Uncontrollable Cramps - First Call - What's up?

Started by IvanD
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IvanD

IvanD

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Hey guys,

I feel like this would be a good place to ask this seeing there are EM docs running around this place!

I'm a freshman in a lib arts college and have just started working as a first responder for club sports. I'm a trained WFR and have been on the job for less than a month.

Today our school had a frisbee conference for which my partner and I had to be on call all day (my partner couldn't be reached, he's a EMT-B, so I responded alone). So I got a call late afternoon, was told that they had a guy "going in shock". It's also worth noting that it's 40 degrees outside today.

I booked it and got there 5 mins later, someone there thought he was going into shock and laid him down, raised his legs and wrapped him up with lots of blankets and jackets. Security got there (our security aren't trained medically) and called the medics in.

Since he was lying there all wrapped up already, I started with taking a history and vitals. His HR was 92, skin was relatively P/C/C never got around to others. But the history taking revealed that he had no allergies, took a vicodin, no past history of illnesses (though before I arrived, he told others he took a vicodin for a broken clavicle, but when I asked he said he hasn't broken anything for 4 years), also found out that for food he's only had a bagel and a banana since 8:30am and also claimed to have had a sip of alcohol, he's also been pushing gatorade pretty regularly all day.

Patient's chief complaint was uncontrollable cramping, legs, chest, arms. I was told that the cramps got better as he lied there. But when the medics tried sitting him up he had major cramps in his quads and hamstrings. He also complained of difficulty breathing at times. He was shaking through the entire time.

In the end the medics took him into the truck.

So my question is, what's up?

With my limited knowledge, I am suspecting low blood sugar which caused all the symptoms like cramping, I'm thinking that the difficulty breathing was caused by chest cramps? Can someone speculate what happened?

Just something to note, but how would you guys diagnose this patient? Also is there anything I did wrong/what could I have done better?

Thanks guys! Sorry for the mad long post.

Ooh, he also told someone that he's had an abnormal heart rhythm since he was a child but he didn't know anymore about that.
 
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Not a doc but here is a good place to start for some general info: http://en.wikipedia.org/wiki/Muscle_cramps

Wikipedia is your friend with this kind of stuff.

Muscle cramping in athletes is very common, especially if they have been sweating over a prolonged time without replacing those lost electrolytes.
 
sorry to say there's absolutely no way to diagnose that guy over the internet from your story. though i'm curious why he took a vicodin and only had a "sip" of alcohol. What could a first responder actually do? check vitals and a fingerstick, maybe give fluids. Nothing else without knowing more.
 
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What about speculations/differentials? Is low blood sugar/hypoglycemia a possibility? Just curious as to whether my gut instinct back there was correct.

If I had more time I would have given him some food to begin with.
 
FR is a step below EMT. Generally they don't have IV certs, so their treatment would be extremely limited to non-invasive therapies. Splinting, O2, history, basic primary and secondary surveys. It's only a 40 hour class or so.

I agree, no way to help you out too much here. You'd be better off trying to get hold of the medic who took the pt in and following up that way.
 
One concept that is important here is that not everything can be given a discrete diagnosis. We gets lots of people with odd constellations of symptoms that wax and wane and change. When something doesn't look like an actual syndrome you treat it symptomatically and wait for it to go away or declare itself (i.e. turn into something recognizable).

This is the reason we spend so much time in medicine, especially emergency medicine, ruling stuff out.
 
No doctor either, but a medical student and a former EMT-I. Something that always bothered me in EMS was not knowing the diagnosis or what was truly going wrong. As DocB said just roll with the punches and treat your patient's symptoms to the best of your ability and get as much information for the medics before they arrive.

I am assuming the medics loaded him up immediately or something? Were you not able to see a D-stick reading, BP, SpO2%, 12 lead ECG, ect.

D-stick would have been pretty high on my list of priorities along with a solid set of vitals to see if he really is shocky or not.
 
Dehydration, electrolyte imbalance, poisoning, terrorist attack... take your pick. You did the right thing by getting him to the medics. Most likely he would get to a hospital, get some labs, IV fluids, and maybe an ECG. If his symptoms resolve and nothing looks too abnormal then he gets sent home. We don't always get to make a perfect diagnosis.
 
