hyperventilationn whats your pre hospital care???

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Permalink Reply by PAMedicAdam on October 25, 2009 at 11:22am

While hyperventilation syndrome is a fairly common issue specifically in teenage females, it is still important to attempt to rule out other pathologies that may be actually causing the rapid rate. The diagnosis of anxiety induced hyperventilation should be last on the list.

The treatment in the prehospital arena should not include a "paper bag" as this can actually cause hypoxia in the healthy person. I typically coach the patient on breathing and may utilize a semi nonrebreather mask without oxygen, but with both of the vents on the sides opened up. Between coaching and using the mask, the issue usually resolves. Again...it is important to make sure the patient is NOT hypoxic before doing this therapy. Look at SPO2 etc...

One of the worst things that you could do is to with hold oxygen from a person who is not actually hyperventilating but really tachypneic. Real damage could be done; thus, if in doubt give oxygen.

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Permalink Reply by asysin2leads on October 25, 2009 at 12:43pm

Ummmmm, you realize that putting an NRB on a person without oxygen is pretty much the same thing as having them breathe into a paper bag, right?
Explain to her what's going on. Tell her the tingling and stiffening are because of her hyperventilation. The problem with these situations is that they feed off of emotion, so you have to become somewhat detached from the symptoms, and while showing you care, not getting caught up in it. The first thing to do is send everyone except the patient and ONE (1) parent, the calmer of the two, out of the room. Then in a calm, firm voice tell her that she needs to slow her breathing down and to take deep, slow breaths. Getting all hand wringy and dramatic will only serve to make it worse.
Or you can just cheat, give her 3 to 5 of valium, and call it a night.

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Permalink Reply by franc on October 25, 2009 at 1:19pm

ya pulse oximeter is very helpful, and breathing exercise and controlling the enviroment to lessen the emotion placing him in a neutral area is some of the management i sually do???.. well why does it common to female?? can we give low flow oxygen at a rate of 2 lpm via nasal cannula>>

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Permalink Reply by PAMedicAdam on October 25, 2009 at 3:17pm

Ummm..No actually breathing into a paper bag is not the same as using a semi non rebreather mask with the ventilation holes open. With a paper bag you are are solely rebreathing expired air; thus, with every breath the oxygen concentration decreases. I understand that a paper bag is not air tight, but it is pretty close. Utilizing the mask as I described passively increases the carbon dioxide level of the air being inhaled, and has a slightly lower concentration of oxygen, but it does not decrease with each breath as with breathing into a bag.

asysin2leads said:

Ummmmm, you realize that putting an NRB on a person without oxygen is pretty much the same thing as having them breathe into a paper bag, right?
Explain to her what's going on. Tell her the tingling and stiffening are because of her hyperventilation. The problem with these situations is that they feed off of emotion, so you have to become somewhat detached from the symptoms, and while showing you care, not getting caught up in it. The first thing to do is send everyone except the patient and ONE (1) parent, the calmer of the two, out of the room. Then in a calm, firm voice tell her that she needs to slow her breathing down and to take deep, slow breaths. Getting all hand wringy and dramatic will only serve to make it worse.
Or you can just cheat, give her 3 to 5 of valium, and call it a night.

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Permalink Reply by Robert Sullivan on October 25, 2009 at 3:58pm

One thing I've had good luck with is to have the patient blow into a capnography circuit. I attach the pulse ox probe and coach them to blow into the circuit. I show them the monitor, explain that their getting plenty of oxygen, and that they will feel better if they slow their breathing down and get their ETCO2 reading up. I think this helps the patient think about something else.

Of course if they're hyperventilating and their ETCO2 reading is high, we get going to the hospital.

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Permalink Reply by Nathan on October 25, 2009 at 8:10pm

Sending everyone out of the room is about reducing stimuli and "making their world smaller". Beyond this and the other great ideas moving to their level and placing your face close to theirs also "makes their world smaller". (you might be surprised how well that works) Basically Im talking about getting in their face, within a few inches. This may not work in all situations but it does work well for many. Pay attention to your tone of voice speak softly and calmly. Then there's the ones who have just completely lost it and I dont think there's anything wrong with a little Valium. If you dont want to give Valium for whatever reason remember, eventually they'll pass out and their breathing will slow down!

Why is it common to female??? Um, well. There's these things called hormones, their great in the right amounts but if they get a little out of whack.....
Its also a "more acceptable" means of getting attention for females than it is for males.

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Permalink Reply by asysin2leads on October 26, 2009 at 12:59am

Uh huh. Here's the thing. Breathing into a paper bag fell out of favor because in the narrow chance that the person's hyperventilation was caused by other than a psychogenic factor, such as a blood clot, having them breathe into a paper bag would make the situation worse. You're still doing the same thing even if you are letting in some oxygen, which is increasing the amount of carbonic acid and lowering the pH of their blood stream. On the off chance of that this 12 year old, say, had a spontaneous pneumothorax, or threw a clot, and you had her breathe into a paper bag, or deliberately put her on an NRB without oxygen, it would still be bad. And yes, I have seen pulmonary emboli initially misdiagnosed in the field as panic attacks. I've also seen the same thing happen with heart attacks. That's why no paper bags, and if you're using a mask, you should hook it up to oxygen.

