Transcript

0:10

We're back on board. So, real quick about Caitlin is, excuse me. She's currently an athletic trainer for Jackson County Central in Jackson, Minnesota. She's also, she's a licensed credentialed EMT, an athletic trainer, does, when she's not doing her stuff with her school in the summertime. She's also doing PRN work with, ambulance, service, up in the Jackson County area.

0:41

And with that as well is, she also has a strong a strong passion that I follow on on social media with her dogs, her 2 kids, her husband, doing some other fun stuff. So with that, I'm a turn it over to Caitlin as she's gonna get us rock and rolling in this next session.

1:01

Heck, yeah. I don't know how I'm supposed to follow, Karen. I mean, she was fantastic, but I will do my best.

1:10

Let's see here. You're good to go. Oh, you're gonna be fantastic. I know, that's, let's see here. I think you should be ready to you should go ahead and share your screen, I think.

1:19

Yeah. And, everyone, don't forget to ask your questions. We can raise your hand. We're gonna go and get started. We're only a couple minutes behind, but never fear.

1:28

We're gonna get caught up, with this as well. And, Caitlin, the floor is all yours.

1:34

Well, thank you so much for having me again. I am so excited to talk about this. So my topic today is all about hyperventilation syndrome. I have no disclosures to, well, disclose other than I'm here. So, so the objectives of this one is gonna be, you know, learning oop.

2:03

Hold on. There we go. Basically, we're gonna talk about how to do a good quick scene size up when you have a patient who is hyperventilating. We had kind of a good a good segue from Karen's presentation into mine, especially at the end with some of those questions and those breathing techniques. We're gonna talk about some of that, in my presentation.

2:28

So it's a really good segue. We're gonna talk about utilizing secondary assessment, in a big way and getting getting that thorough history on that struggling athlete. And then we're gonna talk about assessment tools and high pressure situations. You know, in the heat of competition, what do we do? So it's not gonna be anything too crazy.

2:56

Tell me if I'm going too fast, but we'll get started. So initially, as with any situation, we wanna do a proper scene size up. So is the scene safe? Luckily, us as athletic trainers, most of the time, our scene is going to be safe. So then we have to look at the safety of the athlete.

3:17

And then, you know, are they in a situation we need to remove them from? How are they struggling? You're doing that primary assessment that we usually honestly, at least in my experience, we don't even realize we're doing. We walk up to the athlete. We're looking at them.

3:34

We're assessing them. We're assessing those ABCs before in a way, before we even put hands on the athlete, because we we observe a lot more than than we realize. So what are we looking for in an athlete who's got who who is hyperventilating? You know, in in most of our settings, especially secondary school, collegiate, pro athletes, there will be some normal level of dyspnea after a hard competition or after a hard race. So, you know, those of us in the secondary school setting, cross country.

4:17

Right? The end of a cross country meet, everyone's coming across that finish line, and they're heaving, and they are acting like they're gonna die. But we know what's normal for that situation. So what are we looking for that are abnormal signs of dyspnea? So first off, hyperventilation is an increased minute volume of respirations that exceed metabolic demand.

4:44

So what happens is they're huffing and puffing like the big bad wolf, and they're blowing off too much carbon dioxide. And so there's an imbalance in the blood gases, And that extra oxygen and the not enough carbon dioxide can lead to kind of a more acidic, or, alkalosis. It can lead to alkalosis in the blood, and that is gonna cause basal constriction, and that's gonna cause a lot of the symptoms that we're gonna talk about. So brief brief overview of hyperventilation. So when does it go from normal to abnormal?

5:29

So we're looking for athletes who feel like they can't catch their breath no matter what they do for recovery. They're breathing harder than you'd expect them to and using a lot of accessory muscles to do that. If they complain of numbness and tingling in their fingers, toes, around their mouth and nose, those are abnormal. Another big one is chest pain. Do they have chest pain with their hyperventilation?

5:58

And did they faint? I mean, that that's a big one. And the vasoconstriction that is caused by that alkalosis in the blood leads to even cerebral vasoconstriction. So the blood the brain is getting less blood, and that can lead to the fainting. Now luckily, when they faint, things usually normalize.