So if this happened to my homie on the basketball court I'd give him a gatorade
 
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Moderate Hypokalemia (electrolyte imbalance related)
Causes muscle cramps - and more importantly can cause cardiac disrrhythmias that may present with the overall "shock" appearance you described.
I've seen this presentation more than once at marathon events and in gyms where the workouts are more than "routine"
Best pre-hospital treatment = keep patient relaxed, do not encourage physical exertion, transport - ALS = NS lock with no fluid infusion unless hemodynamically unstable, ECG with capture for ED review, glucose check, PSO2 reading. The ED will draw basic labs including electrolytes and if it is determined the patient is significantly hypokalemic, will start a banana bag (potassium drip).
Don't mind the lady that disregarded your initial assessment. There are alot of medical "types" that disregard other people's assessments because they're punks. From your description it is obvious you assessed the patient well.
BTW - a "few sips of alcohol" = a few cans, "one beer" = a six pack, and "a few beers" = a case.
 
koticsky said:
The ED will draw basic labs including electrolytes and if it is determined the patient is significantly hypokalemic, will start a banana bag (potassium drip).
Click to expand...

Overall a good assessment of what to do in the field. However, a banana bag is a yellow-colored bag filled with thiamine and folate meant for alcoholics. It does not contain potassium as a standard additive. A potassium drip (or K-rider) is clear.
 
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deuist said:
Overall a good assessment of what to do in the field. However, a banana bag is a yellow-colored bag filled with thiamine and folate meant for alcoholics. It does not contain potassium as a standard additive. A potassium drip (or K-rider) is clear.
Click to expand...


Thank you, I humbly acknowledge the correction!😀
 
koticsky said:
Moderate Hypokalemia (electrolyte imbalance related)
Causes muscle cramps - and more importantly can cause cardiac disrrhythmias that may present with the overall "shock" appearance you described.
I've seen this presentation more than once at marathon events and in gyms where the workouts are more than "routine"
Best pre-hospital treatment = keep patient relaxed, do not encourage physical exertion, transport - ALS = NS lock with no fluid infusion unless hemodynamically unstable, ECG with capture for ED review, glucose check, PSO2 reading. The ED will draw basic labs including electrolytes and if it is determined the patient is significantly hypokalemic, will start a banana bag (potassium drip).
Don't mind the lady that disregarded your initial assessment. There are alot of medical "types" that disregard other people's assessments because they're punks. From your description it is obvious you assessed the patient well.
BTW - a "few sips of alcohol" = a few cans, "one beer" = a six pack, and "a few beers" = a case.
Click to expand...

What exactly do you mean by this? Your response looks like you opened a protocol book and typed what you saw. Unless the patient is severely hypokalemic they are not going to start a drip in most cases, PO K would be the choice treatment.
 
What exactly do you mean by this? Your response looks like you opened a protocol book and typed what you saw. Unless the patient is severely hypokalemic they are not going to start a drip in most cases, PO K would be the choice treatment.
Click to expand...

Your observations are incredibly conclusive with little knowledge - much like all of our observations are incredibly conclusive with little knowledge. Isn't that what this forum is about? To engage in discussions about "possible" causes? :eyebrow:

FYI, depending on the facility and more importantly, the attending physician, the parameters (both in Sx/Sympt. and Lab values) for what is considered moderate vs. severe will change - as does the ultimate decision re: PO or IV.
 
Oral route is much quicker when feasible. Just open up and down the hatch. Getting K in through the IV route is much slower, particularly if the patient only has peripheral IV access. The question is whether the oral route is appropriate or not.

And if you have a patient that is symptomatic with a lot of ectopy, you can certainly put up a K rider in addition to giving PO.
 
i think dehydration is much more likely than hypokalemia as a cause for the symptoms. i also think hypoglycemia is unlikely unless he is a diabetic on meds/insulin.
 
You need to be careful when a layperson tells you someone is "going into shock." Very few of them understand what that term means, and the public definition of this word is more akin to someone being emotionally upset or traumatized over something.

Common things being common, it was probably just dehydration and an electrolyte disturbance. Personally, I'd prefer IV potassium over swallowing those horse pills.
 
koticsky said:
Moderate Hypokalemia (electrolyte imbalance related)
Causes muscle cramps - and more importantly can cause cardiac disrrhythmias that may present with the overall "shock" appearance you described.
I've seen this presentation more than once at marathon events and in gyms where the workouts are more than "routine"
Click to expand...

