The Victim of Drowning Abused Drugs February 2014

The Victim of Drowning Abused Drugs February 2014 CE Condell Medical Center EMS System Site Code: 107200 E-1214 Prepared by: Sharon Hopkins, RN, BSN, EMT-P Rev 2. 14 1

Objectives Upon successful completion of this module, the EMS provider will be able to: Discuss definition and circumstances of drowning Describe the pathophysiology of drowning. Discuss the assessment and management of the patient who has drowned. List the categories of drugs most commonly abused. 2

Objectives cont’d Describe the effects on the body systems based on the drug abused. Describe complications noted with abuse of drugs Discuss assessment and management of the patient who has abused drugs. Describe the benefits of using capnography in patient assessment and in defining patient care. Actively participate in interpretation of waveform capnography. 3

Objectives cont’d Actively participate in review of selected Region X SOP’s. Actively participate in case scenario discussion. Review responsibilities of the preceptor role. Successfully complete the post quiz with a score of 80% or better. 4

Definition and Stats of Drowning is death by suffocation due to immersion in water l Death is within 24 hours of the incident Near-drowning is survival past the 24 hour mark from the incident Most likely victims are young and healthy 3 likely victims Toddlers Adolescents Elderly Recovery dependent on prompt rescue and resuscitation 5

Background on Drowning Toddlers drown in bathtubs, toilets, and buckets/pails of water Adolescents drown usually around larger bodies of water l Males proportionately higher than females Coastal areas – swimming pools most likely site Alcohol involved in approximately 40% of drownings l 75% involves use in and around boats 6

Drowning Usually occurs silently and quickly Often within reach of a rescuer l Near-by help do not recognize the situation Image of person drowning is a movie concept l l l Most people struggle to breathe and have no breath left to yell for help Most people do not wave their arms around; they use their arms to try to lift themselves out of the water Most people drowning look like they’re “playing” 7

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Potential Outcomes of Drowning Death Morbidity l Development of disability or injury related to the incident Survival with no morbidity Most surviving children found within 2 minutes; most who die are found beyond 10 minutes 9

Definitions Morbidity l l Development of disability or injury related to the incident State of being diseased or unhealthy related to the incident Mortality l Incidence of death in a population 10

Pathophysiology of Drowning An injury to primarily the pulmonary system and central nervous system (CNS) Prognosis is linked/related to l l Submersion time which directly affects the severity and duration of hypoxia Temperature of the water 11

Pathophysiology of Drowning Victim initially holds their breath Involuntary laryngospasm triggered by water in the airway Victim unable to breath causing decreased oxygen levels and increased levels of carbon dioxide With decreasing O 2 levels, laryngospasm releases, victim gasps, hyperventilates, and possibly aspirates water hypoxemia 12

Pathophysiology cont’d Water enters lungs only if actively inhaled; water does not passively infuse into lungs Developing hypoxemia and acidosis contribute the most to morbidity and mortality 13

Older Term: Dry Drowning Definition – airway closes due to laryngeal spasms from the presence of water l Hypoxemia is cause of death Includes 10 -20% of submersions Sequence involves l l l Laryngospasm Hypoxia Loss of consciousness 14

Older Term: Wet Drowning Definition – water inhaled which interferes with respirations which affects cardiovascular system Water is aspirated Surfactant is diluted l Chemical covering alveoli that keeps them open facilitating respirations Decrease in transfer of gases Atelectasis develops Ventilation perfusion mismatch occurs l Blood pumped thru deoxygenated lungs causing a decreased level of O 2 in circulating blood volume 15

Mammalian Diving Reflex Sudden exposure to cold water (<200 C (680 F)) l l l Breathing stopped - apnea Bradycardia Vasoconstriction of nonessential vascular beds • Blood shunted to heart and brain Metabolic processes slowed down Noted especially in young children Patient may appear dead l Patient cannot be pronounced if cold & dead; must be warm & dead 16