6:21

But, obviously, we don't want them to get to that point where they hyperventilate themselves so much that they pass out. We don't want that. So my big thing here with scene size up and the key scenes of what you're looking for is it will not look like normal metabolic recovery. So we're used to seeing our athletes trying to catch their breath, hands on knees, tripod position, or, you know, those of them that put their hands up above their head. It will stand out.

6:53

So trust your gut and check on them if you're not sure if they're doing okay or not. So another big thing to to think about is what's the level of competition that they are currently in? Is it really high stakes? Because a lot of times, hyperventilation, it can be caused by an actual medical condition underlying. But in this case, hyperventilation syndrome is very closely linked to anxiety, and performance anxiety.

7:33

So is it a really high stakes competition? Is it a championship? You're more likely to see that you're more likely to see the hyperventilation syndrome in athletes who have that anxiety and are competing at a high level. You may even see it more if they are losing. So another thing to keep in mind, is, you know, where are you in competition?

7:59

What's going on? What demands are being placed on that athlete besides the metabolic demands? So hyperventilation does have multiple causes. I just kinda touched on that a little bit. The true syndrome comes in, and it's very closely related to panic attacks.

8:17

So it may look like asthma or other obstructive respiratory conditions at first, but they are definitely distinct conditions. Some panic attacks may lead to hyperventilation syndrome, and hyperventilation syndrome may lead to a panic attack, but they are not the same. Excuse me. So keep that in mind. As an AT, EMT, having those dual credentials on scene assessment is really just another tool in the toolbox.

8:49

I mean, if you're just an athletic trainer, you have the same you have the same tools. You have the same skill set. It just having those dual credentials is a wider knowledge base to draw from because we as athletic trainers usually see horses. So, with respiratory conditions, we're thinking asthma, illnesses, anxiety, but it doesn't mean we can't see the occasional zebra, like diabetic ketoacidosis, cardiac arrhythmias, drug overdose even, and then spontaneous pneumothorax. Those are all conditions that we could potentially see that can cause hyperventilation.

9:30

So just keep those differentials in mind when you are when you are assessing that patient. So the biz biggest example I have of rapid identification is what we've been talking about so far is the end of a cross country race. You know, everyone's coming across. Their teammates are holding them up. Some of them are are crying.

9:53

There's if you cover my races, there's usually some puking. But you're looking for those who kinda stick out from the crowd. Their their recovery is not following the normal trajectory that you would expect after a hard run. So trust your gut. Check them out if you're not sure.

10:14

It never hurts to go talk to them and make sure they're doing okay. So primary assessment, respiratory rates, that's gonna be a big one, obviously. We're talking about hyperventilation. So as we discussed, hyperventilation is it's an increased breathing rate, that is too fast. So most of us that work with athletics, luckily, we deal with the adolescent age group, so puberty and older.

10:42

So their breathing rate normally is gonna be 12 to 20. Now normal dyspnea after competition or race, it's gonna be elevated for a short time, and it will come back down. If you work with younger, so think, you know, early middle school, they might have a breathing rate of 12 to 30, or even younger if you work with, you know, a significant pediatric population. But that dyspnea is short lived, and it resolves in a short amount of time. So if their breathing rate is sustained, in the adolescent age group, so what most of us deal with, if it is over that 20 breaths per minute for a long time, you are in hyperventilation territory.

11:29

So what you need to look for in that primary assessment, you're doing the ABC check. You're doing scene safety, and you're gonna start trying to figure out what's going on. So there will be some symptoms that they will be able to tell us about. So especially, like, the tingling and numbness in the extremities. That's a big one, with anxiety and panic related hyperventilation like this.

11:59

They might talk about chest pain. They might talk about a headache. And keep in mind, those are all because of that vasoconstriction, because of the alkalosis of the blood. So signs that we need to look for as the provider are, you know, increased levels of visible distress. Are they using all of their accessory muscles to breathe?

12:21

Are they unable to speak more than one word at a time? Big ones, do they have altered mental status? Are they oriented? Look for signs of cyanosis. Look for that bluing in the in the nail beds, around the lips, the gums.

12:37

Did they lose consciousness? That's gonna be another big one. And then if they have any unilateral neurological symptoms. So that tingling in the the fingers and the mouth, with panic reduce or panic induced hyperventilation, it's usually gonna be bilateral. But if it's unilateral, then we need to start thinking about doing a, like, a bigger neurologic exam.

