NOLS Wilderness Medicine Case Study 9 Answer

Case Study 9

The Answer

Assessment

Hyperventilation.
Possible asthma attack.

The Plan

Calm the patient. Try to get her to slow her breathing.
Move to a shady, wind-protected spot.

Anticipated Problems

Inability to resolve the hyperventilation makes the patient very ill.

Comments

Hyperventilation syndrome is an increased respiratory rate triggered by physiological changes such as hand spasms and chest pain. It can be caused by an overwhelming emotional stimulus, pain, or exercise. For example, a person may normally have a fear of heights, and the thought of rock climbing triggers a hyperventilation episode, or a climber may fall and suffer a minor injury, but begin to hyperventilate out of fear and anxiety. People have also been caught up in hyperventilation while breathing hard on a steep hike. The hyperventilation can quickly become the major condition affecting the patient.

S/Sx of hyperventilation:

Anxiety
A sense of suffocation without apparent physiological basis
RR rapid and deep
HR rapid
Dizziness and/or faintness
Numbness or tingling of the hands or around the mouth.
Painful spasms of the hands and forearms.

Rapid respiration increases the loss of carbon dioxide, which causes the blood to become alkaline. The alkaline blood causes fluid/electrolyte shifts resulting in muscle spasms (carpopedal spasms).

Tx

Calm the patient and slow their breathing.
Coach the patient to breathe slowly. It may take some time before the symptoms resolve.

The Tale Continues

The patient continues to breath rapidly and now complains of pain in her hands, which have obvious spasms, and pain in her chest. She is truly scared. Concerned members of the group volunteer that this is heat stroke. You decline the offer of an emergency inhaler belonging to another participant. The hot wind is draining your energy. Your continued assessment is:

Subjective

The patient, a 19-year-old female, complains of dizziness, headache, numb and painful hands, and tingling around her mouth. At 1400 hrs she also began to complain of a burning, non-radiating chest pain and of pain and spasms in her hands.

Objective

Patient Exam:
Repeat patient exam does not find any signs of injury. CSMs in feet are normal; pain and spasms present in her hands. No wheezes or coughing while breathing.

Vital Signs

Vital Signs	TIME	1330 hrs	1400hrs
	LOR	A+Ox4	A+Ox4
	HR	104, strong, regular	96, strong, regular
	RR	28, regular, deep, unlabored	28, regular, deep, unlabored
	SCTM	Flushed, warm, moist	Flushed, warm, moist
	B.P.	Radial pulses present	Radial pulses present
	Pupils	PERRL	PERRL
	T°	Not taken	Not taken

Assessment at 1400 hrs

Hyperventilation
Possible asthma attack.

Plan

Continue to try to calm the patient. Try to get her to slow her breathing.

Anticipated problems

Inability to resolve the hyperventilation makes the patient very ill.

Comments
It’s good practice to think through why people become short of breath, or have breathing difficulty. It’s called the differential diagnosis list. You think about a spontaneous pneumothorax, asthma, and a pulmonary embolism. You’re too low for high altitude pulmonary edema and since she is not ill, pneumonia is unlikely.

It’s unlikely a spontaneous pneumothorax would develop this dramatically in such a short time, but you really can’t rule this out until the episode is done and the symptoms resolve. She doesn’t fit the profile for a pulmonary embolism, but again, this stays on your list until symptoms resolve. You’re worried about her mention of asthma, but notice the lack of wheezing and medications for asthma. It isn’t until this event is over that you can confirm that she indeed has no history of asthma and its mention was just part of her anxiety.

End of the Tale

You’re very concerned about the hyperventilation and renew efforts to slow Katie’s breathing. You focus her by commanding her to look at your eyes and breath when you breathe. After another twenty minutes her respiratory rate is a steady 12 per minute. You notice that there still is no wheezing, which tells you it’s not likely this is asthma. Also, you haven’t seen any signs of skin rashes or other allergic responses.

Eventually the chest pain subsides, then the hand spasms, numbness, and tingling resolve. Katie is exhausted, so you spend the rest of the afternoon resting and hydrating. You probe her history further and find out she has never had an asthma episode, nor has she ever seen a doctor for a respiratory problem. She says she has never had an experience like this before. You’re able to explain what you think happened, and how the hyperventilation triggered the symptoms which exacerbated the hyperventilation and put her into this vicious cycle.

By dinner Katie is symptom free. You sit down with your assistant instructor and start a conversation about how you can manage Katie on steep terrain, and whether your planned route is feasible. With renewed energy and perspective, your mind allows a creative route solution to present itself. In the distance monstrous clouds silently flash and dance with lightning, reminding you rain is a gift and dust is forever.