Pathophysiology of Fresh Water Drowning Fresh water moves across alveolar- capillary membrane into microcirculation l Electrolyte abnormality can occur Fresh water exposure l l l Surfactant destroyed Alveoli collapse Ventilation-perfusion mismatch occurs Pneumonia rare consequence but more likely in stagnant warm water and fresh water 17

Pathophysiology of Salt Water Drowning Salt water increases osmotic gradient l l Fluid drawn into alveoli Surfactant washed out Membrane between alveoli and capillaries damaged Ventilation-perfusion mismatch Lungs non-compliant and become filled with fluid 18

Complications of Submersion Hypoxemia – major complication Water and bacteria enter the lungs l l Development of pneumonia Development of ARDS • Lung condition causing leaky pulmonary capillaries and development of hypoxemia Hypothermia if in cold water Cervical spine injury complicates the capability of the victim to self-rescue 19

Pulmonary Injuries from Drowning Contaminated foreign material contaminates the pulmonary system Particulate matter present Bacteria has a portal of entry Vomitus increases risk of aspiration Pulmonary system exposed to chemical irritants Surfactant destroyed/washed away 20

Obtaining a History Age Underlying medical problems History drug/alcohol use/abuse Length of time submerged/unattended prior to finding Potential trauma with drowning (i. e. : dive) Change in level of consciousness Change in behavior since removal from water Prior or since any seizure activity or chest pain? Vomiting 21

Assessment of the Patient Who Has Drowned “CAB” approach if found unresponsive “ABC” approach if alive Vital signs Neurological assessment l AVPU, GCS, PMS/SMV/CMS, pupils Lung sounds Cardiac monitoring Consideration spinal immobilization/spinal motion restriction 22

Management of the Patient Who Has Drowned Typically based on findings during the assessment phase Closely monitor airway and apply precautions against aspiration Rapid transport l All victims of drowning regardless of presentation should be encouraged to be evaluated by a physician • Some problems are not immediately obvious 23

Region X SOP Adult Near Drowning Adult Routine Medical Care or Adult Routine Trauma Care Spinal precautions Consider CPAP if condition indicates Determine patient stability l Stable? Treat signs and symptoms Patient alert Skin warm and dry Systolic B/P >90 mm. Hg 24

Adult Near Drowning SOP cont’d Unstable? l l Altered mental status Systolic B/P <90 mm. Hg Secure airway Assess for hypothermia If normothermic treat dysrhythmias per protocol If hypothermic follow hypothermic protocol 25

Adult Hypothermic Protocol Adult Routine Medical Care Frostbite l l Move to warm environment Rapidly rewarm frozen areas with warm water (if available) OR Use hot packs wrapped in towel Handle skin like a burn • • • l Protect with light, dry sterile dressing Elevate and immobilize Do not let surfaces rub together Manage pain appropriately 26

Adult Hypothermic SOP cont’d Systemic hypothermia l l Avoid rough handling and excess activity Apply heat packs (as available) to axilla, groin, neck, thorax Assess pulse l l Present? – Continue assessment Absent? • Withdrawal of Resuscitative Efforts policy does not apply to these patients 27

Adult Hypothermic SOP cont’d Pulse absent l Universal Adult Emergency Cardiac Care (CPR) Evaluate flexion of extremities l l Flexible? • Follow cardiac protocol • Extend time between medications to the max • Repeat defibrillation as core temp rises Not flexible? • Follow cardiac protocol • Limit shocks to 1 • Withhold IV medications 28

Pediatric Near Drowning SOP Routine Pediatric Care Spinal Precautions Oxygenate at 100% Determine stability l Stable? Treat signs and symptoms • Awake, alert, normal respirations l Unstable? Abnormal respirations, altered mental status • Assess for gag reflex 29

Pediatric Near Drowning SOP cont’d If gag reflex absent l Intubate and assist ventilations via advanced airway with BVM • 1 breath every 6 - 8 seconds If gag reflex present l Assist ventilations via BVM • 1 breath every 3 – 5 seconds Assess for hypothermia l l Normothermic – treat dysrhythmias Hypothermic – refer to hypothermic protocol • Same as adult 30

