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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

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
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.
slide32

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
question
Question?
  • What initial management is indicated for this patient?
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
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.”
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
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
slide57
Perspective
  • Pathophysiology
  • Epidemiology
  • Physical Exam Findings
  • Diagnostic Findings
  • Signs and Symptoms
  • Differential considerations
  • Scenario
  • Treatment
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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