Diaphoresis

[uglyEMT]

The following question was posed in another thread and didnt want to derail it so I made this one.

DwayneEMTP, on 18 January 2011 - 03:17 PM, said:

Does anyone have any idea what level of hemodynamic compromise is necessary to cause the level of diaphoresis that is mentioned in this pt? I've only seen it in severely ill patients, hemodynamically challenged from either cardiovascular pathologies or trauma, so perhaps my inexperience with it in regards to pts not so sick is pushing me off into the ditch? Has anyone seen this level in a pt that is not critical from something?

Dwayne as promised I looked up a few things and here they are.

First lets look at the pathology of sweating first of all.

Postganglionic neurons innervating sweat glands - which release acetylcholine for the activation of muscarinic receptors - and the adrenal medulla. The adrenal medulla develops in tandem with the sympathetic nervous system, and acts as a modified sympathetic ganglion: synapses occur between pre- and post- ganglionic neurons within it, but the post ganglionic neurons do not leave the medulla; instead they directly release norepinephrine and epinephrine into the blood

The vast majority of sweat glands in the body are innervated by sympathetic "cholinergic" neurons. Sympathetic postganglionic neurons usually secrete norepinephrine and are named sympathetic adrenergic neurons. However, when sympathetic postganglionic neurons innervate sweat glands they secrete acetylcholine and hence are termed sympathetic "cholinergic" neurons. The only sympathetic postganglionic neurons known to secrete acetylcholine instead of norepinephrine.

Now onto possible causes NOT associated with hemodynamic compromise.

The biggest thing I found in relation to not having something that would make a patient "critical" is Hyperhidrosis. Patients with this condition will have exessive sweating without an external or internal influences (ie MI, trauma, shock, exercise).

OK I am going to copy and paste a Wiki link describing the causes and such because it will make it a little easier to follow and in laymens terms for others. Hyperhidrosis I know Wiki isnt the best but it is useful here.

So now that we know there is something that would be non critical but cause excessive sweating.

As far as the amount of comprimise necesssary to initiate sweating according to the pathology posted above it would depend on the sympathetic nervous system's response to said comprimise and on the patient. I am sure the degree of sweating would be different from one to another all based on the number of glands and the amount of chemicals released by the body.

I hope this helps start a discussion and if not then at least I learned something

Edited January 19, 2011 by UGLyEMT

[fiznat]

First, if you are going to cut and paste from Wikipedia articles you should cite them at the very least. The way your post reads now, its as if you are passing that stuff off as your own. I'm sure that wasn't your intention...

Second, I think you're getting way ahead of yourself here. The relationship between diaphoresis and the degree of an illness is not linear. It is an extremely complicated process that integrates a number of biological processes which, frankly, require far more knowledge about neurology than most people have here (myself included). When you start rattling off stuff about pre and post ganglionic neurons I think you're missing the forest for the trees.

What you need to know about diaphoresis is that it is a clinical sign, one of many, that needs to be integrated into a comprehensive patient assessment. "X" amount of sweating doesn't translate into "Y" amount of illness. There are plenty of sick people who sweat, and plenty of healthy people who sweat. The only well to tell the difference is to thoroughly assess.

Edited January 19, 2011 by fiznat

[mobey]

I do not see how anyone can survive this career without a working knowledge of symathetic/parasympathetic nervous system and how it presents physiologicaly. I had to understand it within my first month of EMT school..... there were a couple in my class who did not, and they failed before we even knew how to take a BP.

Rather than trying to understand ganglion, and synaptic structure, just grab an anatomy book, or even hit up youtube and get a working knowledge of the basics of the nervous system.

[island emt]

another additional thought is that there are many folks that just "sweat" heavily all the time,

My brother in law who is now in his mid 40's sweats so bad that he has to change shirts and socks several times per day. I've seen him remove his boots and literally pour sweat out of them after 6 hrs of wearing them as a state trooper.

Not a thing wrong with him medically, just an aberrant physiological process that he lives with every day.

[uglyEMT]

I guess I have alot more to learn.

I appologize for making an ass out of myself.

I will leave this one alone as I do not have the correct grasp of knowledge on the subject. I will also go wack my instructor upside the head for giving us a false sense of knowledge (ie the more sweat, the more symptoms, the worse you are).

Well again i appologise and was called out by my betters which i am thankful for. Time to go hit the books some more and get a better handle on this.

For now I bid you all adu.

[DwayneEMTP]

I guess my response from yesterday got lost in the ozone somewhere...