My understanding was that exercise induces a transient hyperkalemia (muscle releasing potassium and moderate anion-gap metabolic acidosis causing potassium shift from ICF to ECF, with the former being the predominant mechanism). However, I can see that maybe you could see hypokalemia if your fluid replacement does not include potassium (i.e., dilutional hypokalemia). Is this the mechanism or am I thinking about this incorrectly?
 
hemoglobincell said:
My understanding was that exercise induces a transient hyperkalemia (muscle releasing potassium and moderate anion-gap metabolic acidosis causing potassium shift from ICF to ECF, with the former being the predominant mechanism). However, I can see that maybe you could see hypokalemia if your fluid replacement does not include potassium (i.e., dilutional hypokalemia). Is this the mechanism or am I thinking about this incorrectly?
Click to expand...

http://jp.physoc.org/content/421/1/105.short

The above is a link to an abstract re: potassium shift with exertion. Yes, the plasma potassium increases transiently, and if anything will affect the cell's contractability because the intracellular potassium level is now lower.

The assessment also indicated the patient had been drinking Gatorade all day without food - Gatorade has high sodium and does not really have a great potassium replacement component. So, even if it were by nature of hypernatremia that the potassium level was comparatively too low, the same signs - symptoms could result, presenting like hypokalemia with the dx Electrolyte Imbalance.

Please correct me if I have mistated, I am pre-med - and always a student.
 
Electrolyte disturbance is certainly on the differential...any recent diarrhea or vomiting?
I would also think about rhabdomyolysis. DId he have heavy exercise that morning? Is he on a statin? Reportedly some workout supplements can predispose to rhabdo as well.
 
chemist157 said:
Electrolyte disturbance is certainly on the differential...any recent diarrhea or vomiting?
I would also think about rhabdomyolysis. DId he have heavy exercise that morning? Is he on a statin? Reportedly some workout supplements can predispose to rhabdo as well.
Click to expand...

Someone mentioned Rhabdo! But while Rhabdo can be the cause he is therefore going to have electrolyte imbalances (as mentioned before) and most likely hyper-K (instead of hypo) which would be evident on the ECG the medics should have performed but might not have had they not thought that far ahead. The alcohol and Vicodin probably added to the Rhabdo being that those can be contributing factors.

My question from lack of experience, would less severe exercise induced Rhabdo result in Hyper-K that is evident on an ECG? and would Vicodin being an opiode contribute to Rhabdo just like Heroine and other drugs would (thinking dosage here)?
 
I take it this guy was a college student? I think they've gotten more sophisticated since I was in school.

My bet is that he's an "experienced" binge drinker on the weekends, but he still likes to get out and play the next day.

He even knows to have a banana (see above) with his Gatorade. But he knows he'll still feel like s*** so he and his buddies keep some Vicodin around to kill the residual hangover aches. He took one (equal at least two) Vicodin. Doesn't this contain some acetominophin as well? Lovely.

OH, my diagnosis (keeping in mind I'm not a doctor): dehydration, and if there is such a thing: temporary liver failure (or at least a very overworked liver).
 
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WhtNow said:
I take it this guy was a college student? I think they've gotten more sophisticated since I was in school.

My bet is that he's an "experienced" binge drinker on the weekends, but he still likes to get out and play the next day.

He even knows to have a banana (see above) with his Gatorade. But he knows he'll still feel like s*** so he and his buddies keep some Vicodin around to kill the residual hangover aches. He took one (equal at least two) Vicodin. Doesn't this contain some acetominophin as well? Lovely.

OH, my diagnosis (keeping in mind I'm not a doctor): dehydration, and if there is such a thing: temporary liver failure (or at least a very overworked liver).
Click to expand...

Let me first admit as others have done, the complete futility of hypothesizing on a patient I have not done a history or physical on. Having said this, I like your ideas, until you come to the liver part.

To touch your liver, you've got to take 140 mg/kg. Assuming an 80 kg guy, that would be over 25 pills if I'm doing my math right (feel free to crunch the numbers). Even then, there is a good buffer. Your average prescription of 30 pills of 5/325 lortabs out of the ER would be virtually impossible to overdose on without supplementing it with other medications (taking OTC tylenol, or chronically overdosing on tylenol). Regardless, acute tylenol toxicity doesn't make you systemically ill at first. If missed, you would become really miserable in 2-3 days, but the first day, you would just have GI irritation from swallowing over 30 pills (what medication wouldn't give you that?)