PAMedicAdam said:

Ummm..No actually breathing into a paper bag is not the same as using a semi non rebreather mask with the ventilation holes open. With a paper bag you are are solely rebreathing expired air; thus, with every breath the oxygen concentration decreases. I understand that a paper bag is not air tight, but it is pretty close. Utilizing the mask as I described passively increases the carbon dioxide level of the air being inhaled, and has a slightly lower concentration of oxygen, but it does not decrease with each breath as with breathing into a bag.

asysin2leads said:

Ummmmm, you realize that putting an NRB on a person without oxygen is pretty much the same thing as having them breathe into a paper bag, right?
Explain to her what's going on. Tell her the tingling and stiffening are because of her hyperventilation. The problem with these situations is that they feed off of emotion, so you have to become somewhat detached from the symptoms, and while showing you care, not getting caught up in it. The first thing to do is send everyone except the patient and ONE (1) parent, the calmer of the two, out of the room. Then in a calm, firm voice tell her that she needs to slow her breathing down and to take deep, slow breaths. Getting all hand wringy and dramatic will only serve to make it worse.
Or you can just cheat, give her 3 to 5 of valium, and call it a night.

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Permalink Reply by blair4630 on October 26, 2009 at 3:31am

Franc...

1) oxygen doesn't hurt, if you're using the cannula, it's not going to help her re-breathe CO2 to help end the panic attack. On the other hand, if you're using the mask, using the O2 is no problem, as SpO2 and EtCO2 are completely different animals...SpO2 is effected by O2 therapy....EtCO2 is effected by ventilations, either hers or yours (BVM)

2) Capnography is a great tool here to help nail down your diagnosis of hyperventilation as opposed to effortless tachypnea from DKA, or as others mentioned dyspnea from other causes. If she is hypercanpneic with hyperventilations, then think metabolic acidiosis, she is compensating with the tachypnea, don't inhibit that, look for the cause. History, history, history. Also, if you're like me and don't have sidestream capnoghraphy, remember to look for the parasthesias circumoral, extremities, carpalpedal spasms....if you don't see those, that's another red flag, I'd again be thinking metabolic acidosis or a cause of dyspnea.

3) Many have said about getting them to control their breathing by concentrating on controlling the inpiration and expiration. I sometimes engage them in conversation and have them constantly talking, which causing them to have to slow their breathing to get sentences out. Granted, they will be short sentences at first, and this takes several minutes, but it gets their mind off of everything. Once they are starting to slow down a bit, I show them how much progress they've made, which usually puts them at ease, and then I start to coach the breathing. Either way works, figure out your own preference. Be patient, this usually takes 5-10 minutes, but you'll get them there.

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Permalink Reply by Duncan Hitchcock on October 26, 2009 at 5:20am

ABCs or 1,2,3s. I have found that having them say their ABCs or counting slowly as you calmly talk with them works well. As Blair pointed out in his third statement, the key is slow progress with positive re-enforcement.

I'm going to make a bold, non-evidence based statement now.......the vast majority of hyperventilations in the teenage population are just that, anxiety induced hyperventilation. This statement is not intended to suggest or preclude the EMS professional from being cognizant of other causes. To do so violates the fundamental philosophy of patient assessment and history gathering.

As to giving oxygen to this patient....remember the psychological component of the cyclic nature of hyperventilation syndrome in both the patient and the parent. (Remember, with kids you sorta have 2 patients) Doing something, such as low flow O2, helps in addressing this part of the equation.

One last thing. I learned an important saying many years ago and still use it today: When you hear hoof beats, don't think zebras. I'll leave that statement open for further discussion.

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Permalink Reply by TheCannulator on October 26, 2009 at 5:51am

Why make someone re-breathe their own CO2? That's why bags are a no no.

The aim with non pathological hyperventilation is to break the circuit.

I coach them to focus on me alone and all that I say, and that they aren't dying, sick etc etc.

I explain first then ask them to hold and count to five the exhale until they are able to re-control their RR.

Then I worry about explaining the why's and what fors about their hyperventilating.

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Permalink Reply by dr-exmedic on October 26, 2009 at 4:30pm

In my first year or 2 of EMS, I read a tip in a magazine (don't remember if it was JEMS or the other one). The medic would get the pt's information, but keep making errors in repeating the info to the pt (like confirming the spelling correct, etc). Eventually the pt would get so angry at this "dumb medic" that they'd snap out of their little cycle and voila: normal breathing. Never tried it, though.

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Permalink Reply by Jennifer Everett on October 26, 2009 at 10:24pm

I watched a doctor do the following and have used it myself with great success.
Have the patient lie down with head slightly elevated. Place a small book/box of kleenex or anything that they can see move that is not heavy.
Coach them through breathing and have them raise their stomach at the end of exhalation enough to move the box/book, eyes must be open as you talk them through this. By using their stomach muscles to breathe (adults are not belly breathers and babies are and supposedly have less stress ) they are releasing dopamine naturally and it causes/help them calm down. It really works, don't laugh or knock it till you try it. I have used it a number of times and only met one person so far that it did not help. (the mother in the room may have contributed to this not working)
This is after you have assessed and ruled out a more serious cause for the hyperventilation.

Okay got my sheild up! let me have it !
AFTER you try it on your next hyperventilating patient and it works let me know.

Jen

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