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Welcome!. DOT National Standard EMT-Intermediate/85 Refresher. MEDICAL EMERGENCIES. Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease. Possible overdose. Perspective Pathophysiology

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DOT National Standard EMT-Intermediate/85 Refresher

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Dot national standard emt intermediate 85 refresher

Welcome!

DOT National Standard

EMT-Intermediate/85 Refresher


Medical emergencies

MEDICAL EMERGENCIES

  • Allergic reaction

  • Possible overdose

  • Near-drowning

  • ALOC

  • Diabetes

  • Seizures

  • Heat & cold emergencies

  • Behavioral emergencies

  • Suspected communicable disease


Medical emergencies1

Possible overdose

Perspective

Pathophysiology

Epidemiology

Physical Exam Findings

Diagnostic Findings

Signs and Symptoms

Differential considerations

Scenario

Treatment

MEDICAL EMERGENCIES


Overdose poisoning

Overdose/Poisoning

  • Perspective

    • Most poisoned pts- adult

      • Acute oral OD

    • Other common clinical scenarios in children

      • Drug abuse

        • Smoking, snorting, IV

    • Other

      • Environmental, industrial, agricultural

      • Medication reaction or interaction

      • envenomation


Od poisoning

OD/Poisoning

  • General treatments

  • Specific antidotes or treatments


Od poisoning1

General

Support ABCs

Poison control

(1-800-222-1222)

Empty the stomach

Gastric lavage

Syrup of ipecac

Activated Charcoal (adsorbent)

Specific

Toxidromes (common toxic syndromes)

Anticholinergic

Sympathomimetic

Opioid/sedative/

ethanol

Cholinergic

OD/Poisoning


Od poisoning specific antidotes

Acetaminophen

Anticholinergics

Arsenic, lead & mercury

Benzodiazepines

Black widow spider bite

Beta-blockers

Calcium channel blockers

Cyanide

Digitalis

Ethylene glycol

Tricyclic antidepressants

Hydrofluric acid

Iron

Lead

Methanol

Methemoglobin-forming agents

Opioids

Organophosphates & carbamates

Rattlesnake bite

Serotonin syndrome

Sulfonureas

Valproic acid

OD/Poisoning- Specific Antidotes


Poisoning od

Poisoning/OD

  • The leading cause of poisoning in the US is prescription drug OD

    • Intentional and accidental

  • 2006 sedatives, hypnotics, & antipsychotics cause of the most deaths (382)

  • Analgesics most deaths 2006 (307 opioids, 214 acetaminophen containing meds, 138 acetaminophen alone, 61 ASA only, 1 ASA containing med)


Poisoning od1

Poisoning/OD

  • 80% of poisoning fatality intentional ingestion (although not all were suicidal)

  • 2006 - 50% of fatalities suicide attempts


Od poisoning2

OD/Poisoning

  • Toxins/poisons can poison the EMS provider as well as the pt.

  • Decontamination is paramount because the environment may be hazardous, the pt may be hazardous, or their behavior unpredictable.

  • Discuss organophosphate call


Poisoning od2

Poisoning/OD

  • Nerve Agent/Organophosphate Exposure

  • Beta-blocker toxicity

  • Narcotic opioid OD

  • Ethanol OD


Epidemiology

Epidemiology

  • Pesticides = insecticides herbicides, & rodenticides

  • During 2008 >93,000 pesticide exposures reported - Toxic Exposure Surveillance System of the American Association of Poison Control Centers

    • >43,000 exposures to children <6yrs

  • 13 deaths 2008


Epidemiology1

epidemiology

  • Pesticide intoxication

    • Intentional

    • Accidental

    • Occupational


Organophosphates

organophosphates

  • Common

    • Diazinon, acephate, malathion, parathion, chlorpyrifos

  • In addition to insecticides- chemical warfare agent since WWII

    • Sarin - terrorist attack Tokyo subway 1995


Epidemiology2

epidemiology

  • Poisoning primarily from accidental home exposure

    • Recently sprayed or fogged area

  • Other - agriculture, industry & transport of these products

  • Exposure to flea-dip products in pet groomers & children

  • Food contamination

  • Homicide & suicide


Epidemiology3

epidemiology

  • Systemic absorption

    • Inhalation

    • Mucus membrane

    • Transdermal

    • Transconjunctival

    • GI


Pathophysiology

pathophysiology

  • The primary action is inhibition of carboxyl ester hydrolases, particularly acetylcholinesterase (AChE)

  • AChE -enzyme that degrades the neurotransmitter acetylcholine (ACh).

