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Toxicologic Emergencies Case Studies and Management Ray Taylor Valencia Community College Department of Emergency Toxicologic Emergencies Case Studies and Management Ray Taylor Valencia Community College Department of Emergency Medical Services

Notice v All rights reserved. v Slide show used with permission only for the Notice v All rights reserved. v Slide show used with permission only for the purposes of educating emergency medical providers (EMTs and Paramedics) v No portion of this presentation may be reproduced, stored in a retrieval system in any form or by any means (including but not limited to electronic, mechanical, photocopying etc. ) without prior written permission from the author 16 March 2018 Orange County EMS System 2

Toxicologic Emergencies Objectives v Review key prehospital management features of each of the following Toxicologic Emergencies Objectives v Review key prehospital management features of each of the following poisonings: Ø Tricyclic Antidepressants Ø Anticholinergics Ø Acute Dystonic Reaction Ø Beta Blockers Ø Calcium Channel Blockers Ø Carbon Monoxide Ø Cocaine / Sympathomimetics Ø Gamma-hydroxybutyrate (GHB) 16 March 2018 Orange County EMS System 3

Drug Box 16 March 2018 Orange County EMS System 4 Drug Box 16 March 2018 Orange County EMS System 4

2004 Therapy Provided in Human Exposure Cases 16 March 2018 Orange County EMS System 2004 Therapy Provided in Human Exposure Cases 16 March 2018 Orange County EMS System 5

Categories with Largest Numbers of Deaths (2004 TESS Data) 16 March 2018 Orange County Categories with Largest Numbers of Deaths (2004 TESS Data) 16 March 2018 Orange County EMS System 6

Patient Scenario #1 v Dispatch data: “man down” v Scene: safe; Private house; Rural Patient Scenario #1 v Dispatch data: “man down” v Scene: safe; Private house; Rural location v Victims: one, 25 y/o male found unresponsive, with an empty pill bottle in his hand v Historians: victim’s girlfriend 16 March 2018 Orange County EMS System 7

Patient Scenario #1 v. Empty pill bottle found in patient’s hand ® Elavil 50 Patient Scenario #1 v. Empty pill bottle found in patient’s hand ® Elavil 50 mg Tabs #50 3/2/14 16 March 2018 Orange County EMS System 8

Patient Scenario #1 v. Hx: patient’s girlfriend states he has been depressed and ingested Patient Scenario #1 v. Hx: patient’s girlfriend states he has been depressed and ingested 50 x 50 mg tabs 1 hr ago, and progressively became more somnolent until he “passed out” about ½ hr ago 16 March 2018 Orange County EMS System 9

Patient Scenario #1 Primary Survey h. LOC: unconscious, unresponsive h. Airway: open; Saliva accumulating; Patient Scenario #1 Primary Survey h. LOC: unconscious, unresponsive h. Airway: open; Saliva accumulating; Gurgling h. Breathing: resp= 10/min; Sonorous; ê gag reflex h. Circulation: pulse rapid & weak 16 March 2018 Orange County EMS System 10

Patient Scenario #1 Secondary Survey v V/S: BP=70/40, HR=140, RR=assisted, 02 sat=82% v SKIN: Patient Scenario #1 Secondary Survey v V/S: BP=70/40, HR=140, RR=assisted, 02 sat=82% v SKIN: dry, flushed, no track marks v HEENT: pupils fixed & dilated (6 -7 mm), no evidence of head trauma v LUNGS: clear & equal bilaterally v COR: RRR v ABD: soft, decreased bowel sounds v NEURO: unresponsive, no gross focal deficits 16 March 2018 Orange County EMS System 11

Patient Scenario #1 Prehospital Secondary Interventions v. Cardiac monitor: What is the antidote? 16 Patient Scenario #1 Prehospital Secondary Interventions v. Cardiac monitor: What is the antidote? 16 March 2018 Orange County EMS System 12

Tricyclic Antidepressant Toxicity Specific Treatment Na. HCO 3 IS THE TREATMENT OF CHOICE 16 Tricyclic Antidepressant Toxicity Specific Treatment Na. HCO 3 IS THE TREATMENT OF CHOICE 16 March 2018 Orange County EMS System 13

Tricyclic Antidepressants Define the Toxidrome v Anticholinergic Hyperthermia, blurred vision, dry mouth, flushed skin, Tricyclic Antidepressants Define the Toxidrome v Anticholinergic Hyperthermia, blurred vision, dry mouth, flushed skin, hallucinations, tachycardia, and seizures v Quinidine-like=Na channel blockade Negative inotropy, prolonged Q-T, hypotension, and ventricular dysrhythmias v Alpha-adrenergic blockade Hypotension v Antihistamine CNS sedation 16 March 2018 Orange County EMS System 14

Tricyclic Antidepressant Toxicity Clinical Features v Mild-to-moderate toxicity Ø Ø Sinus tachycardia Slurred speech Tricyclic Antidepressant Toxicity Clinical Features v Mild-to-moderate toxicity Ø Ø Sinus tachycardia Slurred speech Dry mouth Drowsiness lethargy v Severe toxicity Ø Ø RAPID PROGRESSION OF SYMPTOMS IS CHARACTERISTIC OF SEVERE TCA TOXICITY Coma Seizures Dysrrhythmias Hypotension Can we predict who will go on to severe toxicity? 16 March 2018 Orange County EMS System 15

