18 year old male: Structure Fire Rehab

It's just before midnight when your pager goes off for a structure fire. You and your partner scramble down from the bunkhouse and to your truck. The engine company is already rolling out the door as you check enroute.

Upon arrival, you see a small home, heavy smoke and flames showing. The radio crackles as the engine company establishes command and announces a working structure fire. Automatic mutual aide is dispatched as well.

You stage your ambulance out of the path of incoming fire apparatus and check in with command to set up rehab.

As crews are rotated off attack lines, they check into the rehab sector. Their air bottles are topped off while they get their vitals taken, rest, and rehydrate.

Your partner waves you over to a young firefighter, who appears pale and diaphoretic, who she says has a "really fast pulse."

  • Pulse: 190, regular at the radials
  • BP: 118/54
  • Resps: 24, unlabored
  • SpO2: 90% r/a
  • SpCO: 4%

He denies any complaints as you put him onto the monitor.

He says he, "feels fine" but that he, "may be a little tired."

  • Allergies: none
  • Medications: none
  • PMHx: none
  • Last ins/outs: normal dinner, "some energy drinks"
  • Events: on air for ~20 minutes

Your partner grabs a towel to dry him off for a 12-Lead. While you're placing the leads he asks when he can, "get back on a line."

After 15 minutes in rehab he's had 8 ounces of water and 12 ounces of a sports drink. Your parter grabs a second set of vitals:

  • Pulse: 160, regular at the radials; 180 when standing
  • BP: 112/74
  • Resps: 20, unlabored
  • SpO2: 94% r/a
  • SpCO: 0%

What is your interpretation of his initial rhythm and his 12-Lead ECG?

Are there any significant findings on the 12-Lead ECG?

His Lieutenant walks over to you in the rehab area and asks, "well Doc, can he be released yet?"

34 Comments

  • Adam says:

    I see sinus tach with the P-waves buried in the T-waves on the initial 3-lead, and again on the 12-lead. I would say the computerized interpretation is wrong (shocker!) and misinterpreting the buried p-waves as a BBB.
    I don't think there's anything to worry about here, but his rate is still pretty fast. Assuming we go by the "Max Heart Rate-220 minus age" rule, a rate of 190 isn't unheard of in this young guy. He's calming down in front of you, but I would say he can't "get back on a line" for a little while yet. More hydration (water, not gatorade), get him out of his turnout gear, a little O2 by a simple face mask, coach his breathing, maybe try a vagal and see if that does anything, continue to monitor for the time being.
    Since he's not going back on the line for a little bit, you might give him a little fluid bolus.

  • Matt says:

    I feel there is still reasonable concern.  Given the ineffectiveness of CO monitors, and the high potential for other inhaled toxins such as cyanide, caution is your best course here.  I agree with the assessment of the 12 Lead expressed above.  My concern lies within his O2 Sat after 20 minutes out, at his age I would have expected a more dramatic increase.

  • Bill says:

    I agree with Adam.  He is a young guy, 18, and he is on a worker, he's got adrenalin, he's got exertional tachycardia which he compensating well with.  I would continue to monitor him keep the fluids PO. and O2, explain to him why he is down for the remainder.  Maybe question him about stimulant intake, i.e. Red-Bull etc…  a computerized diagnostic of a rhythm interpretation is crap.  Treat the patient not the numbers.
     

  • Jeff says:

    I also agree with Adam to a point…. I think that simple oral hydration would be acceptable in this case. NFPA says his heart rate needs to come down to at least 120 after sitting for 5 minutes at rehab. Otherwise all of his other v/s are appropriate by NFPA's standards. I see no cause for concern here. He needs to take the recommended rest, hyrdrate, and repeat v/s. If he is still asymptomatic and his v/s are within the recommended parameters. Put him back in the game….

  • Matt L. says:

    The patient is suffering from general fatigue and dehydration. The rhythm is sinus tachycardia secondary to physical activity, energy drinks and dehydration.
    The proper treatment is either PO or IV fluids. Optimal treatment would be 1000 ml NS and a 16 oz bottle of Gatorade over about 20 minutes. Remove the turn out gear but don't rapidly cool the patient with ice packs, fans or an extremely cooled environment. Chilling will only further increase body heat and consequently, pulse rate. Remember, while a fan or AC vent blowing directly on you won't chill you, it will chill someone who is diaphoretic, dehydrated and already hot.
    Sinus tachycardia, even rates of 190, is a normal physiologic response. Slowing the patients pulse through vagal means would be harmful to the patients hemodynamic status. The pulse is up because the body is compensating for a lack of fluids. The fact that the patient still has a normotensive pressure tells you he's still compensating. If you perform vagals and lower the pulse it will very likely result in hypotension, syncope, etc.
    The key to aiding this patient is fluids, fluids and fluids. Ventilatory rate is fine, as are the SpO2 and SpCO. You will rarely find an SpO2 of 98, 99 or 100 with a pulse rate >150.

