Part 1: Medical Emergency Sepsis Part 2: Addiction and Opiates

1. Part 1: Medical EmergencySepsis Part 2: Addiction and Opiates Edward EMS 2nd Quarter 2014 ECRN

2. What is Sepsis? Bad, Bad Stuff! • Presence of infection along with systemic inflammatory response • Complex condition • High mortality rate • 20-50% Sepsis Emergency Video

3. Comparison with Other Diseases Cases per 100,000 Deaths per year Mortality Incidence Breast cancer2 Colon cancer2 CHF3 Severe sepsis4 Colon cancer2 Severe sepsis4 AIDS1 AIDS1 AMI Mortality from severe sepsis remains unacceptably high, even with the best standard care4 Data from: 1. National Center for Health Statistics, 2001. 2. American Cancer Society, 2001. 3. American Heart Association, 2000. 4. Angus DC, et al. Crit Care Med. 2001;29:1303-1310.

4. How Does Severe Sepsis Compare to Your Current Care Why do you think that severe sepsis has not received the same focus as these other common disease states? American Heart Association. Heart Disease and Stroke Statistics 2006 Update. 2. National Center for Health Statistics. Available at: www.cdc.gov/nchs/fastats/pneumonia.htm. Accessed 2/04/05. 3. Angus DC et al. Crit Care Med 2001;29(7):1303-1310.

5. SIRS- Recap of Symptoms Systemic Inflammatory Response Syndrome • Fever • HR • RR • WBC • PaCO2 <32 • Two or more of these clinical symptoms

6. S I R S Infection SIRS Sepsis Severe Sepsis SIRS with a presumed or confirmed infectious process • Sepsis • with 1 sign of organ dysfunction, • hypoperfusion or hypotension. • Examples: • Cardiovascular • (refractory hypotension) • Renal • Respiratory • Hematologic • CNS • Unexplained • metabolic acidosis Adult Criteria A clinical response arising from a nonspecific insult, including ≥ 2 of the following: Temperature:> 38°C or < 36°C Heart Rate: > 90 beats/min Respiration: > 20/min WBC count:> 12,000/mm3, or < 4,000/mm3, or > 10% immature neutrophils Shock SIRS = Systemic Inflammatory Response Syndrome Bone et al. Chest.1992;101:1644-1654.

7. Systemic Inflammatory Response • Body’s normal response to infection • WBCs (monocytes & macrophages) perform phagocytosis • Generate & release cytokines • Nonspecific mediators of inflammation

8. Systemic Inflammatory Response • Hemodynamic compromise including arterial hypotension, peripheral vasodilation, hypovolemia from capillary leak and myocardial depression • Endothelial damage ↑ capillary permeability & edema formation leading to organ system dysfunction

9. Pathophysiology Review CardiovascularTachycardia Hypotension Altered CVP and PAOP CNS Altered consciousness Confusion RespiratoryTachypnea  PaO2  PaO2/FiO2 ratio RenalOliguria Anuria  Creatinine HepaticJaundice  Liver enzymes  Albumin Hematologic  platelets,  PT/INR/ aPTT  protein C  D-dimer Metabolic Metabolic acidosis  Lactate level  Lactate clearance Modified from criteria published in: Balk RA. Crit Care Clin. 2000;16:337-352. Kleinpell RM. Crit Care NursClin N Am 2003;15:27-34

10. Stages- Severe Sepsis • Leading cause of death in noncoronary ICU (US) • 10th leading cause of death overall (US) • >750,000 cases of severe sepsis annually • In the US alone, more than 500 patients die of sepsis per day

11. Stages- Severe Sepsis • Acute organ system dysfunction • Increased severity of illness and length of stay • Mortality rates of 20% to 50%.

12. Stages- Septic Shock Sepsis + Hypotension (despite fluid resuscitation) _____________ SEPTIC SHOCK • Multiple Organ Dysfunction Syndrome • Altered organ function in acutely ill patient

13. Causes/Sources • Urinary- especially with Foley catheter • Wounds • GI • Lung • Other sources such as invasive lines • 30% of cases have no identifiable cause

14. Break Time Break Time

15. Differences Among the Ages Adult vs. Pediatrics You are the EMD- what resources would you need to dispatch to this call? Click Here

16. Adult Sepsis • Age > 65 y/o compromise 65% of the sepsis population • Immunocompromised due to aging • Multiple chronic diseases • Older folks get SICKER QUICKER and WORSE

17. Pediatric Sepsis • Neonatal Sepsis • Increased risk from: • Mom has group B strep while pregnant • Pre-term • Mom’s water breaks >24 hrs before delivery • Common Infections: • RSV • Cytomegalovirus • E. Coli • Herpes • Other Risks: • Hospitalization • Exposure to those with infection

18. Pediatric Sepsis- Older Children • Daycare • School • Sports • Invasive procedures or surgery • Wounds • Staph aureus • MRSA • UTI • Ear infections • Pneumonia • Meningitis

19. Scenario • Dispatched for a 4mo old with a seizure • EMD- what additional questions would you be asking the caller? • EMD- what/how many units would you dispatch? • EMS- what/how many units would your department send to this type of call?