Prognosis of Drowning Victim Often poor l l Related to multiple factors Patients worse off Initial presentation full arrest Those remaining comatose Those with fixed and dilated pupils Those in respiratory arrest Duration of hypoxemia impacts potential for survival and for body system insult 31

Prognosis cont’d Morbidity and death primarily from l l l Laryngospasm Pulmonary insult • Resulting hypoxemia and acidosis Effects on the brain and other organ systems from hypoxemia and acidosis Secondary death risk from development of ARDS Patients presenting awake and conscious have best chance of full recovery 32

Patients with Altered Mental Status Consider etiology – AEIOU-TIPPS Alcohol Trauma/temperature Epilepsy Infection Insulin Psychogenic Overdose/opiates Poisoning Uremia Shock / seizure / stroke / shunt 33

Drugs Potentially Abused Opioids/Narcotics – depresses CNS; depresses ventilations, creates feeling of euphoria Synthetic – Tramadol, Propoxyphene (Darvon), Fentanyl Semisynthetic – dextromethorphan, hydrocodone (Vicodin®, Lortab®), oxycodone (oxycontin, Percodan®, Percocet) Natural – codeine, morphine, paregoric, heroin 34

Opioids/Narcotics cont’d Long term effects l l l Restlessness Muscle and bone pain Insomnia Vomiting Cold flashes 35

Narcotic - Heroin Harvested from opium poppy 3 -6 months from planting to harvesting Snorted, injected, smoked Constricted pupils Droopy, watery eyes Dry mouth Nausea/vomiting Slow slurred speech Mental clouding Loss of coordination pulse pain sensitivity appetite sexual drive 36

Heroin cont’d Long term effects l l l Physical and psychological dependence Tolerance Mood swings Seizures Coma 37

Definitions Physical dependence l Psychological dependence l l Perceived “need” or “craving” for a drug Can last a long time even after use stops Addiction l Changes in the body after repeated use of drug that requires continued administration of drug to prevent withdrawal symptoms Compulsive drug-seeking behavior; loss of control in use of drug; drug most important thing for user Physical tolerance l Shortened duration and intensity of effects creating need for increasingly larger doses to attain desired effect 38

Drugs Potentially Abused Stimulants l Chemical substances (natural or synthetic) that affect the CNS and accelerates activities Caffeine Nicotine Adrenalin Cocaine Amphetamines 39

Stimulant - Cocaine Euphoria then depression Dilated pupils Nasal tissue irritation, perforated septum Tooth decay – anesthetic effect on gums Vasoconstriction at point of injection Increased heart rate Severe chest pain AMI – most common in 18 -45 year-old; l Coronary artery spasm and platelet activation contribute to coronary occlusion; may have no evidence noted on angiogram inspection 40

Stimulant – Cocaine cont’d Long term effects l l l Strong psychological dependence Physical tolerance Eating disorders Impotence Seizures Strokes 41

Stimulant - Cocaine Smoked l l l Effects quicker/stronger Onset 7 seconds; duration 15 minutes Short period of high Injected l l Highly water soluble – dissolves easily in water Onset 15 -30 seconds; duration 15 -20 minutes 42

Stimulant - Cocaine Crack cocaine l l Process of converting cocaine hydrochloride (HCl) back to cocaine base for smoking Ingredients added to cocaine, heated, then cooled, then filtered to collect crystals Free basing l l Process of converting cocaine HCl back to cocaine base for smoking Onset 8 - 10 seconds Effects 5 - 10 times more intense than snorting • Theory that freebasing removes contaminants making a purer product Requires adding a solvent in process which risk of explosion and fire 43

Stimulant - Methamphetamine Powder, liquid, tablets Injected, inhaled, smoked, oral Smoked – in bloodstream 5 -10 seconds High lasts 80 More potent than amphetamine Physical & psychological dependency Tolerance develops quickly Users volatile, paranoid, unreliable Intense tremendous energy; impulsive 44