  • Dean says:

    I dont think there is too much to be concerned with. Low o2 but that can be corrected with…O2. The rate will prob drop more as the O2 demand will be satisfied. I would continue with fluids as hes lost quite a bit.

  • John M says:

    I agree with Matt. I have had this happen with energy drinks before and have since stopped drinking them on the job. Have not had any difficulties since. Fluids is definitely the answer PO or IV.

  • Nick Adams says:

    He's not going back on the line just yet Chief…….lol.  this kid is dehydrated.  I agree with Adam's interpretation of 220 – age.  That does not mean, however, that this is not SVT.  220 – age is only a guide to help you distinguish between Sinus Tach and SVT…….not set in stone.  The biggest thing that I'm noticing here is that the patient's HR decreases with rest and hydration.  If this was truely SVT, this would not have happened.  He has a difference of 20 points in his heart rate with sitting/laying and standing.  This is positive orthostatic VS, indicating dehydration.  The 12 lead does show a RBBB pattern in V1.  This most likely is due to an increased HR (rate dependent RBBB).  The low SpO2 of 90% with a heart rate of 190 and an SpO2 of 94% with a HR of 160 indicates that there is a V/Q miss match……..Q problem. The blood is going by the alveoli too quicky, not giving enough time for exchange.  His heart rate needs to be slowed down with rehydration.  Probably could use a liter of fluids (NaCl). You could do 2-4 lpm O2 via NC until they are rehydrated and the heart rate slows down.  Once the FF's HR & SpO2 are within normal limits, and negative orthostatics, they should be able to return too duty.

  • AT says:

    I would say he’s probably very dehydrated. That could be the cause for his SVT. In any case the sports drink won’t help (it may make him feel worse as it is probably hypertonic in nature). What he needs is IV fluids and O2.

  • James Barber-EMT says:

    Well first glance at this 12 lead does show a sinus tachycardia. oxygen saturations at such a young age should definitely only be my concern for now. keep the patient out of the house and cool down longer. oxygen, fluids, reaccess vital signs.

  • Adam says:

     What makes it Sinus Tach and NOT SVT is the presence of p-waves. There are definitely p-waves buried in those t-waves, and I bet they'd be even more evident if you sped up the print speed on the monitor and stretched things out a bit. What I was referring to about the "220 minus age" was not that it meant it wasn't SVT. I was referring to the fact that this heart rate isn't outside of what can be expected of a person of this age under these conditions, e.g. a rate this fast can probably be attributed to hard work, profuse sweating, and adrenalin, rather than having some other sinister origins.
    I had a feeling that this was due to dehydration due to the pulse changes but I'm a VERY new Paramedic and just didn't know for sure. Either way, I thought we should treat the patient rather than the monitor. He's compensating well, so let's look at underlying causes. He's improved with rest and with fluids, so let's continue with more of the same and see where it gets us. If it's solely my decision, he's out for the remainder of the fire. He needs more water than he needs Gatorade, that stuff is TERRIBLE for you. A fluid bolus is also indicated, as I said, but since he's awake and alert and compensating well, you can also let him continue with the PO fluids and see where that gets you. He's bound to be thirsty, and having to concentrate on drinking a certain amount over a set period of time will be forced relaxation.
    I'm not overly concerned about his SpO2 or SpCO, again, treating the patient and not the monitor. He's outside in fresh air now, let's give him some O2 and see where it takes us.
    Excellent point about the vagal, though, I didn't think about it possibly leading to hypotension and syncope, etc. Didn't think of that.

  • Jeff says:

    Definitely NOT SVT….. Treat the patient, not the monitor or the pulse ox. He is asymptomatic. He is fatigued and slightly dehydrated. PO fluid or if you really need to show everyone you know how to drop a line, then put in an IV and give him some fluid. 

  • Bill says:

    Probably dehydration and some effects of the "energy" drinks. He's not going anywhere for a while as far as I would be concerned. Dehydration is probably an issue here. Keep an eye on O2 and CO readings. Have him drink water or a water gatorade mix 50/50, give a 500 ml fluid bolus, recheck all vitals after 20 minutes or so including O2 sats and a CO check.  Do a second 12 lead, just to be safe.Check a GBS, also. If pt is still not back down to a NSR, I would transport for further evaluation. There may be something a little more sinister going on.

