1. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DOT National Standard EMT-Intermediate/85 Refresher DOT National Standard EMT-Intermediate/85 Refresher Welcome!

2. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease

3. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES Possible overdose Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment

4. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training OD/Poisoning General –Support ABCs –Poison control (1-800-222-1222) –Empty the stomach Gastric lavage Syrup of ipecac –Activated Charcoal (adsorbent) 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

5. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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

6. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Poisoning/OD Nerve Agent/Organophosphate Exposure Beta-blocker toxicity Narcotic opioid OD Ethanol OD Nerve Agent/Organophosphate Exposure Beta-blocker toxicity Narcotic opioid OD Ethanol OD

7. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Perspective Ethanol has been used by humans since prehistory as the intoxicating ingredient of alcoholic beverages Dried residue on 9,000-yr-old pottery found in China imply that Neolithic people consumed alcoholic beverages Ethanol has been used by humans since prehistory as the intoxicating ingredient of alcoholic beverages Dried residue on 9,000-yr-old pottery found in China imply that Neolithic people consumed alcoholic beverages

8. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Perspective Ethanol (CH 3 CH 2 OH, molecular weight 46.07) is a colorless, volatile liquid and is the most frequently used & abused drug in the world

9. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Perspective Most morbidity from acute ethanol intoxication is related to secondary injuries rather than direct toxic effects Toxicity most commonly results from ingestion, but ethanol may also be absorbed via inhalation or percutaneous exposure Most morbidity from acute ethanol intoxication is related to secondary injuries rather than direct toxic effects Toxicity most commonly results from ingestion, but ethanol may also be absorbed via inhalation or percutaneous exposure

10. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Perspective Ethanol is readily available in many different forms. Standard alcoholic beverages –12oz of beer = 2-6% ethanol by volume –5oz of wine = 10-20% ethanol by vol. –1.5oz of 80-proof spirits = 40% ethanol by vol. Ethanol is readily available in many different forms. Standard alcoholic beverages –12oz of beer = 2-6% ethanol by volume –5oz of wine = 10-20% ethanol by vol. –1.5oz of 80-proof spirits = 40% ethanol by vol.

11. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective In the 18th century & until Jan 1980, the UK defined alcohol content in terms of “proof spirit” Defined as the most dilute spirit that would sustain combustion of gunpowder In the 18th century & until Jan 1980, the UK defined alcohol content in terms of “proof spirit” Defined as the most dilute spirit that would sustain combustion of gunpowder

12. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective The term originated in the 18th century, when payments to British sailors included rations of rum

13. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective To ensure that the rum had not been watered down, it was “proved” by dousing gunpowder in it

14. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective Then tested to see if the gunpowder would ignite If it did not, then the rum contained too much water and was considered to be “under proof” Then tested to see if the gunpowder would ignite If it did not, then the rum contained too much water and was considered to be “under proof”

15. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective It was found that gunpowder would not burn in rum that contained less than 57.15% alcohol by volume (abv) Therefore, rum that contained this percentage of alcohol was defined to have “100 degrees proof” It was found that gunpowder would not burn in rum that contained less than 57.15% alcohol by volume (abv) Therefore, rum that contained this percentage of alcohol was defined to have “100 degrees proof”

16. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective An alcohol content of 57.15% abv is very close to a 4:7 ratio of alcohol to the total volume of the liquid Thus, the definition amounted to declaring that (4 divided by 7) x 175 = 100 degrees proof spirit. An alcohol content of 57.15% abv is very close to a 4:7 ratio of alcohol to the total volume of the liquid Thus, the definition amounted to declaring that (4 divided by 7) x 175 = 100 degrees proof spirit.

17. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective Rum that contains 50% abv had (3.5 divided by 7) x 175 = 87.5 degrees proof spirit Alcohol proof in the US is defined as twice the percentage of alcohol by volume Consequently 100-proof whiskey contains 50% alcohol by volume Rum that contains 50% abv had (3.5 divided by 7) x 175 = 87.5 degrees proof spirit Alcohol proof in the US is defined as twice the percentage of alcohol by volume Consequently 100-proof whiskey contains 50% alcohol by volume

18. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology Ethanol is rapidly absorbed after oral administration & blood levels peak about 30-60 minutes after ingestion The presence of food in the stomach prolongs absorption and delays the peak blood level Ethanol is rapidly absorbed after oral administration & blood levels peak about 30-60 minutes after ingestion The presence of food in the stomach prolongs absorption and delays the peak blood level

19. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology High concentrations of ethanol in the stomach may cause pylorospasm & delays gastric emptying Theoretically, one standard drink will elevate the blood ethanol level by 35mg/dl, assuming instantaneous & complete absorption & no distribution or metabolism High concentrations of ethanol in the stomach may cause pylorospasm & delays gastric emptying Theoretically, one standard drink will elevate the blood ethanol level by 35mg/dl, assuming instantaneous & complete absorption & no distribution or metabolism

20. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology Only a small proportion of ethanol is excreted unchanged in the urine >90% is eliminated via enzymatic oxidation by 3 pathways in the liver: –Alcohol dehydrogenase pathway - principle –Catalase - minor –Microsomal ethanol-oxidizing system - minor Only a small proportion of ethanol is excreted unchanged in the urine >90% is eliminated via enzymatic oxidation by 3 pathways in the liver: –Alcohol dehydrogenase pathway - principle –Catalase - minor –Microsomal ethanol-oxidizing system - minor

21. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology Alcohol dehydrogenase pathway (ADH) –Starts in stomach More pronounced in men than women More pronounced in tolerant individuals Alcohol dehydrogenase pathway (ADH) –Starts in stomach More pronounced in men than women More pronounced in tolerant individuals

22. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology Conversion process process –Metabolism of ethanol to acetaldehyde (catalyzed by a 2nd class of ADH in liver) –Acetaldehyde >> acetate by aldehyde dehydrogenase (ALDH) –Acetate >> CO 2 + H 2 O Mutation in mitochondrial ALDH have a decreased ability to metabolize acetaldehyde Conversion process process –Metabolism of ethanol to acetaldehyde (catalyzed by a 2nd class of ADH in liver) –Acetaldehyde >> acetate by aldehyde dehydrogenase (ALDH) –Acetate >> CO 2 + H 2 O Mutation in mitochondrial ALDH have a decreased ability to metabolize acetaldehyde

23. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology Acetaldehyde accumulation –30% of Caucasians –40% of Asians –80% of Native Americans flushing Acetaldehyde accumulation –30% of Caucasians –40% of Asians –80% of Native Americans flushing

24. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology A 70kg adult male metabolizes 7 to 10 g of alcohol per hour, corresponding to an hourly decrease of the blood ethanol level by approximately 15 to 20 mg/dL/hr The tolerant individual may increase this clearance of ethanol to 30mg/dL/hr A 70kg adult male metabolizes 7 to 10 g of alcohol per hour, corresponding to an hourly decrease of the blood ethanol level by approximately 15 to 20 mg/dL/hr The tolerant individual may increase this clearance of ethanol to 30mg/dL/hr

25. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology The exact mechanism of inebriation is still unclear, but current theories postulate that ethanol acts upon a variety of neurotransmitters –GABA A –Blocks NMDA CNS stimulant & CNS depressant! The exact mechanism of inebriation is still unclear, but current theories postulate that ethanol acts upon a variety of neurotransmitters –GABA A –Blocks NMDA CNS stimulant & CNS depressant!

26. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology Blood alcohol concentration symptoms 0.05% Euphoria, talkativeness, relaxation 0.1% CNS depression, nausea possible vomiting, impaired motor & sensory function, impaired cognition >0.14% Decreased blood flow to brain 0.3% Possible unconsciousness 0.4% Possible death >0.55% death

27. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Differential Diagnosis Considerations Acute alcohol intoxication is a dx of exclusion –Hypoglycemia –Hypoxia –Carbon dioxide narcosis –Mixed alcohol-drug OD –Ethylene glycol poisoning –Methanol poisoning –Hepatic encephalopathy –Psychosis –Severe vertigo –seizures Acute alcohol intoxication is a dx of exclusion –Hypoglycemia –Hypoxia –Carbon dioxide narcosis –Mixed alcohol-drug OD –Ethylene glycol poisoning –Methanol poisoning –Hepatic encephalopathy –Psychosis –Severe vertigo –seizures

28. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Review Protocol Go to ALOC-Adult

29. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment

30. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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. 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.