EMTCity helped me make the diagnosis!

[CBEMT]

*Note- some details may have been changed to protect patient confidentiality.

Dispatch: "Difficulty breathing."

Initial impression: anxious-appearing male, weight being supported by friends. Patient's head is facing up and away from midline. Patient's legs are twisted in such a way as to not allow standing without support.

HPI: Friends state they found the patient having difficulty walking, they grabbed him before he could fall. Patient states he began having trouble walking over the last several hours due to increasing muscle rigidity in his extremities and neck, and felt like he was unable to breath normally because of the neck stiffness. Denies pain per se but uncomfortable with stiffness. Denies LOC, headache, dizziness, n/v/d, incontinence, ETOH, or drugs of abuse. Admits to being transported last night for ETOH, released by the ED this morning (currently afternoon).

Hx/Rx/Allergies- Depression/Zoloft/NKDA

PE: Early 20's male, intact airway, adequate air movement, clear lung sounds, rapid radial pulse. No JVD, unable to determine tracheal shift at first due to position of head, later determined to be midline. Abdomen soft/non-tender. No incontinence. CSM/PMS intact in all extremities. Stroke scale negative. PERRL. Skin warm/dry/pink. BGL slightly elevated but not of concern. SPO2 98% at room air. Monitor- Sinus tach at 120 without ectopy, corresponds to radial pulse. BP 118/80, respirations 30. Once secured to stretcher, patient brings arms into chest as if posturing, states he feels as though this movement was involuntary.

It was at this point that I was wracking my brain for differentials- stroke or bleed? Manifestation of a previously undiagnosed tumor? Some sort of seizure activity I hadn't seen before? Severe panic attack? What?

Then, out of nowhere, it happened. I sh!t you not, a vision of an EMTCity thread page popped into my head, with one word in big bold enormous letters-

DYSTONIC REACTION!

I mention it to my partner (one of the few people I know who might know about dystonics), and his eyes go wide. "Yeah. Yeah!"

Still, I hesitated. Everything I know about dystonic reactions I learned here, and I tried to picture explaining my pushing a drug in a way not covered under my protocols based off of knowledge that I got on an internet bulletin board. Or I could be completely offbase. I'd obviously never seen one, and don't know anyone who has. What were the chances I'd get one, but not my 20+ year veteran friends?

So instead of tossing the Hail Mary and doing it anyway, or just punting and leaving it for the ER to sort out, I onside kicked.

While obtaining IV access, my partner called Med Control at our destination hospital and explained the patient's presentation. First thing the doctor said was "That sounds like a dystonic reaction." My partner affirmed that this was our impression as well, but due to the protocol issue we wanted to clear our treatment plan with him. He approved 50mg of IV Benadryl, and we were off.

The Benadryl didn't have as dramatic an effect as I'd hoped, but by the time we arrived at the ER the patient seemed to have an easier time holding his head midline and at a proper elevation, though he himself said he felt about the same as he had when we first arrived.

I haven't read the full follow up yet, but was told later that the ER diagnosis was in fact a dystonic reaction, and they gave more Benadryl along with some Ativan. If the followup provides any further insight I'll post that when I get it.

So thanks everybody. This one's for you.

[Lone Star]

*Note- some details may have been changed to protect patient confidentiality.

Dispatch: "Difficulty breathing."

Initial impression: anxious-appearing male, weight being supported by friends. Patient's head is facing up and away from midline. Patient's legs are twisted in such a way as to not allow standing without support.

HPI: Friends state they found the patient having difficulty walking, they grabbed him before he could fall. Patient states he began having trouble walking over the last several hours due to increasing muscle rigidity in his extremities and neck, and felt like he was unable to breath normally because of the neck stiffness. Denies pain per se but uncomfortable with stiffness. Denies LOC, headache, dizziness, n/v/d, incontinence, ETOH, or drugs of abuse. Admits to being transported last night for ETOH, released by the ED this morning (currently afternoon).

Hx/Rx/Allergies- Depression/Zoloft/NKDA

PE: Early 20's male, intact airway, adequate air movement, clear lung sounds, rapid radial pulse. No JVD, unable to determine tracheal shift at first due to position of head, later determined to be midline. Abdomen soft/non-tender. No incontinence. CSM/PMS intact in all extremities. Stroke scale negative. PERRL. Skin warm/dry/pink. BGL slightly elevated but not of concern. SPO2 98% at room air. Monitor- Sinus tach at 120 without ectopy, corresponds to radial pulse. BP 118/80, respirations 30. Once secured to stretcher, patient brings arms into chest as if posturing, states he feels as though this movement was involuntary.

It was at this point that I was wracking my brain for differentials- stroke or bleed? Manifestation of a previously undiagnosed tumor? Some sort of seizure activity I hadn't seen before? Severe panic attack? What?

Then, out of nowhere, it happened. I sh!t you not, a vision of an EMTCity thread page popped into my head, with one word in big bold enormous letters-

DYSTONIC REACTION!

I mention it to my partner (one of the few people I know who might know about dystonics), and his eyes go wide. "Yeah. Yeah!"