Meth cont’d attention span Intense itching – “bugs” Tremors Euphoria Rapid speech Hallucinations Violence Stages: Rush up to 30 min High 4 -160 Binge-3 -15 days; ingest more to continue high Tweaking (end of binge)– psychotic state; paranoia, depression, aggression Crash – body shuts down, deep sleep 1 -3 days meth hangover – lasts 2 -14 days; deteriorated state, exhausted; starts over to feel better withdrawal – painful & difficult; lasts 30 -90 days; depressed, energy, no pleasure, crave the drug 45

Drugs Potentially Abused Bath salts – outlawed in most States l l Strong stimulant that creates aggression & hallucinations l So named due to resemblance to bath salts Labeled “not for human consumption” to avoid much oversight Synthetic similar to amphetamines Unable to identify exact chemical composition so treatment can be hampered/ difficult l 3 most common chemicals: mephedrone, pyrovalerone, methylenedioxyprovalerone (MPDV) 46

Bath Salts cont’d Snorted, injected, ingested with food/drink Strongly addictive; triggers intense cravings Agitation Hallucinations heart rate Kidney pain temp or chills Paranoia Chest pain High B/P Muscle tension Nausea Confusion May overheat and tear off clothes 47

Bath Salts cont’d Pt often reports they thought they were going to die; heavy drug users swear they will never use this again Paranoia aggressive, uncontrollable attacks on others, self-destructive with complete disassociation with reality Probably won’t respond to requests Pepper spray and tasers not likely to be effective Effects last 3 -4 hours or longer 48

Drugs Potentially Abused Depressants l Tranquilizers – used medically for anxiety, depression, sedation, seizures, anesthesia, sleep control, as antipsychotics • Anti-anxiety – Rohypnol, Valium, Xanax l l Barbiturates – seconal, Phenobarbital Non-barbiturate – haldol, Quaaludes 49

Depressants – Rohypnol - Roofies Intended as pre-med for anesthesia and treatment for insomnia Left no taste, odor, or visible effect in drinks (changed in 1977 to be visible in drinks) Onset 20 -30 min; duration 8 -120; detectable 720 Impairs judgment inhibitions Blackout/amnesia Dizziness Drunk like behavior Gait ataxia Slurring & stuttering pulse, B/P 50

Common Over-The-Counter (OTC) Products ASA and Tylenol commonly added to many over-the- counter products Inadvertent overdosing can be common 51

Drugs Commonly Abused Acetaminophen – Tylenol® Most common poisoning Suppository, tablet, liquid, drops, caplets Max dose 4000 mg/day (8 extra strength; 12 regular) >7000 mg/day could be severe OD l (14 extra strength; 22 regular) Symptoms start approximately 120 ingestion post 52

Acetaminophen – Tylenol® cont’d 1 st 24 hours l Abdominal pain l Sweating l Pale, tired 24 – 72 hours l Pain RUQ l Dark colored urine 72 - 96 hours l l l • appetite • Nausea//vomiting/diarrhea • Jaundice • urine production Blood in urine • Hungry, shaky, weak & tired Blurred vision • Fever Tachypnea, tachycardia • Confusion, coma 53

Acetaminophen – Tylenol® cont’d Good recovery if treated within 8 hours of overdose l Improvement within 7 days Liver failure and death in few days without rapid treatment Increased risk l l l Alcoholic intake >3/day Smoker Known liver disease 54

OTC Drugs Commonly Abused Acetylsalicylic acid – Aspirin Availability makes it a common source of unintentional and suicidal ingestion l Found in multiple OTC products Tablet, capsules, liquid, topical Affects multiple systems: l l l Central nervous Pulmonary Metabolic • Cardiovascular • Hepatic • Renal 55

Acetylsalicylic acid – Aspirin Earliest signs & symptoms l l Nausea & vomiting (common) Diaphoresis • Tinnitus Vertigo • Tachycardia Hyperventilation (common) As toxicity progresses l l l Agitation Hallucinations Lethargy • Delirium • Convulsions • Stupor 56