Review of Clinical Findings 16 March 2018 Orange County EMS System 16 Review of Clinical Findings 16 March 2018 Orange County EMS System 16

2004 Poisoning Fatalaties 16 March 2018 Orange County EMS System 17 2004 Poisoning Fatalaties 16 March 2018 Orange County EMS System 17

Distribution of Poisoning Fatalities (2004) due to Antidepressants 16 March 2018 Orange County EMS Distribution of Poisoning Fatalities (2004) due to Antidepressants 16 March 2018 Orange County EMS System 18

Overdose And Poisonings – General Approach 16 March 2018 Orange County EMS System 19 Overdose And Poisonings – General Approach 16 March 2018 Orange County EMS System 19

Overdose And Poisonings – General Approach General considerations v. For any overdose or poisoning Overdose And Poisonings – General Approach General considerations v. For any overdose or poisoning include determining the particular agent(s) involved, the time of the ingestion/exposure, and the amount ingested. Bring empty pill bottles, etc. , to the receiving facility. 16 March 2018 Orange County EMS System 20

Overdose And Poisonings – General Approach Basic Life Support v Secure airway while maintaining Overdose And Poisonings – General Approach Basic Life Support v Secure airway while maintaining cervical spine immobilization, as necessary. v Administer supplemental oxygen (100%) v Record and monitor vital signs v Nothing by mouth (depending on agent, patient may be at risk for seizure or rapid loss of consciousness with subsequent aspiration) 16 March 2018 Orange County EMS System 21

Overdose And Poisonings – General Approach Advanced Life Support v Advanced airway/ventilatory management as Overdose And Poisonings – General Approach Advanced Life Support v Advanced airway/ventilatory management as needed v Initiate cardiac monitoring, record and evaluate ECG strip v Record & monitor 02 saturation & end-tidal C 02 (if available by nasal cannula) v IV Na. Cl 0. 9% KVO or IV lock Ø If systolic BP remains < 90, administer boluses of 0. 9% Na. Cl at 200 -300 ml until systolic BP > 90 § Contraindicated if evidence of congestive heart failure (e. g. rales) 16 March 2018 Orange County EMS System 22

Overdose And Poisonings – General Approach Advanced Life Support v If patient has an Overdose And Poisonings – General Approach Advanced Life Support v If patient has an altered level of consciousness: Obtain a Glucometer reading. v If hypoglycemic (reading 70 [< 60 in stroke]) with IV access: Ø Dextrose 25 gm, IV bolus. Ø May repeat as needed q 5 or 10 minutes to blood glucose > 100 mg/dl Ø Thiamine 100 mg, IV with initial dextrose v If hypoglycemic (reading 70 [< 60 in stroke]) without IV access: Ø Glucose paste (Glutose) or other glucose agent (e. g. orange juice) if patient alert enough to self administer oral agent, or Ø Glucagon 1 mg, IM Ø If there is no change in mental status, administer Naloxone (Narcan) 2. 0 mg, IV bolus. § If no respiratory depression, use 0. 4 mg IV dose Ø If IV access has not been established, administer Naloxone (Narcan) 2. 0 mg, IM. § NOTE: If drug overdose is strongly suspected, administer Naloxone prior to Dextrose and Thiamine. v Refer to specific subprotocols when a specific agent has been identified or is strongly suspected. 16 March 2018 Orange County EMS System 23

Overdose And Poisonings – General Approach Medical Control (Contact Medical Control for further orders Overdose And Poisonings – General Approach Medical Control (Contact Medical Control for further orders 16 March 2018 Orange County EMS System 24

Antidepressants 16 March 2018 Orange County EMS System 25 Antidepressants 16 March 2018 Orange County EMS System 25

Antidepressants 16 March 2018 Orange County EMS System 26 Antidepressants 16 March 2018 Orange County EMS System 26

Tricyclic and Tetracyclic Antidepressants Basic Life Support v Secure airway v Administer supplemental oxygen Tricyclic and Tetracyclic Antidepressants Basic Life Support v Secure airway v Administer supplemental oxygen 100% v Record and monitor vital signs 16 March 2018 Orange County EMS System 27

Tricyclic and Tetracyclic Antidepressants Advanced Life Support v Advanced airway/ventilatory management as needed v Tricyclic and Tetracyclic Antidepressants Advanced Life Support v Advanced airway/ventilatory management as needed v Begin cardiac monitoring, record and evaluate ECG strip v Record and evaluate 12 -lead ECG v Record & monitor 02 saturation & end-tidal C 02 (if available by nasal cannulae) v IV 0. 9% Na. Cl KVO 16 March 2018 Orange County EMS System 28