  • Doc Cottle says:

    Stop screwing around and get this guy to the ED.
    While I appreciate not "treating the monitor," you have a patient who, after a quarter-hour of rest and hyration, still has a HR of 180, and is hypoxic. Because this isn't a "patient," but a fire-fighter, you are not thinking viewing him with your typical perspectve. When would hang out in a patient's living room, waiting to see "where it takes us?"
    Probably, he's just hypovolemic and tuckered out. Probably. But this is not a normal physiologic state in a young male. I'm also concerned about heart failure, stimulant abuse, toxic inhalation. I'm also concerned about his electrolyte status, since this sort of exertional/heat stress is associated with  severe hyponatremia, and a couple jugs of Gatorade is not exactly going to make that better.
    The idea that the cardiac output is too fast to allow for effective oxygen transfer from the alveoli is simply not true – oxygen transfer is essentially instantaneous. Oxygen loading can be impeded by alveolar fibrosis or edema, however.
    Portable CO monitos are not accurate, and he needs a venous sample drawn now. He should also be assessed for methemoglobinemia, which would explain the oxygen saturation. Read this abstract: Methemoglobinemia resulting from smoke inhalation.
    http://www.ncbi.nlm.nih.gov/pubmed/2648673
     

  • Brian D. says:

    Definitely ST, 12 lead is unremarkable, other than rate. SpO2 is good, no need for supplemental O2…. Fluids, either p.o. or IV indicated. Not time for him to be put back in the game, just yet. His HR is coming down nicely in the follow up V/S. Perhaps seom hydration and rest is all he needs. I don't believe anything "sinister" is going on here, but if he fails to get back to a normal HR in due time, he should be evaluated at the ED.

  • MediMike says:

    *cough*Technically sinus tach IS an SVT*cough* Haha…

  • scott says:

    dehydratation is my first working assessment… possibly evan some heat exhaustion..no temp done but if temp elavated would explain low sp02… 1 degree celcius increase in body temp 02 demand increase 7% no SOB really though… just something else to consider…stay safe peeps.

  • Madmeg says:

    hmm- first evaluation- pale and sweaty, that doesn't look like a heat exhaustion, we'd expect flushed, so his perfusiuon is compromised and as people have pointed out a young guy like this should be able to cope with a raised heart rate when exerting himself. Do those T waves look peaky to anyone? or is it just a buried p wave? If peaky isn't that hyponatraemia? so he needs some salt. I'm not familiar with the effects of using BA, is the fact he's been on air for 20 minutes significant ? And I really don't think his O2 sats are matching up- yes treat the patient not the monitor but the patient was pale and sweaty and after 15 minutes his HR hasn't come down that much, I'd expect it to have reduced in a fit guy by now.
    He's definitely off the fireline and I think he needs further evaluation, there may be a congenital defect of the heart or something else going on. I would expect an 18 year old to tell you he feels fine in these circumstances- and I don't reckon I trust him! What does he LOOK like?

  • Nick Adams says:

    ADAM – Very good assessement.  I was not implying anything about your assessment, or the 220 minus your age thingy……I use it all the time myself.  Your assessment and treatment are of good quality.
    MEDIMIKE – LOL……If you take the term literally it is, because it is a tachycardia that is superior to the ventricles…lol.
    SCOTT – Increased temp does not decrease SpO2.  You're right in saying that increased temp does, in fact, increase the comsumption of O2.  SpO2 is measured at the capillary level and should therefore be close to 100% in any situation (unless V/Q mismatch).  There would be a drop in SvO2 with increased metabolic demand and consumption of O2 at the tissue level.

  • Rose says:

    Agree with all the above comments.  He is not ready to return yet and needs further care.  I do not like his B/P or SpO2.  Would consider more fluids, preferably IV to keep the electrolytes in balance.  I would also have the Captain or Safety Officer ck this guys SCBA to make sure there are no holes or problems with the equipement.  His sats should not be this low if he was on bottled air.

  • Adam Mason says:

    I don’t think the computer is completely wrong. He has an incomplete RBBB and a prolonged QT. Not a good combination. He may have Brugada’s, but the rapid rate and wandering baseline totally obscure any ST segment changes. Rehydration is important, since he had energy drinks and worked a fire. Peaked T waves are dehydration, and he’s rediculously tachy. Not a wait and see.

