Anxiety as a Clinical Finding

Anxiety JPEGIt’s 0200. Your shift is dragging on, and all you want to do is go home. You and your partner get called for a complaint of difficulty breathing in an apartment complex. As you roll up to the scene, you see a mid-20s female walking out to your ambulance. You disregard the engine coming to assist you and walk the girl to your truck. She’s hyperventilating and appears markedly anxious. You attempt to coach her through her breathing, assess her lung sounds and hear clear and equal breaths throughout, and note an SpO2 of 98% on room air. She’s just anxious, right? You secure the patient for transport, and transport her to the emergency department with no other interventions. How many of us have done this? Why are we so quick to dismiss anxiety as a non-issue?If you listened to Episode 14: The Suspected Pulmonary Embolism Patient, you can probably see where we are going with this… We are wrong most of the time when we blow off the anxious patient, but we keep doing it…

WHY DON’T WE ASSESS ANXIOUS PATIENTS?

It’s time to cut the bravado bullshit… I remember the first time I did a 12-lead on a 20 year old complaining of chest pain. I would have bet my paycheck that this patient wasn’t experiencing a STEMI, but I did one anyway knowing that there are other things to look out for. dirty harry jpegNone of my co-workers took me seriously. I was called a cookbook medic.  I could have easily documented that my patient that was hyperventilating and experiencing musculoskeletal chest pain and would have gotten away with it. 99 times out of 100, you might be right, but is it really worth it to be wrong that one time? Even if the patient is just experiencing an exacerbation of an underlying psychological problem, when did a mental health crisis stop being classified as a medical problem? Our job is to help figure out any additional causes of these situations, and not to write them off and make them someone else’s problem. 

WHAT MAKES A PATIENT ANXIOUS?

  • COMPENSATED SHOCK
    • One of the most overlooked causes of anxiety especially after a traumatic incident (i.e. MVC, assault, etc.) is the early stage of compensated shock.
    • We tend to brush off patient complaints of anxiety if the evidence of obvious injuries or abnormal vital signs aren’t present immediately.
    • Restlessness is one of the first signs that patients are starting to trend downwards; if we aren’t trending vital signs in the anxious patient, we aren’t doing our due diligence.
  • RESPIRATORY DISTRESS AND HYPOXIA
    • A 2013 study in the journal of Respiratory Care found that patients with COPD and severe nocturnal hypoxemia have been found to experience significantly higher levels of anxiety to the helpless feeling of “suffocation”.
      • As a result of this, it’s not uncommon to see COPD patients on antidepressants and mood stabilizers; don’t ignore their growing restlessness, though. Plan ahead and be ready for the worst.
      • Patients that have experienced medical emergencies know when they are declining, and as a result can start to panic.
    • PE patients frequently don’t show any clinical signs in the prehospital setting beyond anxiety, hyperventilation, and tachycardia before rapidly declining and even arresting. Remember that these patient will continue to have clear lung sounds and even decent Spo2 saturations for awhile.
  • ANXIETY DISORDER
    • For someone who already struggles with an anxiety disorder, how else would you expect them to react when they are encountered with a new stressor, let alone a legitimate medical emergency.
    • The simple fact that someone has a mental illness history is not a reason in and of itself to disregard a detailed assessment; while it is a piece to the puzzle, it is not the entire picture.
  • ARRHYTHMIAS AND HEART FAILURE
    • A little while ago, a friend of the show donated a set of 12-leads from a mid-60s female experiencing PSVT… the only symptom she was experiencing? Anxiety. Yes, I’m being a bit patronizing, but I think we’ve made our point that anxiety is a clinical sign of bad things going on in the body.
    • American Heart Association classifies some of the most common symptoms of arrhythmias as:
      • Dizziness
      • Shortness of breath (often manifesting in hyperventilation)
      • Palpitations
      • Fast heart rates
    • All of these are symptoms that can be caused by just the sheer sympathetic surge from a purely anxiety-driven episodes, but due to the gravity of what else could be causing them, we need to be better investigators.
    • Patient’s that have experienced heart failure leading to pulmonary edema often present with… anxiety, tachycardia, and dyspnea in the form of hyperventilation.
      • We need to be vigilant in our heart failure patients that are experiencing anxiety; prepare for the worst case scenario up to and including EKG monitoring, IV access, nitro therapy, high flow 02/PPV, and possible airway management.
  • HYPER/HYPOGLYCEMIA AND SEIZURES
    • Whether someone is postictal or is experiencing mild AMS due to a glucose related event, having multiple strangers enter your home while you feel out of control of your own body is a scary event.
    • Be calm, be concise, be firm, be respectful.
    • The American Diabetes Association released a study in 2004 that revealed acute hyperglycemic spikes in Type II diabetic patients that can reduce cognitive function and lead to extreme agitation and anxiety.
    • Anybody try to reason with an anxious and agitated hypoglycemic patient? How did that work for you? What were they like once you corrected the hypoglycemia? Night and day difference. 
  • PAIN
    • Have you broken your ankle? Have you had an appendectomy? Talk to someone who has… It’s a horrible experience that makes you feel out of control and miserable. It sounds simple, but sometimes we forget. Controlling pain can help reduce anxiety.
    • A 2001 study in the Journal of Neuroscience even suggests that anxiety amplifies underlying pain.

