Apologies for the delay, your author has been working nights and on the road traveling! We now return you to your regularly scheduled program.
This is the conclusion to 18 year old male: Structure Fire Rehab.
When we left off, we had a young firefighter in our rehab area with an elevated heart rate and positive orthostatics.
He admitted to consuming energy drinks and not hydrating well, however, he had no real complaints. A 3-Lead and 12-Lead were acquired.
A look at the initial 3-Lead shows a heart rate of around 190, with P-waves buried in the preceding T-waves. The notes from the rehab officer indicate this was acquired while the patient was standing. The differentials for this rhythm include sinus tachycardia and SVT. However, given the patient's age and recent activity sinus tachycardia is the more likely diagnosis.
The 12-Lead acquired confirms our suspicions, as once the patient was sat down the rate decreased and the P-waves became more obvious. This is sinus tachycardia with rate related ST/T-wave changes. There is no apparent ischemia or injury present. Some readers noted the rSR' in V1 and V2, however, these are most likely due to lead positioning (one intercostal space too high).
After 15 minutes of rehab he's had a water and a sports drink, with some improvement in his vital signs and no real complaints. However, they are not what we would like!
- Pulse: 160, regular at the radials; 180 when standing
- BP: 112/74
- Resps: 20, unlabored
- SpO2: 94% r/a
- SpCO: 0%
The rehab officer was then asked by a line officer if the young firefighter could return to duty.
The most important consideration is our general impression of the patient and our findings from our physical assessment. In this case the rehab officer felt the patient had overexerted himself, was dehydrated, and was not fit for duty.
Instead, the rehab officer had the patient continue with oral intake of water and sports drinks (alternating), and reassessed the patient at regular intervals. After 30 minutes in rehab the following 3-Lead was obtained:
This is an uncomplicated sinus tachycardia. The patient's vitals were as follows:
- Pulse: 100, regular at the radials; unchanged when standing
- BP: 118/80
- Resps: 16, unlabored
- SpO2: 98% r/a
- SpCO: 0%
At this point the fire was well under control and overhaul was in progress. The rehab officer did not allow the firefighter to return to duty, instead recommending he be transported for evaluation. The firefighter adamantly denied compaints and ultimately refused transport. He was educated on the importance of rehydration and the detrimental effects of sodas and energy drinks during exertion.
In this case IV fluids were withheld in favor of PO fluid replacement. Policies for rehydration may differ by department, however, if the patient is able to drink PO fluids, these should be preferred over IV supplement. Many marathons and triathlons have begun favoring PO over IV rehydration as well.
This course of treatment may surprise many of our readers, however, there is no data to support favoring IV fluids over PO fluids in a patient with hemodynamic changes secondary to exertion. IV fluids should instead be considered when there is symtomatic cardiovascular instability or the patient cannot effectively rehydrate orally1,2.
If your department is involved in the rehab of firefighters, you should have an NFPA 1584 compliant policy3,4 in-place with appropriate rehydration protocols.
A 24 hour call-back found the firefighter in good health and without complaint.
- Casa DJ, et al. Intravenous versus oral rehydration during a brief period: responses to subsequent exercise in the heat. Med Sci Sports Exerc. 2000; 32(1):124-33. [PubMed]
- van Rosendal SP, et al. Intravenous versus oral rehydration in athletes. Sports Med. 2010; 40(4):327-46. [PubMed]
- National Fire Protection Association (NFPA) 1584, Standard on the Rehabilitation Process for Members during Emergency Operations and Training Exercises. Quincy, Mass: NFPA, 2008. [Overview]
- McEvoy M. The Elephan on the Fireground: Secrets of NFPA 1584-Compliant Rehab. Fire Engineering. Aug 2008; 161(8). [Full Text]