  • ACh is found in the central & peripheral nervous system, neuromuscular junction, & RBCs


Pathophysiology1

pathophysiology

  • Once AChE has been inactivated, ACh accumulates throughout the nervous system, resulting in overstimulation of muscarinic & nicotinic receptors

  • Clinical effects are manifested via activation of the autonomic & central nervous systems & at nicotinic receptors on skeletal muscles


Pathophysiology2

pathophysiology

  • In plain English =

    • The messengers for the parasympathetic system are usually controlled

    • The messenger deactivators have been disabled

      • Therefore the messengers of the parasympathetic system are unregulated & are overstimulating the parasympathetic system


Pathophysiology3

pathophysiology


Organophosphate poisoning physical exam findings diagnostic findings s s

Organophosphate poisoning: Physical Exam Findings, Diagnostic Findings, S/S

  • Pt’s are on a continuum

    • Mild, moderate, severe

    • Analogy - movie

  • Progression

    • Analogy drain

      • Stable

      • Fast

      • Slow


Organophosphate poisoning physical exam findings diagnostic findings s s1

Organophosphate Poisoning: Physical Exam Findings, Diagnostic Findings, S/S

  • AB-SLUDGEM

  • ALOC

  • Bronchorrhea(watery sputum), Breathingdifficulty or wheezing, Bradycardia

  • Salivation, Sweating, Seizures

  • Lacrimation

  • Urination, Defecationor Diarrhea

  • GI upset

  • Emesis

  • Miosis, Muscle activity.


Organophosphate poisoning physical exam findings diagnostic findings s s2

Organophosphate poisoning: Physical Exam Findings, Diagnostic Findings, S/S

  • AB-SLEDGEM is an over-simplification

  • Clinical presentations depend on the specific agent involved, quantity absorbed, & route of exposure

  • Organophosphate poisoning is not a single entity

    • substantial variability in clinical course, response to oximes, outcomes


Organophosphate poisoning physical exam findings diagnostic findings s s3

Organophosphate Poisoning: Physical Exam Findings, Diagnostic Findings, S/S

  • Acetylcholine is the presynaptic neurotransmitter at nicotinic receptors in the sympathetic ganglia & adrenal medulla

  • Pallor, mydriasis (pupil dilatation), tachycardia, HTN


Organophosphate poisoning physical exam findings diagnostic findings s s4

Organophosphate poisoning: Physical Exam Findings, Diagnostic Findings, S/S

  • Parasympathetic overstimulation usu. predominates, but mixed autonomic effects are common.

  • Nicotinic overstimulation at the neuromuscular junctions results in

    • Muscle fasciculations, cramps, & muscle weakness

    • Can progress to paralysis, areflexia


Organophosphate poisoning physical exam findings diagnostic findings s s5

Organophosphate poisoning: Physical Exam Findings, Diagnostic Findings, S/S

  • The cholinergic toxidrome may vary depending on the predominance of muscarinic, nicotinic, and central neurologic manifestations and the severity of the intoxication


Organophosphate poisoning physical exam findings diagnostic findings s s6

Organophosphate poisoning: Physical Exam Findings, Diagnostic Findings, S/S

  • Other mneumonics for the muscarinic effects of cholinesterase inhibition

  • SLUDGE DUMBELS Killer Bees

  • Salivation, Lacrimation, Urinary incontinence, Defecation, GI pain, Emesis

  • Defecation, Urination, Muscle weakness, miosis, bradycardia, bronchorrhea, bronchospasm, Emesis, Lacrimation, Salivation

  • Bradycardia, bronchorrhea, bronchospasm


Differential diagnosis considerations

Differential Diagnosis Considerations

  • Direct acting cholinergic agents: bethanechol or pilocrapine

  • Digitalis, clonidine, calcium or Beta-receptor agonist poisoning

  • Miosis, bradycardia, lethargy & respiratory - opiod overdose

  • Nicotine poisoning


Scenario

Scenario

  • Dispatch info:

    • You are dispatched to Village Store in Yosemite Valley for a 44 y/o male who is threatening suicide. The time of call is 17:00 and your response time to the scene is approximately 5 minutes.