Tricyclic and Tetracyclic Antidepressants Advanced Life Support v If Altered Mental Status Ø See Tricyclic and Tetracyclic Antidepressants Advanced Life Support v If Altered Mental Status Ø See Altered Mental Status Protocol v If Seizures Ø See Seizure Protocol v If wide complex (QRS >0. 12 sec), hypotension, or any arrhythmias Ø Sodium Bicarbonate 1 meq/kg IV § Repeat in 5 or 10 minutes v If Torsades de pointes Ø Magnesium Sulfate 2 gm, IV in 100 ml NS bolus (if no renal disease). 16 March 2018 Orange County EMS System 29

Tricyclic and Tetracyclic Antidepressants Medical Control (Contact medical control for further orders 16 March Tricyclic and Tetracyclic Antidepressants Medical Control (Contact medical control for further orders 16 March 2018 Orange County EMS System 30

Patient Scenario #2 Dispatch data: Scene: Victims: Historians: Hx: “man in custody” airport police Patient Scenario #2 Dispatch data: Scene: Victims: Historians: Hx: “man in custody” airport police station one patient and police patient states he swallowed a handful of rocks, is now extremely agitated, and is c/o feeling too shaky 16 March 2018 Orange County EMS System 31

Patient Scenario #2 Primary Survey LOC: Airway: Breathing: Circulation: alert, anxious and agitated clear Patient Scenario #2 Primary Survey LOC: Airway: Breathing: Circulation: alert, anxious and agitated clear and equal bounding and rapid pulse 16 March 2018 Orange County EMS System 32

Patient Scenario #2 Secondary Survey V/S: Skin: Heent: Lungs: COR: ABD: Neuro: 16 March Patient Scenario #2 Secondary Survey V/S: Skin: Heent: Lungs: COR: ABD: Neuro: 16 March 2018 BP=180/120, HR=140, RR=30, O 2 sat=96% profusely diaphoretic clear rapid and regular soft, nontender extreme psychomotor agitation Orange County EMS System 33

Patient Scenario #2 Cardiac monitor: SINUS TACHYCARDIA, RATE 140 What is the antidote? 16 Patient Scenario #2 Cardiac monitor: SINUS TACHYCARDIA, RATE 140 What is the antidote? 16 March 2018 Orange County EMS System 34

Patient Scenario #2 v. Benzodiazepines ØDiazepam/Valium ØLorezapam/Ativan ØMidazolam/Versed 16 March 2018 Orange County EMS Patient Scenario #2 v. Benzodiazepines ØDiazepam/Valium ØLorezapam/Ativan ØMidazolam/Versed 16 March 2018 Orange County EMS System 35

Hyperdynamic/ Hyperadrenergic Agents v. Cocaine (crack) v. Ketamine/phencyclidine (PCP) v. Amphetamine/methamphetamine (ice, crystal meth) Hyperdynamic/ Hyperadrenergic Agents v. Cocaine (crack) v. Ketamine/phencyclidine (PCP) v. Amphetamine/methamphetamine (ice, crystal meth) v. Ephedrine and derivatives, 2 -agonists v. Caffeine, nicotine, theophylline v. Dextromethorphan 16 March 2018 Orange County EMS System 36

Adrenergic Agent Overdose Toxidrome u Tachycardia u Hypertension u Hyperthermia u Agitation u Diaphoresis Adrenergic Agent Overdose Toxidrome u Tachycardia u Hypertension u Hyperthermia u Agitation u Diaphoresis Complications u Angina/infarction u Dissecting aorta u Seizures u Intracranial bleed u Rhabdomyolysis What are critical acute problems? 16 March 2018 Orange County EMS System 37

Cocaine and Sympathomimetic Overdose Basic Life Support v Secure airway v Administer supplemental oxygen Cocaine and Sympathomimetic Overdose Basic Life Support v Secure airway v Administer supplemental oxygen v Record and monitor vital signs 16 March 2018 Orange County EMS System 38

Cocaine and Sympathomimetic Overdose Advanced Life Support v Advanced airway/ventilatory management as needed v Cocaine and Sympathomimetic Overdose Advanced Life Support v Advanced airway/ventilatory management as needed v Begin cardiac monitoring, record and evaluate ECG strip v Record and evaluate 12 -lead ECG v Record & monitor 02 saturation & end-tidal C 02 (if available by nasal cannulae) v IV Na. Cl 0. 9% KVO 16 March 2018 Orange County EMS System 39

Cocaine and Sympathomimetic Overdose Advanced Life Support v If seizures, refer to Seizure Protocol Cocaine and Sympathomimetic Overdose Advanced Life Support v If seizures, refer to Seizure Protocol v For patients with sympathomimetic toxidrome (hypertension, tachycardia, agitation): Ø Diazepam (Valium) 5 mg, slow IV Or Ø Midazolam (Versed) slow IVP or IM § Less than 60 y/o 1 mg/minute titrated to effect (Maximum 5 mg) § Greater than 60 y/o 0. 5 mg/minute titrated to effect (Maximum 3 mg) Ø Repeat either medication in 5 -10 minutes if signs and symptoms continue 16 March 2018 Orange County EMS System 40

Cocaine and Sympathomimetic Overdose Medical Control (Call Medical Control for any additional orders or Cocaine and Sympathomimetic Overdose Medical Control (Call Medical Control for any additional orders or questions 16 March 2018 Orange County EMS System 41