This is part of the reason our maximum prescription out of the ER tends to be 25-30 pills, because we as a profession assume the worst about patients, that they are stupid or untrustworthy. That is the reasoning behind most OTC packaging (certainly there are always exceptions). In general, Pharmaceutical companies package OTC meds so that one package contains about the max dose of medication to not cause an overdose. Lidocaine is similarly packaged. If you need more than what comes in a vial of lidocaine, then you are running the risk of lidocaine toxicity for an average sized adult and need to get the wound repaired under general (besides the fact that a wound that big is going to take hours to repair).
 
crewmaster1 said:
And call him a *****.
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Likely best case scenario... the guy is a complete weany as crewmaster suspects.

Worst case scenario, he is dehydrated, and started hyperventilating after vigorous exertion and that the cramps are due to acidosis and carpal spasms.

I would bet he is just one more victim of the widespread disease called whinybuttitis, which leads to 50-60% of ambulance transports being a complete waste of time.
 
Lawsonc said:
Someone mentioned Rhabdo! But while Rhabdo can be the cause he is therefore going to have electrolyte imbalances (as mentioned before) and most likely hyper-K (instead of hypo) which would be evident on the ECG the medics should have performed but might not have had they not thought that far ahead. The alcohol and Vicodin probably added to the Rhabdo being that those can be contributing factors.

My question from lack of experience, would less severe exercise induced Rhabdo result in Hyper-K that is evident on an ECG? and would Vicodin being an opiode contribute to Rhabdo just like Heroine and other drugs would (thinking dosage here)?
Click to expand...

My understanding is that heroine and sedative medications like alcohol tend to cause rhabdo from being too immobile during a drug induced coma, leading to ischemic injury from prolonged pressure on muscles. This is opposed to meth or cocaine which cause it from too much activity, leading to muscle break-down.

I'm not sure many medics would do a 12 lead in the field for a young healthy guy not complaining of chest pain. Those 3-5 lead readouts always look really funky to me. I often see ST elevation on those that goes away when a real 12 lead is obtained. Those are purely for rhythm in the field, to answer the question, "Can I shock or not?" Trying to guess electrolye imbalances imperically in the field off EKG readouts seems futile to me. You can't treat hypokalemia, and I've never heard of a protocol in the field for treating presumed hyperkalemia with albuterol. Too many unknowns in that situation and I think you are more likely to do harm than good, or simply waste your time mentally masturbating as we are all doing right now.
 
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Jarabacoa, thanks for correcting my overactive imagination. I knew myself that a relatively small dose of tylenol is not generally lethal or damaging when combined with alcohol since I had used myself as a guinea pig back when I was in college. (Tylenol was all the rage back then).

So I knew the liver had great resiliency (at least mine did and I survived college).🙂 Nevertheless, I couldn't resist jumping all the way to liver failure with this guy.<g> I was just hoping for the slam dunk. I should have stopped at dehydration.
 
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Jarabacoa said:
. . . and I've never heard of a protocol in the field for treating presumed hyperkalemia with albuterol. . .
Click to expand...


It's recently been added to Maryland EMS Protocol. I don't know that it's ever been used, however.
 
Jarabacoa said:
My understanding is that heroine and sedative medications like alcohol tend to cause rhabdo from being too immobile during a drug induced coma, leading to ischemic injury from prolonged pressure on muscles. This is opposed to meth or cocaine which cause it from too much activity, leading to muscle break-down.

I'm not sure many medics would do a 12 lead in the field for a young healthy guy not complaining of chest pain. Those 3-5 lead readouts always look really funky to me. I often see ST elevation on those that goes away when a real 12 lead is obtained. Those are purely for rhythm in the field, to answer the question, "Can I shock or not?" Trying to guess electrolye imbalances imperically in the field off EKG readouts seems futile to me. You can't treat hypokalemia, and I've never heard of a protocol in the field for treating presumed hyperkalemia with albuterol. Too many unknowns in that situation and I think you are more likely to do harm than good, or simply waste your time mentally masturbating as we are all doing right now.
Click to expand...

Of course treatment for hyperkalemia is used in the field!

Its part of ACLS- Hs and Ts

I'll give you a perfect example.