But I remember it started with, "Really? We're really going to bag on the EMTB for exploring neurologic anatomy/physiology? Really? What the fuck is up with that??"

I'm confident that that statement still belongs in this thread, though Ugly your "I'm going to go now and throw myslef on my sword" comments in this and the other thread are equally bullshit. You are much smarter and stronger than to cry just because you got you weenie smacked, whether you deserved it or not. And I don't believe that you did.

I actually loved that you started this thread, and liked your post a lot. What was also lost was my statement saying that I have just been to far from this for a long time to give an intelligent reply so need to brush up before commenting, which is my goal for today.

I'm flattered that you created a thread to try and offer point/counter point to the question I asked in the other thread. Driving outside of your normal lane to try and attack this problem, in my mind, represents the best of what we try to do here. But I'd really, really like you to employ some new tools next time something like this happens.

First, lose the self pity. I'm not sure if you were having a bad day or what, but it doesn't suit you. You've never let people tell you that you don't belong in ALS discussions before, you shouldn't have allowed it to happen this time.

Second, next time someone tells you that you shouldn't be fucking around in areas 'over your head', because you don't belong there, or you won't need it, tell them to go piss up a rope. Many folks here, particularly the ones in this thread are smart enough to guide you through those subjects, but no one, not even those here are smart enough to know what knowledge you need, and I'm disappointed that they tried to dissuade you instead of help.

Anyway, having said all of that I had better get my morning work done. I'll try and get back to this thread in a bit, because if you don't belong here, I sure as hell don't belong here because I don't remember how any of that shit works at the level you're looking to discuss it.

Have a great day all!!

Dwayne

[uglyEMT]

Thanks for the kudos Dwayne. Guess at 6am my words got lost a little.

I am not throwing myself on a sword here at all. I am just backing a way alittle and going to do some research. I found out I have alot to learn beyond your basic anatomy and physiology. Yes I know I am breaking into the ALS side of things and guess what I will make mistakes sometimes and I expect to be called out when I do.

I have no pity for my mistake, it was a mistake and I own it. I tried my best and used what analitical skills I had to try and grasp the larger picture but without sufficent understanding of the problem I came off as a wacker.

Hey it happens, I bet we all had that happen in the begining. I dont mind getting called out about it, it makes me a better provider because now I will go and research this more. I will go read some more indepth anatomy books. I will try to understand the sympathetic/ parasympathetic systems better. Yes we glossed over it in school and I think thats where I thought I had the knowledge. 18 pages of a text book doesnt knowledge make. Now I want to learn it better so next time when i offer an opinion it may be more on par with my better peers.

As you said you know me and pity doesn't suit me. When i first came on this site I was a whinny little bitch that I thought unless you were ALS or a bunch of other intials your were not taken seriously. I got over myself and realized you all were pushing me to be a better provider thats all. Well this is one of those pushes, I stepped up and struck out. OK I get it, now I will go get more knowledge and maybe next time I step to the plate I will knock it out of the park or at least get a base hit LOL

Again thanks for the kudos and again I am sorry if my last post came off as throwing myself on my sword. I just ment that until I gained more knowledge on the subject to the point of not talking out my ass after some weak internet searching I will refrain from the discussion.

Keep it coming brother, make me a better provider!

[DwayneEMTP]

...I have no pity for my mistake, it was a mistake and I own it. I tried my best and used what analitical skills I had to try and grasp the larger picture but without sufficent understanding of the problem I came off as a wacker.

You and I still disagree on this. I believe that you proved to belong in EMS more than just about anyone I've ever met. Doing what you did was right, the mistake you made was trusting that if you tried and then fell on your face that the others in the thread would pick you up and lead you around the puddle you fell in, and that just didn't happen. Had it come from someone else, or not been as filled with such enthusiasm then maybe I would feel differently, but I doubt it. Because of your questions I will be spending the spare time in my next few day review the physiology/pathophysiology surrounding your question. And that's what we're supposed to do, right? When did we decide that you have to know the answers before you ask a question? I'm still a little pissed, ok, a lot pissed by the attitude of, "Ummmm,,,,Yeah....You don't really belong here as you don't have the necessary education to understand it, nor will you likely ever use is, so...well....buh bye now..." Fuck that.

I will be truly disappointed if you leave this experience believing that being brave and motivated enough to bite off more than you were prepared to chew somehow made you look like an asshole, or a whacker. If you choose to follow that line of reasoning then you must apply it to all that come after you. If it's right for you, it's right for them. Are you prepared to do that?

...Hey it happens, I bet we all had that happen in the begining. I dont mind getting called out about it, it makes me a better provider because now I will go and research this more.