Acetylsalicylic acid – Aspirin Hyperthermia – indicates severe toxicity especially in young children Patient becomes severely hypoxic Dehydration due to vomiting, increased respiratory rate, hyperthermia GI hemorrhage more likely in chronic intoxication Field care is supportive 57

Acetylsalicylic acid – Aspirin Sample Ingestion for 166# / 75 kg Adult <150 mg/kg – no toxicity l 11, 250 mg – 35 adult ASA 150 -2300 mg/kg – mild to moderate toxicity l 22, 500 mg – 69 adult ASA 301 – 500 mg/kg – serious toxicity l 37, 500 mg – 116 adult ASA >500 mg/kg – potentially lethal toxicity l >37, 500 mg 58

Product Potentially Abused Ethylene glycol – Antifreeze Colorless, odorless, sweet tasting liquid 120 ml (4 oz) could be fatal to average sized man 1 st symptom similar to drinking alcohol (ethanol) Within few hours l Nausea & vomiting, convulsions, stupor, coma 59

Ethylene glycol – Antifreeze Overdose l l l Damage to brain, lungs, liver, kidneys Metabolic acidosis Shock Organ failure Death Outcome depends on time treatment started 60

Drugs Accidentally Ingested Nicotine ingestion l 1 full cigarette, 3 butts, one piece of nicotine chewing gum swallowed can be toxic to a toddler Product can be tempting smelling like mint, vanilla, and cherry Patient needs a medical evaluation 61

Nicotine Ingestion Mild poisoning l l Vomiting Lethargy • Sweating • Tremors Severe poisoning l l l Confusion Paralysis Seizures Field care is supportive 62

Paraphernalia Expected in Environment Syringes, needles Scales Baggies Pipes for smoking Coffee filters Glass vials Spoons Hemostats 63

Paraphernalia cont’d Pacifiers – prevents teeth grinding Vicks inhaler – opens nasal passages allowing for bigger “hit” snorted Glow sticks – to be amused by light show when waving stick around 64

Complications of Drug Abuse Destruction of nasal septum due to snorting cocaine 65

Complications of Drug Abuse Abscess at injection site and infection from intense scratching of imaginary “bugs” “Meth mouth” l Enamel eroded away due to corrosive chemicals in product 66

Complications of Drug Abuse Brain changes from use of ecstasy l l Left side is a normal brain scan Right side is 3 weeks since last use of drug 67

Complications of Drug Abuse Red indicates use of glucose – the energy source for brain function Decreased red = decreased glucose use = decreased brain activity 68

Assessment of Patients Abusing Drugs Having high index of suspicion important Assess thoroughly to identify the product to determine measures to control it Rescuer risk l l l Exposure risk during hands-on assessment Disease transmission – hepatitis C, HIV Injury due to violent patient 69

Assessment of the Patient With Abusive Behavior with Drugs Start with ABC’s l CAB if patient is in arrest Frequently monitor for changing vital signs Frequently monitor for change in respiratory status Usually perform routine medical assessments and possible trauma assessments 70

Management of Patients Abusing Drugs Protect rescuer safety first then patient Most field care is supportive and based on signs and symptoms evident Consider use of law enforcement support for violent patients Violent patient may need sedation as soon as possible l Agitation and increased activity could worsen the patient condition 71

Adult Altered Mental Status SOP Consider etiology l l l Diabetes Drug Overdose Poisoning Alcohol related Stroke Adult Routine Medical Care Immobilize C-spine as indicated 72

Adult Altered Mental Status SOP Obtain blood glucose level and record l l If <60 administer D 50% - 50 ml IVP/IO OR Glucagon 1 mg IM/IN If not alert, respirations decreased or narcotic overdose suspected l Narcan 2 mg IN/IVP/IO every 5 minutes as needed to achieve desired effect Improvement in ventilatory status Max total 10 mg 73