You show up at a Dialysis clinic where a patient prior to getting Dialysis treatment, after missing 2 sessions codes and is in cardiac arrest.

CBAD IF-
Calcium
Bicarb
Albuterol
Dextrose-Insulin
Furosemide

and we will leave the Kayexalate for the nurses. "smerks with a dirty smile"

I have not had a chance to run a Hyper-K Code in the field, but I have seen some brought into the ER (when doing clinicals) Medics used Calcium and Bicarb, within 10 minutes the woman was trying to pull the tube and required sedation.

EDIT-

I read your original post wrong, hence my second post about the albuterol protocol, we learned about it in school and in all the places I've worked it not been something I "can't" do, I just never have been presented with a patient where I thought it was indicated, I'm curious about the exact wording in that protocol as well.
 
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I am curious about that protocol for albuterol, the systems I worked in were more "open to interpretation" as far as a cardiac arrest was concerned it was your call on what route to go but it had to follow AHA guidelines, so Bicarb and Calcium could be used if indicated.

I know in a county nearby, insulin and dextrose has been used with online medical consultation, I just don't know the details.

If you had a patient that fit the profile (renal failure) and was conscious/alert and had cardiac ectopy along with elevated and spiked or peaked T waves, I could see albuterol being a first line drug, but depending on the urgency and the type of ectopic beat (frequency and nature) I would be more prone to grab the amio/lido drip based on my experience as a new medic so far.

Can anyone chime in on this?
 
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In regards to treating a hyperkalemic pt w/ albuterol.... albuterol is indicated in moderate to severe hyperk @ 10-20mg over 15 minutes...it isn't a first line rx and take into consideration if the pt is conscious and tachycardic or hx of coronary syndromes you may not want go that route

Insulin can be used in an IV injection because it increases the activity of Na-K ATPase, which causes a shift of potassium into the cells...the glucose is used simply to prevent hypoglycemia with the administration of insulin

If I were running a code and had ECG signs of hyperk, I would try to treat the underlying condition instead of the monitor. Run my first line meds and then jump into hyperk protocol before I would hang a bag of amio/lido
 
Lawsonc said:
You show up at a Dialysis clinic where a patient prior to getting Dialysis treatment, after missing 2 sessions codes and is in cardiac arrest.
Click to expand...

Point taken. However, the ESRD patient who is non-compliant on dialysis is a much different beast than the whiny healthy kid lying on a soccer field.

Besides, do you really want to do anything that brings the above patient back? If they are above 50 years old, that patient is good and dead and really should stay that way. Yes, I did just say that and no I wasn't being too facetious.
 
Lawsonc said:
I would be more prone to grab the amio/lido drip based on my experience as a new medic so far.

Can anyone chime in on this?
Click to expand...

What ectopy are you going to be treating with an amiodarone drip?

V. tach?

If anything, a beta-blocker is going to make them have less ectopy and a B-agonist is going to make them have MORE.
 
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Understandable, that all makes perfect sense, I guess I side tracked and started talking about something else other then the original patient. Albuterol is still indicated (so I've been told/read), I just can't tell you what kind of patient I would give it to, for that reason. (hence why I'm asking the poster who mentioned the protocol)

The amio and lido are still indicated for the V-tach as you mentioned, hell lets add synchronized cardioversion to the list as well. My post mentioned depending on the severity and urgency I would go straight for the anti-arrhythmic. Maybe I was not clear. Now if indicated (you have reason to believe its hyperk) and an arrest, the CBADIF as far as the resuscitation is concerned is then applied like EMS5 mentioned, jump on the calcium/bicarb bandwagon.


In regards to termination of resuscitation, thats something I will not agree or disagree with on a public forum.
 
I'm all for termination of resuscitation if your not getting a good response (ie ROSC)... the pt already has a myriad of health issues, and IF you end up successfully resuscitating, you've done nothing except to write another chapter of veggie tales...

and make a couple docs go "oh darn there goes another ICU bed"
 
EMS5 said:
I'm all for termination of resuscitation if your not getting a good response (ie ROSC)... the pt already has a myriad of health issues, and IF you end up successfully resuscitating, you've done nothing except to write another chapter of veggie tales...

and make a couple docs go "oh darn there goes another ICU bed"
Click to expand...

dead bodies don't go for rides, that is for sure, I can agree with that.
 
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