Drug Induced Tachycardias Management Considerations v. Consider sodium bicarbonate for wide complex rhythms v. Drug Induced Tachycardias Management Considerations v. Consider sodium bicarbonate for wide complex rhythms v. Standard ACLS algorithms may not be effective v. Utilize pressors if patient hypotensive 16 March 2018 Orange County EMS System 42

Patient Scenario #3 Patient information: v 35 year-old farmer was working in his field Patient Scenario #3 Patient information: v 35 year-old farmer was working in his field when it was unexpectedly crop-dusted by a confused pilot v 1 hour later: he complains of difficulty breathing 16 March 2018 Orange County EMS System 43

Patient Scenario #3 v. ROS: ØGI: + N/V/D, abdominal cramps ØSkin: + profuse sweating Patient Scenario #3 v. ROS: ØGI: + N/V/D, abdominal cramps ØSkin: + profuse sweating ØEye: + blurred vision ØCNS: +dizziness and restlessness ØGU: + incontinence 16 March 2018 Orange County EMS System 44

Patient Scenario #3 v. VS: T=100. 8°F, BP=90/50 mm Hg, HR=42 bpm, RR=36/min, O Patient Scenario #3 v. VS: T=100. 8°F, BP=90/50 mm Hg, HR=42 bpm, RR=36/min, O 2 sat=86% v. PE: ØHEENT: profuse diaphoresis, BL constricted pupils, visual acuity, copius tearing ØLungs: diffuse BL rales, rhonchi, and wheezes ØABD: hyperactive bowel sounds 16 March 2018 Orange County EMS System 45

Patient Scenario #3 Cardiac monitor: SINUS BRADYCARDIA, RATE 42 What is the antidote? 16 Patient Scenario #3 Cardiac monitor: SINUS BRADYCARDIA, RATE 42 What is the antidote? 16 March 2018 Orange County EMS System 46

Patient Scenario #3 v. Atropine 16 March 2018 Orange County EMS System 47 Patient Scenario #3 v. Atropine 16 March 2018 Orange County EMS System 47

Mechanism of Action v Organophosphates and nerve agents inhibit acetylcholinesterase ØThis allows acetylcholine to Mechanism of Action v Organophosphates and nerve agents inhibit acetylcholinesterase ØThis allows acetylcholine to accumulate v Acetylcholine produces hyperstimulation of cholinergic nervous system ØMuscarinic stimulation: smooth muscles contract (eg, airway constriction); glands produce mega-secretions ØNicotinic stimulation: skeletal muscles contract (twitching) 16 March 2018 Orange County EMS System 48

Cholinergic Toxidrome “SLUDGE” v. Salivation v. Lacrimation v. Urination v. Defecation v. Gastrointestinal (nausea, Cholinergic Toxidrome “SLUDGE” v. Salivation v. Lacrimation v. Urination v. Defecation v. Gastrointestinal (nausea, cramps) v. Emesis Look for pinpoint pupils! 16 March 2018 Orange County EMS System 49

Cholinergic Toxic Effects v General: sweating v Eye: lacrimation, miosis, blurred vision v Pulmonary: Cholinergic Toxic Effects v General: sweating v Eye: lacrimation, miosis, blurred vision v Pulmonary: wheezing, rales, bronchorrhea v GI: salivation, n/v/d, cramps v CV: bradycardia, v. Muscle: fasciculations, cramps, weakness, twitching v. Sympathetic ganglia: tachycardia, hypertension v. CNS: anxiety, restlessness, confusion, ataxia, coma, seizures, insomnia hypotension v GU: urinary incontinence 16 March 2018 Orange County EMS System 50

Anticholinergic Poisoning/Organophosphates Basic Life Support v Wear protective clothing including masks, gloves, and eye Anticholinergic Poisoning/Organophosphates Basic Life Support v Wear protective clothing including masks, gloves, and eye protection. Ø Toxicity to ambulance crew may result from inhalation or topical exposure. Ø Any traces of contamination must be removed from the vehicle prior to the next transport. v Secure airway v Administer supplemental oxygen v Record and monitor vital signs v Decontaminate patient Ø Remove clothing Ø Irrigate with normal saline – may also use soap and water § Contain run-off of toxic chemicals when flushing 16 March 2018 Orange County EMS System 51

Anticholinergic Poisoning/Organophosphates Advanced Life Support v Advanced airway/ventilatory management as needed v Begin cardiac Anticholinergic Poisoning/Organophosphates Advanced Life Support v Advanced airway/ventilatory management as needed v Begin cardiac monitoring, record and evaluate ECG strip v Record and evaluate 12 -lead ECG v Record & monitor 02 saturation & end-tidal C 02 (if available by nasal cannulae) v IV 0. 9% Na. Cl KVO or IV lock 16 March 2018 Orange County EMS System 52