13:05

You know, strokes strokes are a zebra in adolescents, but they happen. So make sure you are being thorough in that that quick primary assessment. When we're in a high pressure sports environment, so like we like we talked about in the last slide, that championship cross country race or or whatnot, How do we as athletic trainers adapt our care to that high pressure environment? So for me, it's always been positioning myself to have the greatest, observational advantage. So hanging out at that finish line or sitting where I can see everyone.

13:45

You know, a lot of us have issues with spectators standing in front of us at events. Position yourself so that that's not an option for them and be watching. Keep your head on a swivel, because, again, you know, everyone's coming across that cross country finish line, and you know what normal recovery looks like, those abnormal cases are they're gonna set off warning bells. So if you're watching, you will you'll be able to pick them out. Be aware of your surroundings, but my big thing is don't focus on the eyes that are on you.

14:22

You have eyes for your athletes, for your patients. If something happens, there will be eyes on you. But as most of us know, it's easy to tune those out when when stuff is going down and we have a job to do. So just, you know, be prepared, keep watchful, and, again, like, don't don't let the the sport environment hang you up. Rely on your training.

14:50

You you know what to look for. So that brings me to, the secondary assessment. So this one is gonna be the most important in determining what is the cause of the hyperventilation. So using OPQ RST. So quick refresher, it's onset, provokes quality, rate, severity, and time.

15:14

So remember that those that OPQRST is the s in your sample history. So that's all under signs and symptoms. So ask those open ended symptom inventory questions. You know, hey. What are you feeling?

15:29

Talk to me. What's going on? Don't, hey. Are you having trouble breathing? Unless unless they're in significant distress, in which case you're not gonna need to ask.

15:38

You're gonna notice. So signs we observe, they they do look similar across many conditions. So the subjective from what the athlete can tell us is gonna be what will maybe change the diagnosis and the course of treatment. So the big one is allergies or one of the big ones. What are their allergies, and have they had any possible exposure?

16:03

And even be mindful of, like, cold urticaria, especially up here in the northern states. If they have any sort of urticaria like that, that can lead to difficulty breathing. So you might have to think outside the box and, you know, not just think about bees, nuts, eggs, the typical allergies we see. Medications. What are they on?

16:29

Be familiar with the most common medications used for asthma and allergy treatments. Did they get stung by a bee? Do they have an EpiPen? Do they take a daily allergy medication for pollen like Karen talked about? Do they have a rescue inhaler for for asthma?

16:47

Do they have something else like, vocal cord dysfunction? What works for them? What do they have? So you're gonna wanna be thorough. And a lot of us, we ask these questions already without even thinking about it.

17:04

So, you know, you just run down the list. The biggest one here that I think is the most important in the OPQ RST in sample history is their pertinent history. What health conditions do they have, if any? Pay very attention to if they have respiratory, cardiac, immune, or psychological conditions because those are gonna be what sets hyperventilation syndrome apart. So the reason for that is hyperventilation syndrome is an exclusionary diagnosis.

17:41

All other options have to be ruled out first. So if you have a positive history for underlying health conditions, especially like asthma or allergies, that treatment is gonna go beyond handing them a paper bag and coaching them on breathing. You're gonna want in that secondary assessment, if they do have a positive health history for underlying conditions, you are gonna want to do that that further system review or system exam. So listen to their lung and heart sounds. Are they wheezing?

18:15

Do you hear Strider? Take their vital signs. With with hyperventilation, their SpO 2, their oxygen reading is gonna be near or at 100%. They are gonna be really, really oxygenated. But remember, the issue is they don't have enough carbon dioxide.

18:37

They are too oxygenated. So one of the things that is kind of getting to be or, like, is in the works of getting to be a bigger point of care in athletic training, kinda coming over from the EMS side, is end tidal c o two readings, so that capnography. A lot of us, especially, solo athletic trainers like myself in the high school setting, we are not gonna have that capnography available to us until the ambulance comes. But if you are one of the lucky athletic trainers, who can get access to that and use it on the regular, do so. That capnography can really help rule in or out what is going on.

