RESCUE ROUNDSKENT HOSPITALNOVEMBER 15, 2012

Kelly McDonough, DO

PGY2

A little about me….

Everything I need to know I learned in EMS

Call #1

You arrive at the fire house at 6am for your day shift and start checking out the back of your truck. You finish re-stocking and just as everyone is about to sit down to scrambled eggs and coffee, the tones go out for your first call of the day…

“Please respond to the Bank of America for the person with altered mental status”

Everything I need to know I learned in EMS

Stop for coffee before you get to

work.

Call #1

You and your partner hop in the truck and respond down to the BOA. You are met on arrival by the Police Lt. who tells you “We got called for this guy because he was trying to break into an ATM. He’s been acting really weird…I think something is wrong with him”.

Call #1

Convinced that this is either a turf job or a case of acute incarceritis, you grab your equipment and approach your patient, who is sitting, handcuffed, on the curb in front of the bank.

Call #1

At first glance: Male in his 30s Looks agitated, disheveled, sweaty Tells you he was not trying to steal the

ATM, it was “his ATM” which he “invented and built himself” because he is “the smartest person in the world”. He is speaking very fast.

Call #1

Bloodshot eyes Pupils look like saucers

He agrees to let you take his vitals:BP 180/100, HR 110, RR 28, O2 Sat 98%RA

Call #1

While you are taking his BP, you notice track marks. He starts yelling about wanting to make a “complaint against the f&%$ing cops” for beating him up. He says they punched him in the chest and now it hurts.

You ask if he uses drugs– “No, I don’t do that stuff”

Everything I need to know I learned in EMS

People lie

Call #1

Now what?a) Turf him back to the police. This guy is

just high and your coffee is waiting for you.

b) Have him sign a refusal, he is only complaining of chest pain because he wants to file a lawsuit against the PD.

c) Do a quick PE & EKG to cover your butt.

Call #1

Now what?a) Turf him back to the police. This guy is

just high and your coffee is waiting for you.

b) Have him sign a refusal, he is only complaining of chest pain because he wants to file a lawsuit against the PD.

c) Do a quick PE & EKG to cover your butt.

Call #1

PE Alert, oriented X3 but confabulating and

paranoid Agitated, very sweaty Pupils dilated, equal, reactive to light LS clear, equal Heart regular but tachycardic No obvious trauma Tympanic temp: 102°

Call #1

You are not able to get much more of an story out of him… Can’t tell you how he got there Can’t tell you where he was coming from Can’t tell you what he was doing prior to

the police arriving

DDX?

Hypoglycemia Hypoxia Trauma Stroke Thyrotoxicosis Seizure/postictal Heat stroke

Call #1

Call #1

Call #1

He denies any PMH/MEDS/ALL He (still) denies drug use But, what about those track marks?

Reluctantly admits to shooting coke last night

Everything I Need to Know I Learned in EMS

Crack is Whack.

Call #1

Now what?a) O2, fluids, & cool him

b) O2, fluids, cool him, NTG but not Aspirin because CP is from vasoconstriction, not thrombus

c) Give O2, fluids, cool him, NTG and Aspirin

d) Take a few minutes to get the rest of his demographic information

Call #1

Now what?a) O2, fluids, & cool him

b) O2, fluids, cool him, NTG but not Aspirin because CP is from vasoconstriction, not thrombus

c) Give O2, fluids, cool him, NTG and Aspirin

d) Take a few minutes to get the rest of his demographic information

Cocaine

Inhalation (smoke) Intranasal Intravenous Intraoral (parachuting) Subcutaneous (skin popping) Per Rectum

Cocaine

Other drugs similar to cocaine: PCP Amphetamines

Meth Psuedoephedrine

Bath salts

Cocaine Stimulates the ANS

Dilated pupils ↑Heart rate ↑Heart squeeze Piloerection Vasoconstriction

Constricts pupils Heart rate Heart squeeze Vasodilation Salivation Digestion Urination Defecation