Anticholinergic Poisoning/Organophosphates Advanced Life Support Ø If Altered Mental Status § See Altered Mental Anticholinergic Poisoning/Organophosphates Advanced Life Support Ø If Altered Mental Status § See Altered Mental Status Protocol Ø If Seizures § See Seizure Protocol Ø If signs of severe toxicity, (severe respiratory distress, bradycardia, heavy respiratory secretions – do not rely on pupil constriction to diagnose or to titrate mediations) § Atropine 2. 0 mg IVP every 5 min – titrate until respiratory secretions/distress begins to decrease. 16 March 2018 Orange County EMS System 53

Anticholinergic Poisoning/Organophosphates Medical Control (Contact medical control for further orders 16 March 2018 Orange Anticholinergic Poisoning/Organophosphates Medical Control (Contact medical control for further orders 16 March 2018 Orange County EMS System 54

Patient Scenario #4 Patient Information: v 28 year-old female c/o inability to open her Patient Scenario #4 Patient Information: v 28 year-old female c/o inability to open her mouth, and tightness in the muscles of her jaw and face v. Patient states she thought she was given a “valium” at a party earlier 16 March 2018 Orange County EMS System 55

Patient Scenario #4 v. P. E. is unremarkable except for decreased range of motion Patient Scenario #4 v. P. E. is unremarkable except for decreased range of motion of the jaw due to muscle contractions v. VS: all within normal limits What is the antidote? 16 March 2018 Orange County EMS System 56

Patient Scenario #4 v. Benadryl 16 March 2018 Orange County EMS System 57 Patient Scenario #4 v. Benadryl 16 March 2018 Orange County EMS System 57

Antipsychotics/Acute Dystonic Reaction Commonly used antipsychotic-antipsychotic related medicines (e. g. antiemetics) in medical practice Antipsychotics/Acute Dystonic Reaction Commonly used antipsychotic-antipsychotic related medicines (e. g. antiemetics) in medical practice include but, are not limited to the following: 1. Prochlorperazine (Compazine) 2. Promethazine (Phenergan) 3. Thorazine 4. Prolixin 5. Haloperidol 16 March 2018 Orange County EMS System 58

Antipsychotics/Acute Dystonic Reaction Basic Life Support v Secure airway v Administer supplemental oxygen v Antipsychotics/Acute Dystonic Reaction Basic Life Support v Secure airway v Administer supplemental oxygen v Record and monitor vital signs 16 March 2018 Orange County EMS System 59

Antipsychotics/Acute Dystonic Reaction Advanced Life Support v v Advanced airway/ventilatory management as needed Begin Antipsychotics/Acute Dystonic Reaction Advanced Life Support v v Advanced airway/ventilatory management as needed Begin cardiac monitoring, record and evaluate ECG strip Record and evaluate 12 -lead ECG Record & monitor 02 saturation & end-tidal C 02 (if available by nasal cannulae) v IV 0. 9% Na. Cl KVO or IV lock v For dystonic reactions, administer v Diphenhydramine (Benadryl) 25 mg, IV. Ø Repeat Diphenhydramine (Benadryl) 25 mg, IV if inadequate response, in 10 minutes 16 March 2018 Orange County EMS System 60

Antipsychotics/Acute Dystonic Reaction Medical Control (Call Medical Control for any additional orders or questions Antipsychotics/Acute Dystonic Reaction Medical Control (Call Medical Control for any additional orders or questions 16 March 2018 Orange County EMS System 61

Patient Scenario #5 Patient Information: v. You respond to a basement apartment in January. Patient Scenario #5 Patient Information: v. You respond to a basement apartment in January. The apartment is being heated with a portable gas heater. v. You find an elderly male who is confused and c/o headache associated with general malaise and nausea v. You note an extremely strong gas odor 16 March 2018 Orange County EMS System 62

Patient Scenario #5 v. V/S: BP=110/50, HR=102, RR=30, O 2 sat=95% ØMucous membranes: “cherry Patient Scenario #5 v. V/S: BP=110/50, HR=102, RR=30, O 2 sat=95% ØMucous membranes: “cherry red” ØLungs: clear ØNeuro: no focal findings What is the antidote? 16 March 2018 Orange County EMS System 63

Carbon Monoxide Serious CO Toxicity v. LOC or near syncope v. Confusion v. Focal Carbon Monoxide Serious CO Toxicity v. LOC or near syncope v. Confusion v. Focal neurologic changes v. Myocardial ischemia v. Hypotension v. Acidosis 16 March 2018 Orange County EMS System 64

Carbon Monoxide Type of Air Room 320 100% oxygen 60 Hyperbaric 02 16 March Carbon Monoxide Type of Air Room 320 100% oxygen 60 Hyperbaric 02 16 March 2018 T ½ (minutes) 20 Orange County EMS System 65

Carbon Monoxide Basic Life Support v Remove the patient from the contamination source v Carbon Monoxide Basic Life Support v Remove the patient from the contamination source v Secure airway v Administer supplemental oxygen (100%) and note time oxygen started v Record and monitor vital signs 16 March 2018 Orange County EMS System 66

Carbon Monoxide Advanced Life Support v Advanced airway/ventilatory management as needed v Begin cardiac Carbon Monoxide Advanced Life Support v Advanced airway/ventilatory management as needed v Begin cardiac monitoring, record and evaluate ECG strip v Record and evaluate 12 -lead ECG v Record & monitor 02 saturation & end-tidal C 02 (if available by nasal cannulae) v IV Na. Cl 0. 9% KVO 16 March 2018 Orange County EMS System 67