19:24

So just to touch briefly on it, a normal waveform for capnography, so, like, you and me breathing is gonna have, like, a rectangular shape. And the the level of c 02x, like, exhalation amount is gonna be between 3545 millimeters of mercury. So when our patient is hyperventilating, that reading is gonna be below 30. If they are having an asthma attack or bronchospasm, that reading on the capnography is gonna be more kinda slurred on the front end, and it's gonna look more like a shark fin. So there are other ways that end tidal capnography can really help us here.

20:11

So if they if they're hyperventilation, if it does cause fainting, you're gonna see that in the capnography. That's gonna be reflected in that little line reading. So the respiratory rate and the capnography are gonna be inversely proportionate. So as their as their respirations go up, their capnography reading is gonna be shorter. It's gonna be smaller.

20:37

So if and when they faint, they're gonna be apneic for just a very short period of time. And then when they come to, that capnography is gonna be higher because their body is now gonna expel more of what it needs to. So, if you do have capnography, it's a great tool. But, again, it's more common in the EMS setting than it is in athletic training, but I know that it's an emerging tool, for us athletic trainers. So one thing to keep in mind about capnography, if you do have the benefit of using it, keep in mind that other severe conditions and causes can cause identical waveforms.

21:22

So when in doubt, call EMS transport. There's a reason they are hyperventilating and cannot catch their breath. It's if they faint, it usually rectifies itself, although it can be frightening, for the athlete, for their teammates, for those around them. So just like with any other syncope case, protect the athlete from further harm. Let them come to stay calm.

21:53

So applying the OPQ RST and sample under stress, Review it, know it, and practice, practice, practice. My big thing that helps me, as an athletic trainer and an EMT is just knowing that OPQRST is the s in sample. So if you think if you if you wanna think of it this way, your acronym can get a lot longer. It can be o p q r s t a m p l e. That's a lot.

22:24

But if that helps you remember and stay to your order, it's gonna it's gonna help you. Because like I said, we ask most of these questions anyway. They're there to keep us on track so we don't miss anything. And if you forget where you're at in taking that history, run through the letters. You'll you'll catch where you left off.

22:45

So data collection, be methodical. Have an order planned out. It'll minimize holes in in your information that you're gathering, and this this is gonna be especially important when you're taking vitals. Go in with a game plan just like our teams do. That end tidal c o two capnography, use it if you've got it.

23:08

But like I said, it's it's a rarity for us right now in athletic training, but it's slowly being integrated more and more. In the clinical setting, providers may obtain arterial blood glasses blood gases in a lab setting. That is not something we obviously are gonna do, but, those readings can help determine, you know, some of the the cause of the hyperventilation too. So effective assessment during a game, I'm sure we've all had athletes who have been hyperventilating at some point. If you haven't, just wait.

23:49

It'll happen. But the big thing for me, I've I've had it with swimmers, cross country runners, even just, you know, EMS patients that may not be in a game setting, but they're they're scared. So my first step is I remove them from play and find a quiet spot away from prying eyes. You know, it's scary enough to be hyperventilating, and you don't need to feel the pressure of everyone watching you while you are trying to catch your breath and feeling like you're suffocating. The next thing that I usually do is find out if there was a mechanism of injury that I missed or didn't see.

24:33

Were they hit to the head? Were they hit in the stomach? Did they get the wind knocked out of them? You know, we watch like a hawk, but especially think of, like, a football game. There are so many guys out there.

24:47

There's a lot of action happening. We're not going to see everything. So I always find out especially were you hit in the head. That is my big one. And then if if those are negative, you didn't miss anything.

25:03

They just started hyperventilating. Coach them on the breathing techniques. Karen's presentation talked about some of that. If you can stay calm, they will calm down. So calm is contagious, just like Ray said, and I love that because that is huge if you are coaching someone on a breathing technique.

25:23

If you're ramped up and you're talking and you're getting freaked out, they are not going to calm down. They are not going to slow their breathing. They are gonna key off of you, and it may even feed their panic and that hyperventilation. So stay calm. Slow your talking rate because we naturally wanna match those around us, with Cadence, with Lexicon, with stuff like that.

25:47

So if you are calm and you are slow and methodical, they will feed off of that instead. So if you can calm them down enough to answer your questions, you can get that thorough history. You can get in that really good evaluation and figure out what is going on. So one of the things one of my examples is at my last job, I covered swimming, and I was called to a locker room for an athlete who was hyperventilating. And I get in there, and I one, she was already away from prying eyes.