Still, I hesitated. Everything I know about dystonic reactions I learned here, and I tried to picture explaining my pushing a drug in a way not covered under my protocols based off of knowledge that I got on an internet bulletin board. Or I could be completely offbase. I'd obviously never seen one, and don't know anyone who has. What were the chances I'd get one, but not my 20+ year veteran friends?

So instead of tossing the Hail Mary and doing it anyway, or just punting and leaving it for the ER to sort out, I onside kicked.

While obtaining IV access, my partner called Med Control at our destination hospital and explained the patient's presentation. First thing the doctor said was "That sounds like a dystonic reaction." My partner affirmed that this was our impression as well, but due to the protocol issue we wanted to clear our treatment plan with him. He approved 50mg of IV Benadryl, and we were off.

The Benadryl didn't have as dramatic an effect as I'd hoped, but by the time we arrived at the ER the patient seemed to have an easier time holding his head midline and at a proper elevation, though he himself said he felt about the same as he had when we first arrived.

I haven't read the full follow up yet, but was told later that the ER diagnosis was in fact a dystonic reaction, and they gave more Benadryl along with some Ativan. If the followup provides any further insight I'll post that when I get it.

So thanks everybody. This one's for you.

CB,

It's been said many times that there's tons of information floating around these forum pages, and all one has to do is read; and they'll learn something if they're not careful.

I thought about starting a thread here in the forums thanking EMT City in advance, for getting me kicked out of EMT class. No, it hasn't happened yet; but I'm sure that my instructor is getting rather 'aggrivated' when they say something that I know isn't correct, and I comment about it.

I've already gotten a 'stern talking to' about asking questions that are 'too complex for where the class is at this point'.

The 'problem' as I see it, is that since I know better, the students that are taking this course for the first time need to be taught correctly from the begining! If you teach them bogus information, then they'll carry this 'bogus information' with them into the field.

As I told the instructor, I dont 'know it all' and never professed that I did. But why teach information that has been PROVEN as incorrect? Why not alter the course to include only ACCURATE information?

http://www.emtcity.com/index.php?showtopic=14924&hl=

[scott33]

I have been sniffing around EMS and nursing forums for several years. Aside from the often addictive argumentative posts (whether contributing or not) which can be very amusing, there is an immesurable amount of relevant information to be gained from the likes of EMT City and others.

There can often be some confusion separating the wheat from the chaff with certain posts, but nothing that can't be sorted by going off and doing our own research.

As well as the clinical guidance which is handed out FOC from the more learned members, I have had my entire philosophy of EMS do a complete U-turn in recent years, and I am grateful to certain regular contrubuters for highlighting all the stuff that I didn't wish to acknowledge, when I first started out.

Edited April 20, 2009 by scott33

[fiznat]

CB- nicely done. The best part about this story (as boring as it may be) is though you recognized the pathology, you still knew enough to double check with medical control before you went ahead with the treatment. I think it says a lot about a provider when they realize they're dealing with something they haven't handled before, and seek guidance to make sure the job gets done right.

[firedoc5]

Good going. Way to pay attention to actually learn from here and not just read something.

But that's one reason we are here for. Teach, learn, share.

[WolfmanHarris]

A bit of help here? My patho book was not helpful, A&P had nothing and here's what I got from Bledsoe on dystonia:

"The dystonias are a group of disorders characterized by muscle contractions that cause twisting and repetitive movement, abnormal postures, or freezing in the middle of an action. Such movements are involuntary and sometimes painful. They may affect a single muscle, group of muscles or the entire body.

Early symtpoms of dystonia include a deterioration in handwriting, foot cramps or a tendency of one foot to drag after walking or running. These initial symptoms can be mild and may be noticeable only after prolonged exertion, stress or fatigue. In many cases, they become more noticeable and widespread over time. In other individuals there is no progression."

- Matt

[fiznat]

Hey DocHarris:

http://emedicine.medscape.com/article/814632-overview

[zzyzx]

"I've already gotten a 'stern talking to' about asking questions that are 'too complex for where the class is at this point'."

[medic82942003]

Good job-

see one, do one,teach one. good recall.

[WelshMedic]

CB,

Good call! A dystonic reaction is not something you'll see a lot of, I've only seen it two or three times in 18 years.

The second time was actually quite funny: a had an EMT partner that was always ribbing me about being an RN. He would bemoan the fact that I was paid more when we worked as a team. It was usually just said in a joking way, so I never really minded.

We got a call to a 17 yr old with what the GP called "neurological deficits". Upon arrival we had exactly the same symptoms as your case with a little drooling thrown in for fun. It's usually a very frightening experience for all concerned as it looks grotesque. Everyone looked at one another and wonderd what we were going to do. I asked immediately what meds he was on. I got as an answer: "He started haldol 2 days ago". Bingo!

I asked my partner to draw up our equivalent of Benadryl and gave it. The pt was asymtomatic within a few minutes. I then turned around to my partner and said: "That's why I get paid more than you do".

He has never mentioned the subject of pay since!

WM