Carbon Monoxide Medical Control (Contact Medical Control for further orders 16 March 2018 Orange Carbon Monoxide Medical Control (Contact Medical Control for further orders 16 March 2018 Orange County EMS System 68

Patient Scenario #6 Patient Information: v 75 y/o is dropped off at the station Patient Scenario #6 Patient Information: v 75 y/o is dropped off at the station and is c/o of “weakness and dizziness” v. PMH: hypertension v. After probing several family members who arrive, you discover she has actually been taking Calan 240 mg TID instead of QD 16 March 2018 Orange County EMS System 69

Patient Scenario #6 Primary Survey LOC: Airway: Breathing: Circulation: waxing and waning clear and Patient Scenario #6 Primary Survey LOC: Airway: Breathing: Circulation: waxing and waning clear and equal slow weak pulse 16 March 2018 Orange County EMS System 70

Patient Scenario #6 Secondary Survey v. V/S: BP=80/50, HR=35, RR=16, O 2 sat=88% v. Patient Scenario #6 Secondary Survey v. V/S: BP=80/50, HR=35, RR=16, O 2 sat=88% v. Skin: pale and diaphoretic v. COR: slow and weak v. Neuro: no focal findings v. Glucose check: 280 mg/dl 16 March 2018 Orange County EMS System 71

Patient Scenario #6 v. Cardiac monitor: What is the antidote? 16 March 2018 Orange Patient Scenario #6 v. Cardiac monitor: What is the antidote? 16 March 2018 Orange County EMS System 72

++ Channel Blockers Ca and -Blockers Define the toxidrome (signs and symptoms) v. Does ++ Channel Blockers Ca and -Blockers Define the toxidrome (signs and symptoms) v. Does it fit with the clinical picture? ØBradycardia (± AV block) ØHypotension ØAltered level of consciousness ØHyperglycemia/hypoglycemia 16 March 2018 Orange County EMS System 73

Ca++ Channel Blockers and -Blockers: Specific Therapy Standard ACLS Toxicologic Approach v Atropine — Ca++ Channel Blockers and -Blockers: Specific Therapy Standard ACLS Toxicologic Approach v Atropine — often not v High-dose pressors effective v Glucagon: 5 to 10 mg IV bolus: v TCP 3 to 5 mg/h drip v Dopamine v Calcium: 1 to 3 g, slow IV v Epinephrine bolus 16 March 2018 Orange County EMS System 74

Calcium Channel Blockers include: Ø Amlodipine (Norvasc) Ø Felodipine (Plendil, Renedil) Ø Isradipine (Dyna. Calcium Channel Blockers include: Ø Amlodipine (Norvasc) Ø Felodipine (Plendil, Renedil) Ø Isradipine (Dyna. Circ) Ø Nicardipine (Cardene) Ø Nifedipine (Procardia, Adalat) Ø Verapamil (Calan) Ø Diltiazem (Cardizem) 16 March 2018 Orange County EMS System 75

Calcium Channel Blockers Basic Life Support v Secure airway v Administer supplemental oxygen v Calcium Channel Blockers Basic Life Support v Secure airway v Administer supplemental oxygen v Record and monitor vital signs 16 March 2018 Orange County EMS System 76

Calcium Channel Blockers Advanced Life Support v Advanced airway/ventilatory management as needed v Begin Calcium Channel Blockers Advanced Life Support v Advanced airway/ventilatory management as needed v Begin cardiac monitoring, record and evaluate ECG strip v Record and evaluate 12 -lead ECG v Record & monitor 02 saturation & end-tidal C 02 (if available by nasal cannulae) v IV 0. 9% Na. Cl KVO or IV lock 16 March 2018 Orange County EMS System 77

Calcium Channel Blockers Advanced Life Support v For patients with cardiovascular toxicity with (1) Calcium Channel Blockers Advanced Life Support v For patients with cardiovascular toxicity with (1) bradycardia with rate < 60 or (2) Heart block, including third degree heart block and high grade second degree heart blocks i. e. - Mobitz Type II second degree Ø Administer the following agents for bradycardia or high degree heart block § Atropine 0. 5 mg IV, may repeat X 2 § If no response, Calcium Chloride 1 gram IV (avoid if patient taking digoxin/ Lanoxin) § If no response, may repeat Calcium Chloride 1 gram IV § If no response, Glucagon 3 mg IV § If no response, may repeat Glucagon 3 mg IV § If no response, begin transcutaneous pacing Ø If hypotension § 300 ml Na. Cl 0. 9% bolus, repeat as needed § Administer Calcium Chloride 1 gram IV, may repeat X 1 • Avoid if patient on digoxin/Lanoxin § Glucagon 3 mg IV, may repeat X 1 16 March 2018 Orange County EMS System 78

Calcium Channel Blockers Medical Control (Dopamine IV infusion, titrate 16 March 2018 Orange County Calcium Channel Blockers Medical Control (Dopamine IV infusion, titrate 16 March 2018 Orange County EMS System 79