  • Dan says:

    SVT, might be some buried p but SVT until it slows down.  The v1 weirdness might be physiologic if he is thin and small framed.
    I would think the that 15 minutes is a little long for the recovery.  Possible electrolyte imbalance… Probably dehydrated at the least, possible Na or K problems.  He is 18 and fighting fire, so he's gonna lie about symptoms and history probably.
    Im not running of to the ED but this guy needs to relax for a bit and see what's going on once the hormones clear his system.

  • Flash Larry says:

    No, he can't be released yet and don't expect to get him back for the duration of this fire. Blame it on the EKG that shows a possible cardiac abnormality (the BBB) regardless of whether you think it is accurate or not. That will keep the chief off of your back.
    One thing we don't have here (unless I overlooked it) is a description of this firefighter. Is he a young athletic man, is he large, approaching overweight or is he overweight, or is he a excessively thin fellow like I was. Assuming he is a normally athletic and well developed 18-year old firefighter:
    Still – this really doesn't seem normal. HR is really too elevated and persists, SpO2 is decreased and comes up slowly.
    I agree with the commentator who said that if this weren't a firefighter – for instance if this were a high school basketball player – we would be transporting him to the ED for evaluation and that's what should be done here.

    The EKG is equivocal enough that it demands further cardiac evaluation in a controlled setting. We have a lot of athletes who die from previously undetected cardiac conduction or structural abnormalities – many of them about this age – so we can't overlook that in this situation which is obviously a high-effort high-stress event with the heart rate probably exacerbated by the "high-energy" drinks.

    Continue hydration, non-aggressive cooling, obtain a blood glucose, secondary survey for occult injuries, continued close monitoring of V/S and cardiac,repeat 12-lead, transport to a medical center capable of a full cardiology workup.

    You can't go wrong overtreating and maintaining a high index of suspicion here but you could possibly go very wrong assuming this is just an exertional etiology with a heat component – though that very well may be what is happening.

  • medicsb says:

    IV and a couple liters of normal saline will work faster than PO fluids (of which he has only had ~600ml).  The incomplete RBBB is probably normal for him.

  • Nick Adams says:

    The QTc of 423 ms is mildly on the high side, but is not diagnostic for prolonged QT syndrome…therefore it is not a concern at this time.
    The RBBB pattern in V1 is incomplete and is more than likely due to the rate (rate dependent)
    I think the time that it has taken for this patient's heart rate to come down is secondary to #1 Dehydration, and #2 Energy Drinks (tons of caffeine).
    Should this person be transported to an ED?………..maybe.  It depends what happens after appropriate rehydration.  Good point on the CBG Flash Larry…..I bet it's on the higher side of normal.
    And tell the kid to stay away from those energy drinks.

  • CCC says:

    I would be more than hesitant to administer more fluid to this gentleman.  While he may be admittedly dehydrated after spending 20 minutes on air fighting a structure fire, he has had more than enough time, and PO liquids, for his heart rate to come down.  A rate of 160 after that much rest, and 180 when standing, is certainly worrisome.  While his heart rate certainly suggests orthostatic changes, his blood pressure does not.  I would expect a dehydrated patient to be a) tachycardic, which he is, and b) hypotensive, which he is not.
    Sports drinks, if we are talking Gatorade, which is what I think of when hearing the term "sports drink" do not contain caffeine.  Even after drinking 12 ounces of a caffinated beverage, I would not expect to see a heart rate of 160 at rest. 
    I would be concerned that by administering fluid boluses, I would increase the volume, and therefore the pressure in his vasculature, which would put more strain on his already taxed heart.  This gentleman most certainly needs transport to a hospital for expert evaluation.
    I believe there is a culprit behind his extremely fast rate, and the rate-dependent RBBB, and I would be hesitant to call that culprit physical exertion. 

  • CCC says:

    His young age, the presentation of being under physical exertion when symptoms began, and the RBBB may point towards ARVC.  But that's just a guess.

  • Flash Larry says:

    @CCC – that was also in my mind as well as a couple of other possibilities, hence my choice to transport to a medical center capable of dealing with a cardiac emergency.
    In one version of my post that I revised, I suggested that he needs an echo.
    One could have guessed that with my reference to young athletes and previously undetected heart pathologies – and their relationship with sudden death.
    As I said, this may be nothing at all, just an exertion/heat insult. But in the field, given the departure from what we would expect to be the norm, I would say that without further diagnostics not possible in the field, we can't say for sure what is happening.
    And, as I often say to patients, "You only have one heart and one brain.'

