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 Perspective Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Scenario Treatment

4. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training OD/Poisoning General treatments Specific antidotes or treatments General treatments Specific antidotes or treatments

6. 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

7. 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

8. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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) 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Poisoning/OD 80% of poisoning fatality intentional ingestion (although not all were suicidal) 2006 - 50% of fatalities suicide attempts

10. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. 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

12. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training epidemiology Pesticide intoxication –Intentional –Accidental –Occupational Pesticide intoxication –Intentional –Accidental –Occupational

14. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training organophosphates Common –Diazinon, acephate, malathion, parathion, chlorpyrifos In addition to insecticides- chemical warfare agent since WWII –Sarin - terrorist attack Tokyo subway 1995 Common –Diazinon, acephate, malathion, parathion, chlorpyrifos In addition to insecticides- chemical warfare agent since WWII –Sarin - terrorist attack Tokyo subway 1995

15. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training epidemiology Systemic absorption –Inhalation –Mucus membrane –Transdermal –Transconjunctival –GI Systemic absorption –Inhalation –Mucus membrane –Transdermal –Transconjunctival –GI

17. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology

21. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 Pt’s are on a continuum –Mild, moderate, severe –Analogy - movie Progression –Analogy drain Stable Fast Slow

22. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Organophosphate Poisoning: Physical Exam Findings, Diagnostic Findings, S/S AB-SLUDGEM ALOC Bronchorrhea (watery sputum), Breathing difficulty or wheezing, Bradycardia Salivation, Sweating, Seizures Lacrimation Urination, Defecation or Diarrhea GI upset Emesis Miosis, Muscle activity. AB-SLUDGEM ALOC Bronchorrhea (watery sputum), Breathing difficulty or wheezing, Bradycardia Salivation, Sweating, Seizures Lacrimation Urination, Defecation or Diarrhea GI upset Emesis Miosis, Muscle activity.

23. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Organophosphate poisoning: Physical Exam Findings, Diagnostic Findings, S/S Other mneumonics for the muscarinic effects of cholinesterase inhibition SLUDGE DUMBELS Killer Bees S alivation, L acrimation, U rinary incontinence, D efecation, G I pain, E mesis D efecation, U rination, M uscle weakness, m iosis, b radycardia, b ronchorrhea, b ronchospasm, E mesis, L acrimation, S alivation B radycardia, b ronchorrhea, b ronchospasm Other mneumonics for the muscarinic effects of cholinesterase inhibition SLUDGE DUMBELS Killer Bees S alivation, L acrimation, U rinary incontinence, D efecation, G I pain, E mesis D efecation, U rination, M uscle weakness, m iosis, b radycardia, b ronchorrhea, b ronchospasm, E mesis, L acrimation, S alivation B radycardia, b ronchorrhea, b ronchospasm

28. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training

29. 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 Direct acting cholinergic agents: bethanechol or pilocrapine Digitalis, clonidine, calcium or Beta-receptor agonist poisoning Miosis, bradycardia, lethargy & respiratory - opiod overdose Nicotine poisoning

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

31. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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.

32. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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 Scenario

33. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario INITIAL ASSESSMENT LOC Conscious, but anxious Chief Complaint “I drank this container of insecticide (called parathion) so I can kill myself.” Airway & Breathing Airway is patent & respirations are labored but with adequate tidal volume. Circulation Pulse is weak & slow; skin is signs are normal.

34. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Question? What initial management is indicated for this patient?

35. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Go to “Call Matrix- General”

36. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Question? What initial management is indicated for this pt? –After the scene size up and the initial assessment Diagnostics, Monitoring & Mtg Verbal Survey that includes pertinent positives/negatives & hx, meds, allergies Specific Protocol Treatments What initial management is indicated for this pt? –After the scene size up and the initial assessment Diagnostics, Monitoring & Mtg Verbal Survey that includes pertinent positives/negatives & hx, meds, allergies Specific Protocol Treatments

37. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario Is the pt stable or unstable? What is your rationale? Is the pt stable or unstable? What is your rationale?

38. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario After placing the pt on supplemental oxygen, an IV line of NS is established & set at KVO You conduct a hx & PE After placing the pt on supplemental oxygen, an IV line of NS is established & set at KVO You conduct a hx & PE

39. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario What size IV catheter would you use? –Rationale? What size IV catheter would you use? –Rationale?

40. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario What size IV catheter would you use? –Rationale? Large bore = 14 or 16ga What size IV catheter would you use? –Rationale? Large bore = 14 or 16ga

41. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario Verbal Survey & Physical Exam What did you do to try to kill yourself? “I drank this insecticide” Did you take any other agents? Alcohol, etc? “No, just the insecticide” How much did you drink? “Probably about 16 ounces” What time did you do this? “5 minutes before calling you - 911” How do you feel right now? Are you in pain? “I don’t have pain really. I just feel dizzy & I have abdominal cramps.” Interventions prior to EMS “Nothing” Breath sounds LS clear & = bilaterally

42. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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.”

43. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario Baseline VS & SAMPLE Hx BP, Pulse, Respirations 80/60, HR 40, 10 & slightly labored Oxygen Saturation 100% (on 100% oxygen) S/S Dizzy, abdominal cramps, salivating, defecating allergies “none that I know of” Medications “I don’t take anything” Pertinent Past Hx “I do not have any medical problems.” Last Oral Intake “I ate lunch about 5 hrs ago.” Events leading to present illness “I was depressed & drank the insecticide”

44. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario What is your field impression of this pt? –Give your rationale What is your field impression of this pt? –Give your rationale

45. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 This pt is suffering from organophosphate poisoning. The following assessment findings support a field impression of organophosphate poisoning: –Bradycardia –Low BP –Defecation –Salivation –Insecticide

46. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario What treatment will you provide to this patient?

47. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario General –Position, VS, SPO 2, Oxygen & airway, IV Specific –Atropine 2mg IV/IM q 5 minutes PRN (discuss IM) General –Position, VS, SPO 2, Oxygen & airway, IV Specific –Atropine 2mg IV/IM q 5 minutes PRN (discuss IM)

48. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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

49. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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

50. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario Ongoing Assessment LOC Conscious & alert to person, place & time, but appears drowsy Airway & Breathing Respirations 10; labored Oxygen Saturation 100% (on 100% oxygen) BP, Pulse 80/60, HR 40 Breath sounds LS clear & = bilaterally

51. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario Is further treatment required for this pt?

52. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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 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

53. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Scenario Are there any special considerations for this pt?

54. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training 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). 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).

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

56. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Review Protocol Go to Ingestion/Poisoning Protocol- Adult

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

58. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Questions?

59. 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.