26:24

It was just a couple of her teammates and her coach. And I knelt down beside her, and, you know, what what was talked about at the end of Karen's presentation, I loved that that that human contact. As long as the patient is okay with it, I I do a lot of that. You know, I get down on their level with how she was sitting, her back where it was against the lockers. I put my hand on her knee, and I had her look at me.

26:52

So that's another big thing that I do is I do a lot of intense eye contact. So I have them look me in the eye if they're comfortable, or I have them stare at at the tip of my nose, But I I draw their focus to me so that I can calm them down, and that was what I did with her. I put my hand on her knee. I got her to focus on me, and I coached her through breathing. She did not have any underlying health issues.

27:18

She was not needing any medication. She just was kind of panicking a little bit. So we were able to get her calmed down. And her her tingling in her fingers and around her mouth. She had complained of that.

27:36

That subsided as as we were sitting there talking. And one of my favorite breathing techniques you know, there was a lot of them out there for hyperventilation. You know, we'd we'd joke about the brown paper bag, but, realistically, if you have one at your disposal, that is an okay intervention for someone who is hyperventilating, from panic, basically, or from anxiety. So remember breathing when we're hyperventilating, we have too much oxygen and not enough carbon dioxide. So breathing into a paper bag, what is that doing?

28:14

We are rebreathing the carbon dioxide that we're expelling, and so it actually can kinda help level out those blood gases. So as funny as it is, on, you know, TV shows and whatnot, it is an a pretty decent, low budget way to to help somebody out like this. But my favorite way is I coach them on breathing in through their nose like they're smelling a flower. So you don't want them to, you know, sniff like they're sick or or whatnot. It's just a nice gentle inhale, and then you want them to breathe out through their mouth like they're blowing out a single birthday candle.

28:54

So I found that having those smaller smoother motions really helps kinda ground them. It helps give them something to focus on. You know, a lot of people might say, well, that's that's too much for them to think about. No. I don't think so.

29:10

Keep in mind, athletes, they're used to to working through complex thinking processes in a high stress environment. Now, obviously, if that's not working, we change tactic, and we do give them less to think about more direct, instructions. But I've had really good success personally with the in through your nose, like you're smelling a rose, and out through your mouth, like you're blowing out a birthday candle. It it keeps them focused. It gives them kind of a goal.

29:41

You know? They're trying to emulate those actions, and I find it really helps, even with my EMS patients in the back of the ambulance. If they're freaking out, that's my first go to. You know, we don't we don't slap oxygen on on everyone who is hyperventilating because they're they're well oxygenated. There are no contraindications for oxygen prehospital, but we should always try to calm them down, you know, through breathing techniques and grounding and kind of refocusing their attention, before we administer any medications.

30:16

So my conclusions, we'll wrap it up. The main sites main insights here for us as athletic trainers. Remember that hyperventilation syndrome is usually benign. Although the athlete may disagree, it's they if it's truly the syndrome, it can be treated. You can work through it with them.

30:40

Know your differential diagnoses. Know those underlying respiratory conditions that can cause hyperventilation. Know the mechanisms of injury, the, you know, head injuries. If if they have no. I hope none of you ever see it, but, if they lacerate, like, their spleen from a tackle or something, internal bleeding, that can cause hyperventilation.

31:04

Be vigilant. Know the different things that can happen based on your environment, your sport, that may cause that. And stay calm. If you get ramped up, so will your patient. Use the direct eye contact, or stare at the tip of my nose.

31:23

You know, use that rose candle breathing. You can also close close their mouth and have them plug 1 nostril. You know, you can do all of that too, but I like I like keeping it simple. And I know, you know, myself, I'm an asthmatic. And if I'm struggling to breathe, the last thing I wanna do is close my mouth and plug in plug a nostril.

31:45

It's already hard enough to get air, so, you know, use your best judgment. Use the method that is gonna work the best for your athlete in that given time and situation. If it is true hyperventilation, you should see improvement and resolution of symptoms and a return to baseline in a relatively short amount of time. You won't see improvement, with relaxation or breathing work if it's not psychologically based. So asthma, doing, you know, doing round breathing or square breathing.