Patient Scenario #7 Patient Information: v“ 48 year-old man-suicidal OD-looks bad” v. Friend states: Patient Scenario #7 Patient Information: v“ 48 year-old man-suicidal OD-looks bad” v. Friend states: “overdosed on some pills, got weak and drowsy, called 911” ØHappened: 2 hours ago v. Friend presents empty bottle of Propranolol (prescription filled yesterday for 20 mg tabs, #60) 16 March 2018 Orange County EMS System 80

Patient Scenario #7 Primary Survey v. LOC: obtunded, minimal response to stimuli v. Airway: Patient Scenario #7 Primary Survey v. LOC: obtunded, minimal response to stimuli v. Airway: clear v. Breathing: clear and equal v. Circulation: slow weak pulse 16 March 2018 Orange County EMS System 81

Patient Scenario #7 Secondary Survey v. V/S: HR=30 bpm, BP=50 mm Hg/palp, RR=10/min (shallow), Patient Scenario #7 Secondary Survey v. V/S: HR=30 bpm, BP=50 mm Hg/palp, RR=10/min (shallow), O 2 sat=78% v. Skin: pale and diaphoretic v. COR: slow and weak v. Neuro: no focal findings v. Glucose: 40 mg/dl 16 March 2018 Orange County EMS System 82

Patient Scenario #7 Cardiac monitor: What is the antidote? 16 March 2018 Orange County Patient Scenario #7 Cardiac monitor: What is the antidote? 16 March 2018 Orange County EMS System 83

Common Names v Propranolol (Inderal) v Atenolol (Tenormin) v Metoprolol (Lopressor) v Nadolol v Common Names v Propranolol (Inderal) v Atenolol (Tenormin) v Metoprolol (Lopressor) v Nadolol v Timolol v Labetolol v Esmolol v Acebutolol 16 March 2018 Orange County EMS System 84

Common Names ß ß Combination Drugs v. Corzide (nadolol/thiazide) v. Inderide (inderal/HCTZ) v. Tenoretic Common Names ß ß Combination Drugs v. Corzide (nadolol/thiazide) v. Inderide (inderal/HCTZ) v. Tenoretic v. Lopressor HCT v. Timolide v. Ziac 16 March 2018 Orange County EMS System 85

Beta Blocker Toxicity Basic Life Support u Secure airway u Administer supplemental oxygen u Beta Blocker Toxicity Basic Life Support u Secure airway u Administer supplemental oxygen u Record and monitor vital signs 16 March 2018 Orange County EMS System 86

Beta Blocker Toxicity Advanced Life Support v Advanced airway/ventilatory management as needed v Begin Beta Blocker Toxicity Advanced Life Support v Advanced airway/ventilatory management as needed v Begin cardiac monitoring, record and evaluate ECG strip v Record and evaluate 12 -lead ECG v Record & monitor 02 saturation & end-tidal C 02 (if available by nasal cannula) v IV 0. 9% Na. Cl KVO or IV lock 16 March 2018 Orange County EMS System 87

Beta Blocker Toxicity Advanced Life Support v For patients with cardiovascular toxicity with (1) Beta Blocker Toxicity Advanced Life Support v For patients with cardiovascular toxicity with (1) bradycardia with rate < 60 or (2) Heart block, including third degree heart block and high grade second degree heart blocks i. e. - Mobitz Type II second degree Ø Administer the following agents § Atropine 0. 5 mg IV, may repeat X 2 § If no response, Glucagon 3 mg IV § If no response, may repeat Glucagon 3 mg IV § If no response, begin transcutaneous pacing Ø If hypotension § 300 ml Na. Cl 0. 9% bolus, repeat as needed § Glucagon 3 mg IV, may repeat X 1 16 March 2018 Orange County EMS System 88

Beta Blocker Toxicity Medical Control (Dopamine infusion 16 March 2018 Orange County EMS System Beta Blocker Toxicity Medical Control (Dopamine infusion 16 March 2018 Orange County EMS System 89

Drug Induced Bradycardia v. Beta blockers v. Calcium channel blockers v. Digoxin v. Organophosphates Drug Induced Bradycardia v. Beta blockers v. Calcium channel blockers v. Digoxin v. Organophosphates v. Mushroom v. Clonidine (Alpha 2 agonist) 16 March 2018 Orange County EMS System 90

Dispatch v. It’s 3 a. m. and your partner, both paramedics, are dispatched to Dispatch v. It’s 3 a. m. and your partner, both paramedics, are dispatched to an “unknown problem” in an alley behind a popular nightclub. v. As you pull up, you see a police unit already on scene. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 91

Initial Assessment v. Patient presentation Ø 20 y/o male ØRight lateral recumbent position ØAppears Initial Assessment v. Patient presentation Ø 20 y/o male ØRight lateral recumbent position ØAppears to be unconscious ØSnoring ØVomit on ground 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 92

Discussion v. How would you describe the patient’s status? v. What are your immediate Discussion v. How would you describe the patient’s status? v. What are your immediate concerns? v. What are your next, most immediate actions? 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 93