  • Vince D says:

    I've only been on a handful of fire standbys, but to me this is not a patient who can go back on the line. In fact, he should probably be transported for evaluation. First off he fails the "look test," which I believe to be one of the most specific tests in medicine. It's not sensitive and a lot of folks can be sick without overt signs, but if someone looks bad at a glance there's usually something going on. The second problem is his obviously abnormal heart rate and failure to improve. Vital signs are "vital" for a reason and can't be ignored. I'm not the least bit reassured by his co-oximetry and think that in its current capacity it is a tool with little to no clinical utility, especially as a screen in a very high risk population. In this case his ECG isn't showing me anything unexpected and doesn't add much to his assessment.

    I agree with most people that he is likely dehydrated and maybe experiencing side effects of the caffeine, however dehydration is often a clinical diagnosis and not one that should be made in the field without handoff to a higher level of care for confirmation and to rule out other disease. That is esepcially true in a population at exceptionally high risk of cyanide and carbon monoxide toxicity. It would also be easy to write off his 94% SpO2 as secondary to a whole host of factors, but there is no getting around the fact that 94% in a healthy young man is an abnormal value and, like an abnormal heart rate, cannot be written off.

    If he is my patient, he's definitely not going back on the line and I would do anything in my power to get him to consent to transport. I'm sure there will be protest, but it is our duty to look out for the health of the people under our care and follow through on that to the fullest extent. There are scores of people who have been dehydrated or gotten palpitations secondary to caffeine and done just fine, but this young man is in a high risk group. We are burdened with the knowledge of what could be wrong and tasked to elminate as much risk to his well-being as we can, so in this case, letting him back in would be a failure to do our job.

  • woody says:

    i don't think you can tell from the initial tracing whether this is svt or sinus tachycardia.  all you can really say is that it was a narrow complex tachycardia.  assessing for beat to beat variability could have been useful as little variability expected in svt.  i would have been inclined to give adenosine if i saw little variability in rate.
    from the 2nd tracing, you can see p waves so definitely sinus tachy at that point.  dehydration, caffeine intake, other sympathomimetic intake may all be contributing.
    we don't know what his baseline pulse rate is…that would be helpful.  he should be approaching his baseline after resting for 15 minutes.  i would hold him out at least another 15 min, bolus some fluids, and not send him back in if his resting pulse rate >100 after 30 min of rest.

  • Mel says:

    SVT, possible cyanide poisoning, heat exertion.  I would def get an IV line in and give some fluids, provide oxygen for the moment and see if there are any changes. Cool him down just a tad. I would not want to send him back on the line. RBBB is a given.  His BP is pretty good.  Many things could be considered here…
    Heat for one, dehydration is a possibility.  I know on exertion especially in a fire, my HR usually bumps up into the 180's till rehab.  Take in some gatoraid, poweraid, etc… and Im usually good.  Cyanide is a possibility although everything does not directly point to that… as mentioned before, I would do the stated treatment plan, reassess his progress, and go from there.  It was mentioned before, treat the patient… but I would def keep an eye on everything else.  Def a no though, to being cleared to going back out on the line.

  • BomberoMedic says:

    This guy would be going to the hospital with his presentation on our department regardless.  It is in our SOP's.  A very good point was made above, if this was any other person, they would be going to the hospital.  His initial presentation is pale and poor.  His HR is >systolic HR even minutes after rest and hydration.  Yes, he probably is dehydrated.  That doesn't mean that there are possibly other underlying issues on top of the obvious.  SpO2 still low.  If it was any one else, would an 18 y/o with a low SpO concern you? 

  • BH says:

    Happened to a friend not too long ago.  Transported, evaluated, and released.  But you know what?  That's THEIR call to make, not ours.  Too many medics playing Doctor without being one. 
    Doc Cottle is exactly right- if this kid presented the same way after a 20-minute workout in his basement, you wouldn't dream of re-hydrating him in his living room and then streeting him.  You'd already be at the ER. 

  • Keith says:

    You got to go with Doc on this. In all probability this is sinus tach but too many potential factors are at play to simply allow for continued rest and re-hydration without transport to an ED. Electrolyte abnormalities, CO poisoning, volume depletion, stimulant use are all potential culprits here but I would suspect multifactoral etiology. One must also consider underlying pathology! This would not be the first young person to have intrinsic conduction anomolies. While the ventricular rate is a little slow for it, uncontrolled atrial flutter, while unlikely, would be worth pondering. In the end, PO fluids (sports drink), coupled with volume infusion of at least 500-1000 ml of saline would be appropriate initial care, all while TRANSPOTING the patinet to the ED. I would also consider high flow O2 via NRB. I am not a huge fan of non-titrated oxygen therapy; however, despite the digital CO reading ruling out CO here would be foolish.

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