20. BLS Crew Arrives First….. • Appearance: • Eyes closed • Work of Breathing: • Tachypneic • Shallow • Circulation to Skin: • Flushed • Petechia on arms & legs • Mottled extremities

21. Petechia

22. ALS…… what would you do?

23. Symptoms What might you see for all ages ?

24. Symptoms • Fever • Hypothermia • RR • Altered mental status • Edema • glucose (without being diabetic) • LOW blood pressure • Lower O2 saturation

25. Treatment- Medical EMERGENCY • Early identification • Early treatment • Aggressive treatment

26. Early Identification • Where is the patient coming from? • Ask the patient • Ask the caregivers • Ask the nursing home/rehab staff

27. Treatment- Early & Aggressive • IV fluids • Shock, shock, shock…..no one wants this to happen • SOP bolus amount? • Patient may require at least 30 mL/kg IV fluid bolus • Antibiotics in the hospital

28. Treatment- Early & Aggressive • Dopamine (or other vasopressors) • Results will depend on the age and overall health of patient • Remember that young peds may not have the epi/norepi stores to allow Dopamine to work • What is this patient arrests? • What other medication would you consider? • SODIUM Bicarb

29. Sepsis Definition: • ≥2 SIRS • + Identified or Suspected • Infection Sepsis Screening • Severe Sepsis Definition: • ≥2 SIRS • +Identified or Suspected • Infection • +New Onset Organ Dysfunction • Organ Dysfunction Criteria: • * Acutely Altered Mental Status (unrelated to primary neuropathology) • BP < 90 or 40mmHg less than baseline • SaO2 < 92% or increasing O2 requirements • Lactate > 20 mg/dL • Creatinine > 2mg/dL, or > 0.5mg above baseline • Urine output < 30 mL/hour or < 250mL in 8 hours (if no foley present) • PLT < 100K • INR > 1.5 or Ptt > 60 • Total Bilirubin > 2 • (BPA captures VS from last 2 hours, and lab values from past 24 hours)*

30. STROKE

31. Stroke- A Review • Stroke is the 4th leading cause of death • 800,000 strokes will be diagnosed this year • Stroke is the # 1 leading cause of disabilities in the United States • An estimated 70 billion dollars in direct and indirect costs are related to stroke every year

32. Stroke- Cerebrovascular Circulation • Receives approximately 750ml/min of blood • 15-20% of cardiac output • 20% of oxygen consumed is used to convert glucose to energy • Lack of oxygen for 5 minutes = irreversible brain damage

33. Stroke- Clinical Manifestations • Vary with the extent and location of occlusion • Collateral Flow • Often cover more than one territory

34. Stroke- For EMS • Airway, Breathing, Circulation • Neurologic Exam (Stroke Recognition) • Cincinnati Pre-Hospital Stroke Scale • Establish Time of Onset • Last Time Known Well • Blood Sugar • Notify Emergency Department • Rapid Transport

35. The Future of EMS & Stroke Care • Cleveland Clinic currently in active trial development here in the United States • Trial plan will include: Paramedic, Stroke APN, & EMT • IV t-PA to be started in the ambulance prior to leaving the site • UTHealth also deployed a Mobile Stroke Unit Feb 2014

36. Medication of the Month- Versed • Midazolam • Classification • Action • Route

38. Medication of the Month- Versed • Adult • Sedation/Seizures • IV dose • ___ mg increments • IV/IO • Every ___ min • Max ___ mg • IN dose • ___ mg in ___ mL • IM dose • < ___ kg= ___ mg • > ___ kg= ___ mg • Peds • Seizures • ___ mg/kg IV • ___ mg/kg IN • Max initial dose= ___ mg • Every ___ min • Other uses • ___ mg/kg IV/IO • Max ___ mg/kg • ___ mg/kg IM

39. Rhythm

40. Rhythm • Idioventricular • Rate: 20-40 • Rhythm: regular • P waves: absent or not related • PR Interval: n/a • QRS: > .12

41. Scenario • Let’s go back to the dispatched call for the fall victim at 0518hrs • 84 y/o male sitting in a chair upon EMS arrival, awake and talking • Wife says he got up to the bathroom and fell. She heard it, but wasn’t in the room • What should we do?

42. A Little More Info • He denies head, neck or back pain • HX= dementia, blind in right eye • Meds= unknown • Allergies= NKA • V/S= 107- 12- 68/42- 93% RA • Glucose= 82 • Cardiac Monitor= Sinus Tach • GCS= 15

43. Ambulance Radio Report • ECRNs- What did you get from this call? • Is there anything else that should’ve been asked? • EMS- what do you think the crew missed in their radio report?

44. Outcome- ED Eval & Impression • Pt c/o chills, fatigue • Noted to have AMS by ED doctor • V/S= 101.5- 122- 24- 94% RA- 87/50 • CT head negative • WBC 17.9 • Lactate 19.7 • Admitted to ICU with SEPTIC SHOCK • Who would’ve thought a FALL would turn into sepsis………keep your mind open

45. SKILL TIME • PRACTICE PRACTICE PRACTICE

46. Addiction and Opiates Part 2

47. Objectives • SME video of the month • Opiates affect on the body • 2013 Narcan data study • Review of Toxicologic SOPs • Law Enforcement and Narcan • Addiction as a Disease:Russell Brand

48. Dependence • Body’s adaptation to a drug • Requires increases in dosage to maintain adequate pain relief (tolerance) • Often requires weaning off of medication to avoid withdrawal symptoms

49. Pseudoaddiction Vs. Addiction Pseudoaddiction • Patient’s who are desperate for pain relief • Will take any medication possible (even illegal) to obtain pain relief • Differs from addiction in that their “drug seeking” stops when pain is effectively treated. Addiction • Poor control over drug use • Compulsive drug use • Continued use despite physical, social, and mental harm • Craving the drug

50. Addicts vs. Pain Patients Addicts …take drugs to get high and avoid life … islolate themselves/become lost …unable to interact appropriately with society …unable to hold down a job …continuous downward spiral Pain Patients* …take drugs to function normally and get on with life …interact and make positive contributions to society …active members with their family …often able to work *when pain effectively managed