Adult Altered Mental Status SOP Note: l l l Attempt to identify substance(s) involved Transport with patient any containers of medications found at scene if not a safety risk Consider use of restraints prior to administration of Narcan 74

Pediatric Altered Mental Status Same as Adult SOP l except IV fluid challenge listed • 20 ml/kg Remember frequent reassessment to note how patient is handling the fluid challenge l Medication dosing based on pediatric weight 75

Narcan® (Naloxone) Narcotic/opioid antagonist Can reverse respiratory depression induced by exposure to narcotics l l l l Morphine Hydromorphine Oxycodone Demoral Heroin Paregoric Dilaudid Codeine Percodan Fentanyl Darvon Methadone Talwin Nubain 76

Narcan® (Naloxone) cont’d Onset within 2 minutes l l Reversal effects dependent on amount of narcotic taken Be prepared to repeat dosage as needed to max 10 mg IN/IVP/IO Use cautiously in patients with cardiac irritability and narcotic addiction May cause nausea, vomiting, withdrawal symptoms, seizures 77

Opioid Withdrawal Tachycardia Hypertension Anxiety Dilated pupils Rare but possible: seizures stroke dysrhythmia Sweating Vomiting/diarrhea Rhinorrhea – runny nose Piloerection - goose bumps Yawning 78

Region X SOP – Behavioral Emergencies Establish scene & personal safety Call law enforcement as appropriate Determine & document if patient threat to self/others/unable to care for self Attempt to verbally calm patient Restrain as necessary and document l Reason, type, time, response 79

Region X SOP - Behavioral Emergencies Consider medical etiology l l l Hypoxia Substance abuse/overdose Excited delirium/Hyperthermia Neurological disease (CVA, bleed) Metabolic problem (hypoglycemia) Adult/Pediatric Routine Medical Care If pediatric patient, contact Control for med orders Medical 80

Region X SOP - Behavioral Emergencies Note: All ED’s in Region X are able to accept patients with behavioral issues l All patients must be medically screened prior to admission to psych unit Bring to ED any containers found at scene that do not pose a risk Contact Medical Control in all instances where a refusal of transport is being considered 81

Region X SOP - Behavioral Emergencies For severe anxiety/agitation l l Versed 2 mg IN May repeat 2 mg IN every 2 minutes Titrate to desired effect Max up to 10 mg For additional sedation if required l l l Valium 5 mg IVP over 2 minutes Repeat as needed to max total 10 mg Or Valium 10 mg IM 82

Capnography – A Useful Tool Carbon dioxide (CO 2) is a trace gas Produced as a by-product in the body and delivered to the lungs Detectable in exhaled air Measured as a partial pressure in mm. Hg l PETCO 2 In normal conditions, PETCO 2 35 -40 mm. Hg Correlates with cardiac output 83

ETCO 2 vs PETCO 2 l detectors Colormetric qualitative devices • Indicates presence/absence of CO 2 exhaled at end of the breath l CO 2 is present or not PETCO 2 l Quantitative device • Indicates a precise level of measurable CO 2 exhaled at the end of the breath 84

Capnography Usefulness in Patient Assessment Monitors quality of CPR l l Can optimize the compression depth and rate If PETCO 2 drops below 10 mm. Hg, evaluate to improve CPR technique Indicates correct placement of endotracheal tube Can detect return of spontaneous circulation (ROSC) l If PETCO 2 abruptly increases toward the norm of 3540 mm. Hg, reassess the patient for ROSC ( pulse) 85

Capnography in Patient Assessment What is your interpretation? l Normal waveform; CO 2 exhaled at levels of 3545 mm. Hg Is intervention required? l No 86

Capnography in Patient Assessment What is your interpretation? l Hyperventilation – blowing off CO 2 therefore CO 2 Is intervention required? l l Talk patient through slowing down their rate If bagging, slow down your rate – you are hyperventilating the patient! 87

Capnography in Patient Assessment What is your interpretation? l Hypoventilation, CO 2 levels, is present possibly due to CNS depression, narcotic overdose or heavy sedation Is intervention required? l Yes, assist the patient’s ventilations 88

