO2 by the liter flow. Hypoxia can cause aggitation and the degree may also be dependent on the patient's O2 carrying capacity. A shift might be seen if the patient truly got his pH on the high alkalotic side which can explain other mentation disturbances. However, the body usually responds to that by shutting down momentarily to "regain control" if there is not a true physiological reason at that moment for the body to be "hyperventilated". Link to comment Share on other sites More sharing options...
Richard B the EMT Posted October 7, 2009 Share Posted October 7, 2009 I'll make an educated guess here, but perhaps you should have said "chest pain" instead of "hyperventilation". I am not trying to second guess you, here, I'm just thinking out loud. Link to comment Share on other sites More sharing options...
Kiwiology Posted October 7, 2009 Share Posted October 7, 2009 I wouldn't call this any of those apart from hyperventilation which is not an indication for O2. It is a benign condition that won't do any harm unless like this guy, the patient becomes so hypocapnic and alkalotic they pass out. Call me old fashioned but I'd probably throw his ass on the paper bag treatment to get his CO2 level back up and prevent alkalosis/cereberal vasoconstriction/hypoxia. As for oxygen, I might put him on a couple litres on an NC once he woke up. Link to comment Share on other sites More sharing options...
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