Scenario1

Scenario

  • You arrive at the scene at 17:05 where you find the pt sitting in the aisle of the store. He is sobbing uncontrollably.


Dot national standard emt intermediate 85 refresher

Scenario

  • As you perform an initial assessment the pt tells you that he is depressed because his wife is divorcing him.

  • His respirations are labored, however, he has adequate tidal volume and is able to speak to you in full sentences


Scenario2

Scenario


Question

Question?

  • What initial management is indicated for this patient?


Dot national standard emt intermediate 85 refresher

  • Go to “Call Matrix- General”


Question1

Question?

  • What initial management is indicated for this pt?

    • After the scene size upand the initial assessment

  • Diagnostics, Monitoring & Mtg

  • VerbalSurvey that includes pertinent positives/negatives & hx, meds, allergies

  • SpecificProtocol Treatments


Scenario3

Scenario

  • Is the pt stable or unstable?

  • What is your rationale?


Scenario4

Scenario

  • After placing the pt on supplemental oxygen, an IV line of NS is established & set at KVO

  • You conduct a hx & PE


Scenario5

Scenario

  • What size IV catheter would you use?

    • Rationale?


Scenario6

Scenario

  • What size IV catheter would you use?

    • Rationale?

      • Large bore = 14 or 16ga


Scenario7

Scenario


Scenario8

Scenario

  • Further assessment of the pt reveals that he has defecated in his pants. He is salivating all over his shirt & he tells you he “just doesn’t feel so good.”


Scenario9

Scenario


Scenario10

Scenario

  • What is your field impression of this pt?

    • Give your rationale


Scenario11

Scenario

  • This pt is suffering from organophosphate poisoning.

  • The following assessment findings support a field impression of organophosphate poisoning:

    • Bradycardia

    • Low BP

    • Defecation

    • Salivation

    • Insecticide


Scenario12

Scenario

  • What treatment will you provide to this patient?


Scenario13

Scenario

  • General

    • Position, VS, SPO2, Oxygen & airway, IV

  • Specific

    • Atropine 2mg IV/IM q 5 minutes PRN

      • (discuss IM)


Scenario14

Scenario

  • You administer the atropine indicated for the pt’s condition, after which you note that the pt’s condition seems to remained the same.

  • You continue oxygen therapy & load the pt into the ambulance for transport to the ED


Scenario15

Scenario

  • En route to the ED, the pt’s condition does not improve.

  • You perform an ongoing assessment & then call your radio report to the receiving facility


Scenario16

Scenario


Scenario17

Scenario

  • Is further treatment required for this pt?


Scenario18

Scenario

  • Atropine 2mg IV PRN

    (titrate to HR & s/s)

  • At this point, the pt requires continuous monitoring to ensure complete resolution of his s/s


Scenario19

Scenario

  • Are there any special considerations for this pt?


Scenario20

Scenario

  • Are there any special considerations for this pt?

    • In many cases of organophosphate poisoning the pt requires massive amounts of atropine (13 mg is not unheard of).


Scenario21

Scenario

  • The pt is delivered to the hospital in relatively stable condition, & you give your verbal report to the MD. The pt’s s/s have NOT completely resolved.

  • Following additional assessment in the ED & treatment with the drug- pralidoxime, he is admitted to ICU for 1 week. Then he is discharged home.


Review protocol

Review Protocol

  • Go to Ingestion/Poisoning Protocol- Adult


Dot national standard emt intermediate 85 refresher

  • Perspective

  • Pathophysiology

  • Epidemiology

  • Physical Exam Findings

  • Diagnostic Findings

  • Signs and Symptoms

  • Differential considerations

  • Scenario

  • Treatment


Questions

Questions?


Questions1

Questions?

  • References

    • Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010.

    • Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011.

    • Wolfson, Allan B. ed. , Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.


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