Capnography in Patient Assessment What is your interpretation? l l “Shark fin” appearance indicating obstruction during exhalation Seen in asthma, COPD, airway obstruction Is intervention required? l Yes, bronchodilators or suctioning may be required 89

Capnography in Patient Assessment Pt is intubated. What is your interpretation? l Flattening waveform indicates esophageal intubation; no measurement of exhaled CO 2 Is intervention required? l Yes, extubate, hyperventilate, and reintubate 90

Case Scenario Discussion Review the following cases Determine your general impression Determine appropriate course of action Discuss anything unique to the type of call encountered 91

Case Scenario #1 EMS called to the scene for a 2 year-old found floating in the bathtub They were only out of sight “a few seconds” Pediatric assessment triangle l l l Limp, flaccid, no activity No respiratory movement noted Cyanotic Consider c-spine precautions 92

Case Scenario #1 cont’d CAB assessment l l l Circulation-airway-breathing 5 -10 second pulse check- pulse rapid, regular, weak Respirations absent What intervention is required now? l Support ventilations via BVM • 1 breath every 3 -5 seconds (12 -20/minute) in peds patient • Auscultate breath sounds 93

Case Scenario #1 cont’d Assess for possible trauma Place on the monitor l Interpretation? • Sinus tachycardia 94

Case Scenario #1 cont’d What is the rate of ventilation via BVM? l 1 breath every 3 - 5 seconds (12 - 20/minute) What is the rate of ventilations via an advanced airway (ie: ETT or King airway)? l One breath every 6 -8 seconds (8 – 10 / minute) How is ETT placement confirmed? l Direct visualization, bilateral rise & fall of chest, 5 point auscultation, ETCO 2 yellow, waveform capnography • PETCO 2 35 – 45 mm. Hg noted in perfusing patient 95

Case Scenario #2 EMS called to a private residence for a 32 year-old found unresponsive. Last seen 4 -6 hours ago Found lying on the floor pale, dry, vomitus evident Pulse present but weak Respirations 4/minute with gasping Start thinking causes – AEIOU-TIPS l Hx: Valium, Tylenol, ETOH overdose today 96

Case Scenario #2 What constitutes an overdose of Valium? l 720 – 1240 mg/kg 150# = 68 kg l 68 kg x 720 mg = 49, 090 mg • Or 9, 818 - 5 mg tablets l 68 kg x 1240 mg = 84, 320 mg • Or 16, 864 – 5 mg tablets Hard to OD on valium alone Mixing Valium with alcohol becomes the hazard 97

Case Scenario #2 cont’d Assessments/interventions l Clear airway • Suction, positioning, document presence of vomitus – aspiration likely l Support ventilations • BVM 1 breath every 5 -6 seconds in adults l Prepare to protect airway Suctioning Positioning Advanced airway 98

Case Scenario #2 cont’d IV access l If unable to establish peripheral, then what? • IO – pre-tibial site initial preferred site l How do you confirm IO placement? • Needle stands up • Flushes easily and without infiltration • Fluid flows with pressure bag Obtain blood glucose level l 72 99

Case Scenario #2 cont’d Administer Narcan l 2 mg IN/IVP/IO every 5 minutes; max 10 mg What is the desired effect of Narcan? l l l Improve ventilations Don’t necessarily need patient fully awake Consider application of restraints prior to administration of Narcan If the patient is tubed, what is ventilation rate? l 1 breath every 6 -8 seconds (all ages) 100

Case Scenario #2 cont’d After IO insertion and fluid infusion begun, patient becoming more restless and moving leg around; pulse rate up; facial grimacing present l l What might be the problem? Pain due to infusion via IO route Intervention? l Slow down fluid rate; Lidocaine 50 mg over 60 seconds, wait 60 seconds then begin infusion 101

Case Scenario #3 EMS called for adult found by friends floating in the lake; unknown submersion time 0 -0 -0 Assessment/treatment required? l l l Spinal immobilization Immediate CPR – Perform CAB assessment Place patient on monitor 102