32:21

Sorry. Square breathing. That's not gonna help someone with an asthma attack. They're not gonna get better. But if they're having anxiety, you might see improvement.

32:30

So, one of the the strategies that I like for educating my athletes about hyperventilation, especially with teens these days. They're under a lot of stress, especially in athletics. So I like to talk to them about the links between stress and anxiety and how that affects us physiologically, so how that can lead to hyperventilation syndrome. And I I talk with my kids about breathing regulation exercises. So that square breathing, the rose candle, that type of thing.

33:08

I I instruct them on it ahead of time, especially if I know the kid. If I know that they have a history of anxiety, I instruct them on those techniques so that they have those tools in the toolbox. So if I can't get to them right away, they can start trying those on their own. And then just talking about stress management strategies. You know?

33:29

It can be as simple as, hey. Chunk your homework. Talk to your teachers if you need if you need some help on an assignment. Don't just sit there and struggle. Like, there are ways to mitigate the stress and anxiety ahead of time, if that's their underlying medical history.

33:47

And scenario based training, I am a huge believer in use it or lose it. You know, we can sit and and listen to webinars all day long, but don't forget to put what you learn into practice. So doing those long auscultations, talking with your athletes, and practicing those breathing techniques. You know, it's you may think, yeah. I'll remember it.

34:18

When when it's a high stress situation, we don't we don't rise to the occasion. We sink to our training. So if you use it or if you use it, if you practice it and it becomes, you know, normal for you, it becomes, in a way, muscle memory, you're gonna be just fine. You're gonna know exactly what questions to ask. You're gonna know exactly what assessment to do.

34:41

You're gonna know what to look for. And trust your gut. You know? You you all are working professionals. You you know what you're looking for.

34:51

You know what's normal, and you know what's not. But don't be afraid to to set up scenarios and just run through them. One of my favorite things is I get a volunteer athlete to help me out and be my, quote, unquote, dummy, so that I can practice some stuff. And it's usually one of my seniors. They are more than happy to help out.

35:13

Or, you know, if you have student aids, get them involved. Set up scenarios with them. It'll help you and them. So that way our our athletes will benefit, you know, across the board in the future. And like I said, if you if you haven't had a hyperventilating athlete before, you certainly will at some point.

35:33

So I hope this talk gave you some tools in the toolbox, that you can fall back on and and use should you need to.

35:44

Caitlin, fantastic. You know, this is just a great topic. Appreciate you taking time again today to, join us again. So this is a great you know, the the part 2 of the other side of you know, we have asthma. They have existing condition, and we have this case that could be either emotionally, mitigated or or instigated, so to speak, or they are having some other type of issue.

36:08

I think you hit both those. You know, you need to identify what the problem is, and whether it's not trauma or some something else that they have, encountered or other type of condition. You know, they're de they this could be the symptom or the sign of the comp of them decompensating over something else, and we're focusing on that. But I think you gave some great pointers. You know?

36:31

The the bag still works. You know, that controlled breathing does the other part. You don't have a bag? Like you mentioned, you know, I personally like to like you like you, I try to get I you know, if they're focused and you see them turn their head, turn them in a position where they're not looking at something that's going on like the event. They just tend to, you know, with that, I'll I'll try to get them to close their eyes, hold my hands, close my eyes, control their breathing through their nose, and it just kinda eliminates those sensory issues that they're having.

37:01

And they typically step down pretty fast.

37:04

Yeah.

37:04

I do think that you had a good point. You know, we've we've talked about this on several of our webinars about the utilization of, capnography, entitled c 02. We're gonna we're gonna do another talk on that. I know I know we've we've had several talks. We talk about that, and we see that maybe limited access, but there are some low low, lower end cost, opportunities there to in the event of that, but recognizing signs and symptoms moving forward.

37:33

So, I know we're running a little bit behind schedule, but I again, thank you again, Caitlin, for, joining us today. If anyone else, you can jump on Facebook live. I know that that you can post your question, and we'll get that to Caitlin to an or to answer as well, down the line as well. So, again, Caitlin, thank you again so much. Appreciate you as always, and, look forward to seeing you, this summer down in New Orleans.

38:00

Heck yeah.