ASSISTING THE HYPERVENTILATING PATIENT

  • THE PAPER BAG
    • For the few of you that still think that using a paper bag is a good idea to help a hyperventilating patient…please stop. Here’s why. Hyperventilating patients are experiencing respiratory alkalosis. By placing the bag in front of the patient, you remove the ability of the patient to receive oxygen, and they begin to breathe in CO2.
    • IF the underlying etiology is anything beyond purely hyperventilation, the chances of you causing hypoxia and hypercarbia is enormously high! There are several documented cases of patients that have experienced underlying MIs and hypoxemia that have had fatalities linked to this…
  • HYPERVENTILATION SYNDROME
    • We don’t have the technology to diagnose hyperventilation syndrome.
    • We don’t have the technology to diagnose hyperventilation syndrome.
    • We don’t have the technology to diagnose hyperventilation syndrome.
    • Any questions?
    • Hyperventilation syndrome is now starting to be referred to as psychogenic dyspnea.

DIAGNOSTICS

  • EKG MONITORING
    • Placing continuous EKG monitoring on your patient helps you do a couple of things:
    • Discover possible arrhythmias; especially PSVT, bouts of atrial fibrillation/flutter, and WPW.
    • Underlying cardiac strain, ischemia, or MI.
    • S1Q3T3 suggesting pulmonary embolism; even if this phenomenon isn’t present remember that it only appears in approximately 20% of all PE patients.  Sinus tachycardia is the most common presentation of PE.
  • GLUCOSE MEASUREMENT
    • Any patient that is acting anxious or altered needs to have their glucose evaluated. There is enough literature in circulation that supports loss of cognitive function and coping mechanisms due to hyper/hypoglycemia. It takes five seconds, just do it.
  • EtCO2
    • Someone that is experiencing hyperventilation syndrome (pschogenic dyspnea) will more than likely experience a lower EtCO2. Where this comes into play is that patients experiencing lower cardiac output or other signs of obstructive shock and have a lower EtCO2 should be suspected to have a PE.
    • Continuous waveform capnography can show the beginning stages of bronchoconstriction when audible wheeze may not be present.
  • SPO2
    • I’m not going to go into great detail about this now because we will eventually be doing a show about this, but don’t always trust your SpO2. There are delays in readings and hyperventilation may give an overly optimistic view of your patient’s needs.

SUMMARY

  • We do not have the capability to diagnose that someone is just anxious.
  • There are too many other serious conditions that have similar symptoms to panic disorders or psychogenic dyspnea for us to be cavalier about how we treat patients.
  • Are you going to get in trouble for overtreating (within reason) your patients, or for neglecting to do enough?

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