Case Scenario #3 What is the rhythm? l VF What do you do? l Administer 1 st shock and finish assessing patient to determine further course of action 103

Case Scenario #3 cont’d Decision l Is patient normothermic or hypothermic? • If normothermic, treat dysrhythmia • If hypothermic, determine if extremities flexible l If hypothermic, place warm packs • Axilla, groin, neck, thorax • If extremities can be flexed, administer medications but extend time between to longest available l Repeat defibrillation as core temp rises • If extremities cannot be flexed, then hold meds l Limit defibrillation to 1 attempt 104

Case Scenario #3 cont’d Cannot withdraw resuscitative efforts until patient warmed Adult CPR ratios? l l 1 & 2 man CPR – 30: 2 If pulse present but not breathing, support ventilations 1 every 5 - 6 seconds via BVM • 1 every 6 -8 seconds if via advance airway l If no pulse and advanced airway placed, ventilate 1 every 6 - 8 seconds 105

Case Scenario #4 EMS called for 18 year old running thru streets naked and screaming PD on scene What kind of restraints do you have? l l Verbal de-escalation Manual control Soft restraints Handcuffs only used by PD • If handcuffs used, PD must accompany EMS in the ambulance to the hospital 106

Case Scenario #4 Consider etiology l l l Hypoxia Substance abuse / OD Excited delirium / hyperthermia Neuro disease ( i. e. ; CVA, intracerebral bleed) Metabolic problems (i. e. : hypoglycemia) If peds patient contact Medical Control for medication orders 107

Case Scenario #4 cont’d For severe anxiety / agitation l l Versed 2 mg IN Can repeat every 2 min until a max of 10 mg If additional sedation is required l l Valium 5 mg IVP over 2 minutes Repeat as needed Max total dose 10 mg Or give Valium 10 mg IM 108

Reminder: Preceptor Role Your role is to nurture, guide, grow the student in their role Provide constant feedback and support Student expected to increase their knowledge and skill level over time increasing their independence Dynamic process changing over time Student can only improve with appropriate direction and guidance 109

Review of Ventilation Rates Inadequate breathing with pulse l Infant & child rescue breaths via BVM • 1 every 3 -5 seconds (12 - 20 / minute) l Adult • 1 every 5 -6 seconds (10 – 12 / minute) Ventilations with advanced airway in place l Infant, child, adult • 1 breath every 6 -8 seconds (8 – 10 / minute) • If during CPR, asynchronous with chest compressions 110

Hazards of Hyperventilation As respiratory rates increase above recommended, the patient will be hyperventilating Hyperventilation blows off CO 2 decreasing levels Vessels reflexively vasoconstrict l Impeded blood flow decreases cerebral perfusion Cell death becomes secondary insults 111

Bibliography Aehlert, B. ECG’s Made Easy. 4 th Edition. Mosby Jems. 2011. Bledsoe, B. , Porter, R. , Cherry, R. Paramedic Care Principles & Practices, 4 th edition. Brady. 2013. Region X SOP’s; IDPH Approved January 6, 2012. 2010 American Heart Association Guidelines for CPR and ECC http: //www. sgna. org/issues/sedationfactsorg/medications. aspx http: //www. tustinca. org/weblink 8/0/doc/218449/Page 1. as px http: //www. who. int/water_sanitation_health/diseases/dro wning/en/ 112

Bibliography http: //emedicine. medscape. com/article/772753 -overview www. illinoispoisoncenter. org Poison Control – 1 -800 -222 -1222 Abcpoolsafety. org Swimforlife. com http: //www. nlm. nih. gov/medlineplus/ency/article/000774. htm http: //www. dentalgentlecare. com/drug_use_&_oral_clue s. htm http: //www. drugfreeworld. org/drugfacts/crystalm eth/the-stages-of-the-meth-experience. html http: //www. huffingtonpost. com/2013/11/07/bath-saltszombies-video_n_4234691. html 113