Though we have a ton of great, smart, experienced providers now, we have lost a lot as well. When I was new the board was ruled by akflightmedic and Dustdevil, Rid and a bunch of others. Not that they had the only opinions, or always the right opinions, but they could pretty much be counted on to steer things back in the right direction is they went off into the ditch. There were times when I left discussions with them thinking, "You know what...fuck this. I don't know the right answer, I may never know the right answer, I'm not going to listen to this shit!" But I'd come back. Because they made sense. And many of the opinions that I hold dear now came from them then. And I came to understand that though I had the wacker mentality that being a hero was paramount, they were teaching me that knowledge is king, and all of my good deeds needed to follow intelligence and education. Also, that if I wasn't willing to stand up for my opinions, then they really weren't very important opinions at all....

I once pointed out a post to Babs where I was pretty hard on you, in fact was afraid that I may have scared you off, but you came right back to the thread, had rethought you stance, done some research and didn't slow down for a second! I said, "Hey babe! Will you look at this fucking kid!?! I just kicked his nuts up next to his tonsils and he didn't even skip a beat!! I think he gets it!" Of course "it" is my own personal vision how how the world should be...but it's the right vision, so screw the rest of you guys...

It sounds that though I got all pissy about that thread that you've done what you always do, take the good from it, find a way to get stronger from it, and took off running without missing a beat...Keep taking your chances at bat, even if you don't think you can hit the ball. Because that's how we get better, stronger, braver, more competent, confident.

Good on you brother.

End of rant...(Well, almost. Will you PLEASE use your friggin' spell check??)

Really, really end of rant.

Dwayne

[uglyEMT]

I will be truly disappointed if you leave this experience believing that being brave and motivated enough to bite off more than you were prepared to chew somehow made you look like an asshole, or a whacker. If you choose to follow that line of reasoning then you must apply it to all that come after you. If it's right for you, it's right for them. Are you prepared to do that?

No I am not. I guess again at 6am my thoughts were muddled and not clear. I will stand tall, own my error and be better for it. I will be back here without a doubt, but this time will be with the knowledge to hold my own.

I once pointed out a post to Babs where I was pretty hard on you, in fact was afraid that I may have scared you off, but you came right back to the thread, had rethought you stance, done some research and didn't slow down for a second! I said, "Hey babe! Will you look at this fucking kid!?! I just kicked his nuts up next to his tonsils and he didn't even skip a beat!! I think he gets it!" Of course "it" is my own personal vision how how the world should be...but it's the right vision, so screw the rest of you guys...

It sounds that though I got all pissy about that thread that you've done what you always do, take the good from it, find a way to get stronger from it, and took off running without missing a beat...Keep taking your chances at bat, even if you don't think you can hit the ball. Because that's how we get better, stronger, braver, more competent, confident.

Good on you brother.

I think I know the post you are talking about. Hey I never backed down from a fight and always seemed to persevere through the thick of it. This will only move me; us forward and make me, us stronger because of it.

End of rant...(Well, almost. Will you PLEASE use your friggin' spell check??)

LOL I always forget to do that. Actually just noticed it in the upper right corner.

edited to use spell check LOL

Edited January 20, 2011 by UGLyEMT

[mobey]

OK, now that that is over, I am going back to the original point of this thread.

I am a big fan of providers doing thier own research, but to be honest, the nervous system can be really confusing, and IMO at the EMT-B level you need a specific understanding (does not include synapse).

The nervous system is divided into 2 parts, the Sympathetic, and Parasympathetic.

When the body is injured/struck with illness/under stress, the sympathetic system will be dominant. This sympathetic response is also known as "Fight or flight response".

SYMPATHETIC: Primarily driven by the chemicals Epinephrine & Norepinephrine which the body releases to cause the following:

•stimulates heartbeat (Force of contraction, rate, and electrical excitability)

•raises blood pressure

•dilates the pupils

•dilates the bronchi

•stimulates the conversion of liver glycogen into glucose

•shunts blood away from the skin and extremeties for increased supply to the brain, and heart

*Causes diaphoresis

PARASYMPATHETIC: Works opposite the sympathetic system. Also known as the "Feed or Breed response" This is what system is working now as you sit typing on your computer.

•slowing down of the heartbeat

•lowering of blood pressure

•constriction of the pupils

•increased blood flow to the skin and viscera

Just a quick thought connect the dots for you: Do you administer an Epi Pen as an EMT-B? If so, what is in it? how do you expect your patient to present after having it administered?