Sympathetic

“Fight or Flight”

Parasympathetic

“Rest & Digest”

Cocaine Stimulates the ANS

Dilated pupils ↑Heart rate ↑Heart squeeze Piloerection Vasoconstriction

Sympathomimetic

Constricts pupils Heart rate Heart squeeze Vasodilation Salivation Digestion Urination Defecation

Sympathetic

“Fight or Flight”

Parasympathetic

“Rest & Digest”

Cocaine

Rapidly fatal complications: Hyperthermia

Psychomotor agitation Hypertension

Vasoconstriction Cardiac Arrhythmias

Sinus tachycardia SVT Brugada type pattern

Myocardial Infarction

Other complications:

Delirium From ↑GABA (excitatory NT in brain)

Seizures Respiratory distress/failure

Lung damage from smoking crack Edema of airways/hemoptysis When intubating avoid succinylcholine

Prolongs the effects of cocaine Effects of succinylcholine itself is prolonged

Abscesses Endocarditis

Cocaine

Cocaine induced chest pain ↑HR, ↑oxygen demand of the heart Vasoconstrictioncoronary artery spasmCP Chronic cocaine use can increase

atherogenesisthrombus formatonCP Consider the cath lab in STEMI

DO NOT GIVE βblockers

Sympathetic NS

EPI/NE

α β- Constriction of blood vessels - increased heart rate

-increased heart contractility

-relaxation of smooth muscle in lungs

- relaxation of blood vessels

Sympathetic NS

EPI/NE

α β- Constriction of blood vessels - increased heart rate

-increased heart contractility

-relaxation of smooth muscle in lungs

- relaxation of blood vessels

*you can use Phentolamine,

which is a direct α blocker

Treatment

ABC

Treatment

HyperthermiaGet those shears outCold packs

HTN/Tachycardia/Delirium/SeizuresBENZOS!!!!!Diazepam 10mg q5minLorazepam 1mg q5min

Chest pain/Ischemic EKG changesMONANTG will also help with HTN

Call #2

You just finished your report from the last patient you dropped off at the hospital and as you are standing in the ambulance bay trying to explain what an awful awful is to the Kent resident riding along with you, your radio goes off…

“Please respond to the private residence for the question of an overdose”

Call #2

You respond to the scene where you are frantically being flagged down by a woman standing outside a three family home. As you get out of your truck she is yelling, “HURRY!! She took some pills…I think she is really sick!”

You and your partner grab your equipment and are lead up to the 3rd floor.

Everything I need to Know I learned in EMS

Patients who need to be carried live on the top floor.

Healthy, ambulating patients live on the bottom floor.

Call #2

You are lead to a back bedroom where you find a woman in her 20’s laying on a bed, semi-conscious, with an empty pill bottle next to her. You ask her friend what happened…

“I’m not sure, I don’t really know her…she said she wanted to kill herself”

Call #2

At first glance: Patient is obtunded but RR is approx 18 No obvious trauma Skin color is pink, dry

You yell “Ma’am, wake up” but she does not open her eyes

Call #2

You give her a sternal rub. She pushes your hand away and opens her eyes. You ask her what happened and she mumbles, “Leave me the hell alone and let me die” and then closes her eyes again.

Call #2

Now what?a) Drop an oral airway and assist

ventilations with BVMb) Check a finger stickc) Do a primary surveyd) Scoop and screw—lets get to the hospital,

this lady won’t talk to us anyway

Call #2

Now what?a) Drop an oral airway and assist

ventilations with BVMb) Check a finger stickc) Do a primary surveyd) Scoop and screw—lets get to the hospital,

this lady won’t talk to us anyway

Call #2

ABCs Airway

Patent—she’s talking Lung sounds are clear bilaterally

Breathing RR 18 O2 sat is 97%

Circulation HR 140 BP 90/52

Call #2

Disability GCS= 11 Pupils equal, reactive, dilated FSBS=108

Now lets get an EKG…

Call #2

Call #2•Right Axis deviation•Prolonged QRS•Prolonged QT

Call # 2

You put the patient on oxygen, secure her to your stair chair and begin extrication. While you and your partner are carrying her down the stairs, you try to remember what it was that you learned about overdoses with prolonged QRS complexes in rescue rounds…

