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DOT National Standard EMT-Intermediate/85 Refresher

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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  1. Welcome! DOT National Standard EMT-Intermediate/85 Refresher

  2. MEDICAL EMERGENCIES • Allergic reaction • Possible overdose • Near-drowning • ALOC • Diabetes • Seizures • Heat & cold emergencies • Behavioral emergencies • Suspected communicable disease

  3. Possible overdose Perspective Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Scenario Treatment MEDICAL EMERGENCIES

  4. 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

  5. OD/Poisoning • General treatments • Specific antidotes or treatments

  6. 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

  7. 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

  8. 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)

  9. Poisoning/OD • 80% of poisoning fatality intentional ingestion (although not all were suicidal) • 2006 - 50% of fatalities suicide attempts

  10. 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

  11. Poisoning/OD • Nerve Agent/Organophosphate Exposure • Beta-blocker toxicity • Narcotic opioid OD • Ethanol OD

  12. 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

  13. epidemiology • Pesticide intoxication • Intentional • Accidental • Occupational

  14. organophosphates • Common • Diazinon, acephate, malathion, parathion, chlorpyrifos • In addition to insecticides- chemical warfare agent since WWII • Sarin - terrorist attack Tokyo subway 1995

  15. 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

  16. epidemiology • Systemic absorption • Inhalation • Mucus membrane • Transdermal • Transconjunctival • GI

  17. 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

  18. 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

  19. 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

  20. pathophysiology

  21. 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

  22. 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.

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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.

  30. 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.

  31. 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

  32. Scenario

  33. Question? • What initial management is indicated for this patient?

  34. Go to “Call Matrix- General”

  35. 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

  36. Scenario • Is the pt stable or unstable? • What is your rationale?

  37. Scenario • After placing the pt on supplemental oxygen, an IV line of NS is established & set at KVO • You conduct a hx & PE

  38. Scenario • What size IV catheter would you use? • Rationale?

  39. Scenario • What size IV catheter would you use? • Rationale? • Large bore = 14 or 16ga

  40. Scenario

  41. 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.”

  42. Scenario

  43. Scenario • What is your field impression of this pt? • Give your rationale

  44. 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

  45. Scenario • What treatment will you provide to this patient?

  46. Scenario • General • Position, VS, SPO2, Oxygen & airway, IV • Specific • Atropine 2mg IV/IM q 5 minutes PRN • (discuss IM)

  47. 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

  48. 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

  49. Scenario

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