dot national standard emt-intermediate/85 refresher

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training

QuickTime™ and a

decompressorare needed to see this picture.

QuickTime™ and a decompressor

are needed to see this picture.

DOT National Standard

EMT-Intermediate/85 RefresherDOT National Standard

EMT-Intermediate/85 Refresher

Welcome!


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.MEDICAL EMERGENCIES

• Possible overdose• Possible overdose

• 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


QuickTime™ and a




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


QuickTime™ and a



are needed to see this picture.OD/Poisoning• General treatments• Specific antidotes or treatments• General treatments• Specific antidotes or treatments


QuickTime™ and a



are needed to see this picture.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

• Specific– Toxidromes (common toxic syndromes)• Anticholinergic• Sympathomimetic• Opioid/sedative/ ethanol• Cholinergic


QuickTime™ and a



are needed to see this picture.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

• Hydrofluric acid• Iron• Lead• Methanol• Methemoglobin-forming

agents• Opioids• Organophosphates &

carbamates• Rattlesnake bite• Serotonin syndrome• Sulfonureas• Valproic acid


QuickTime™ and a



are needed to see this picture.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)


QuickTime™ and a




Poisoning/OD• 80% of poisoning fatality intentional ingestion (although not all were suicidal)

• 2006 - 50% of fatalities suicide attempts

• 80% of poisoning fatality intentional ingestion (although not all were suicidal)

• 2006 - 50% of fatalities suicide attempts


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.epidemiology• Pesticide intoxication

– Intentional– Accidental– Occupational

• Pesticide intoxication– Intentional– Accidental– Occupational


QuickTime™ and a




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


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.epidemiology• Systemic absorption

– Inhalation– Mucus membrane– Transdermal– Transconjunctival– GI

• Systemic absorption – Inhalation– Mucus membrane– Transdermal– Transconjunctival– GI


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.pathophysiology


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.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.


QuickTime™ and a




• 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


QuickTime™ and a




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

• Acetylcholine is the presynaptic neurotransmitter at nicotinic receptors in the sympathetic ganglia & adrenal medulla

• Pallor, mydriasis (pupil dilatation), tachycardia, HTN


QuickTime™ and a




• 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


QuickTime™ and a




• The cholinergic toxidrome may vary depending on the predominance of muscarinic, nicotinic, and central neurologic manifestations and the severity of the intoxication

• The cholinergic toxidrome may vary depending on the predominance of muscarinic, nicotinic, and central neurologic manifestations and the severity of the intoxication


QuickTime™ and a




• 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

• 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


QuickTime™ and a





QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.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.


QuickTime™ and a



are needed to see this picture.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.

• You arrive at the scene at 17:05 where you find the pt sitting in the aisle of the store. He is sobbing uncontrollably.


QuickTime™ and a




• 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


QuickTime™ and a



are needed to see this picture.ScenarioINITIAL 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.


QuickTime™ and a



are needed to see this picture.Question?• What initial management is indicated for this patient?

• What initial management is indicated for this patient?


QuickTime™ and a




• Go to “Call Matrix- General”• Go to “Call Matrix- General”


QuickTime™ and a




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


QuickTime™ and a




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


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a




Scenario• What size IV catheter would you use?– Rationale?

• What size IV catheter would you use?– Rationale?


QuickTime™ and a




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


QuickTime™ and a



are needed to see this picture.ScenarioVerbal 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


QuickTime™ and a



are needed to see this picture.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.”

• 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.”


QuickTime™ and a




ScenarioBaseline 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”


QuickTime™ and a



are needed to see this picture.Scenario• What is your field impression of this pt?– Give your rationale

• What is your field impression of this pt?– Give your rationale


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.Scenario• What treatment will you provide to this patient?

• What treatment will you provide to this patient?


QuickTime™ and a



are needed to see this picture.Scenario• General

– Position, VS, SPO2, Oxygen & airway, IV

• Specific– Atropine 2mg IV/IM q 5 minutes PRN

•(discuss IM)

• General– Position, VS, SPO2, Oxygen & airway, IV

• Specific– Atropine 2mg IV/IM q 5 minutes PRN

•(discuss IM)


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a



are needed to see this picture.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


QuickTime™ and a




ScenarioOngoing 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


QuickTime™ and a



are needed to see this picture.Scenario• Is further treatment required for this pt?

• Is further treatment required for this pt?


QuickTime™ and a




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


QuickTime™ and a



are needed to see this picture.Scenario• Are there any special considerations for this pt?

• Are there any special considerations for this pt?


QuickTime™ and a



are needed to see this picture.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).


QuickTime™ and a



are needed to see this picture.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.


QuickTime™ and a



are needed to see this picture.Review Protocol• Go to Ingestion/Poisoning Protocol- Adult

• Go to Ingestion/Poisoning Protocol- Adult


QuickTime™ and a




• 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


QuickTime™ and a



are needed to see this picture.Questions?


QuickTime™ and a



are needed to see this picture.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.

dot national standard emt-intermediate/85 refresher

Documents