And then she starts to seize

Tricyclic Antidepressants

So named because of their shape Used to treat:

Depression ADD Anxiety

Examples: Amitriptyline Nortriptyline

Tricyclic Antidepressants

How they work: Block the reuptake of Serotonin & Norepi in the

central nervous system (SNRI) These neurotransmitters make us feel happy

and focused

But in large quantities can cause delirium, seizures

Tricyclic Antidepressants

4 major effects of TCA OD: Anticholinergic α adrenergic blockade Inhibits Norepi reuptake Na+ channel blockade

Remember this?

Epi/Nepi α β

Vasoconstriction ↑Heart rate

Piloerection Vasodilation

Dilates pupils Relaxes bronchioles

Acetylcholine

Cholinergic Receptors Constricts pupils Heart rate Perspiration Vasodilation Salivation Digestion Urination Defication

Sympathetic

“Fight or Flight”

Parasympathetic

“Rest & Digest”

TCAs are anticholinergic

Epi/Nepi α β

Vasoconstriction ↑Heart rate

Piloerection Vasodilation

Dilates pupils Relaxes bronchioles

Acetylcholine

Cholinergic Receptors Constricts pupils Heart rate Perspiration Vasodilation Salivation Digestion Urination Defication

Sympathetic

“Fight or Flight”

Parasympathetic

“Rest & Digest”

Anticholinergic

No more “rest & digest” “Can’t pee, can’t see, can’t spit, can’t sh

%!” “Blind as a bat, hot as a hare, mad as a

hatter, red as a beet, dry as a bone” Plus, unopposed “fight or flight”

TCAs Block α Receptors

Epi/Nepi α β

Vasoconstriction ↑Heart rate

Piloerection Vasodilation

Dilates pupils Relaxes bronchioles

Acetylcholine

Cholinergic Receptors Constricts pupils Heart rate Perspiration Vasodilation Salivation Digestion Urination Defication

Sympathetic

“Fight or Flight”

Parasympathetic

“Rest & Digest”

TCAs Block α Receptors

Epi/Nepi α β

Vasoconstriction ↑Heart rate

Piloerection Vasodilation

Dilates pupils Relaxes bronchioles

Refractory Hypotension!

Acetylcholine

Cholinergic Receptors Constricts pupils Heart rate Perspiration Vasodilation Salivation Digestion Urination Defication

Sympathetic

“Fight or Flight”

Parasympathetic

“Rest & Digest”

TCAs block Norepi reuptake

TCAs Block α Receptors

Epi/↑Nepi α β

Vasoconstriction ↑Heart ratePiloerection VasodilationDilates pupils Relaxes bronchioles

Acetylcholine

Cholinergic Receptors Constricts pupils Heart rate Perspiration Vasodilation Salivation Digestion Urination Defication

Sympathetic

“Fight or Flight”

Parasympathetic

“Rest & Digest”

Let’s review…

Cardiac Effects of TCAs

Block fast Na+ channels in heart cells slowing conduction, prolonging QRS

Why its bad:

Treatment of TCA OD

So what about our patient? ABCs Seizures

Benzos (again) Hypotension

FLUIDS

Treatment of TCA OD

Prolonged QRS/QT FLUIDS (NaCl), Bicarb (NaHCO3)

Why?

Treatment of TCA OD

Prolonged QRS/QT FLUIDS (NaCl), Bicarb (NaHCO3)

Treatment of TCA OD

Prolonged QRS/QT FLUIDS (NaCl), Bicarb (NaHCO3)

Treatment of TCA OD

Prolonged QRS/QT FLUIDS (NaCl), Bicarb (NaHCO3)

Treatment of TCA OD