Assessment v Your partner opens the patient’s airway and prepares the suction unit and Assessment v Your partner opens the patient’s airway and prepares the suction unit and airway equipment. v You cut the patient’s clothes down his back. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 94

Assessment v. You note: ØPatient unresponsive to painful stimuli ØAirway open, some vomit visible Assessment v. You note: ØPatient unresponsive to painful stimuli ØAirway open, some vomit visible § Your partner suctions the vomit from the airway. ØRespiratory rate slow, shallow § Lung sounds bilaterally ØPulse rapid, full, regular ØNo gross bleeding or trauma apparent 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 95

Discussion v. Have your concerns changed? ØIf so, how? v. Does this patient require Discussion v. Have your concerns changed? ØIf so, how? v. Does this patient require spinal immobilization? v. What are your next, most immediate actions? 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 96

Assessment/Treatment v. Your partner holds c-spine while you continue your exam v. You perform Assessment/Treatment v. Your partner holds c-spine while you continue your exam v. You perform a rapid exam of the patient’s posterior chest, back, and buttocks. ØYou note that lung sounds are clear in all posterior fields. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 97

Assessment/Treatment v. With the police officer’s assistance, the patient is rolled onto a backboard. Assessment/Treatment v. With the police officer’s assistance, the patient is rolled onto a backboard. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 98

Treatment v. Your partner inserts an oropharyngeal airway (OPA) into the patient’s airway, which Treatment v. Your partner inserts an oropharyngeal airway (OPA) into the patient’s airway, which he accepts. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 99

Discussion v. What does this indicate? v. Does this change your assessment of the Discussion v. What does this indicate? v. Does this change your assessment of the situation? ØHow? 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 100

Treatment v. Your partner assists the patient’s respirations while continuing to hold c-spine. 16 Treatment v. Your partner assists the patient’s respirations while continuing to hold c-spine. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 101

Initial Assessment v. You note equal breath sounds bilaterally. v. Vital signs ØHR = Initial Assessment v. You note equal breath sounds bilaterally. v. Vital signs ØHR = 72 regular ØRR = 12 shallow ØBP = 116/72 ØSa. O 2 = 100% with oxygen 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 102

Discussion v. What additional information would you like to have? v. More importantly, how Discussion v. What additional information would you like to have? v. More importantly, how do you get it? 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 103

Assessment v. You ask the officer for any information he may have, and he Assessment v. You ask the officer for any information he may have, and he says: ØPatient was alone when the officer arrived. Ø 9 -1 -1 caller is not on scene. ØNo one in area admits to knowing patient. ØIt’s “rave night” at the club, and “there have been problems with ODs before. ” 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 104

Detailed Assessment v. Your physical exam reveals ØNo smell of alcohol on patient’s breath Detailed Assessment v. Your physical exam reveals ØNo smell of alcohol on patient’s breath ØSkin cool, dry, slightly pale ØNo signs of trauma anywhere on body ØPEARL ØNo “track marks” or tattoos ØNo burns to fingers or lips ØNothing in patient’s pockets 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 105

Detailed Assessment v. Blood glucose = 80 mg/d. L 16 March 2018 Orange County Detailed Assessment v. Blood glucose = 80 mg/d. L 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 106

Discussion v. Based on the information you have, what do you think is wrong Discussion v. Based on the information you have, what do you think is wrong with the patient? v. What are the various substances of abuse that may be involved? How do they compare to your physical exam findings? v. What are your next, most immediate actions? 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 107

Treatment v. Patient is moved to the ambulance 16 March 2018 Orange County EMS Treatment v. Patient is moved to the ambulance 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 108

Ongoing Assessment v. Patient is placed in the ambulance, and you begin transport to Ongoing Assessment v. Patient is placed in the ambulance, and you begin transport to the ED. v. Repeat vital signs ØHR = 78 regular ØRR = 12 shallow ØBP = 122/74 ØSa. O 2 = 100% with oxygen 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 109

Discussion v. As a paramedic, what are your next, most immediate actions? 16 March Discussion v. As a paramedic, what are your next, most immediate actions? 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 110

Ongoing Assessment v. Transport to the ED is started. v. Patient is placed on Ongoing Assessment v. Transport to the ED is started. v. Patient is placed on the cardiac monitor, and a large-bore IV is started. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 111

Detailed Assessment v. Cardiac rhythm 16 March 2018 Orange County EMS System © 2007 Detailed Assessment v. Cardiac rhythm 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 112

Discussion v. Do you administer ØIV glucose? § Why or why not? ØIV naloxone? Discussion v. Do you administer ØIV glucose? § Why or why not? ØIV naloxone? § Why or why not? 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 113

Treatment v. The paramedic decides not to administer D 50, since patient’s blood glucose Treatment v. The paramedic decides not to administer D 50, since patient’s blood glucose is 80 mg/d. L. v. IV naloxone (2 mg) is administered without effect. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 114

Discussion v. Based on all the information you have, what do you think may Discussion v. Based on all the information you have, what do you think may be wrong with the patient? 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 115

Treatment v. With the failure of the naloxone, the paramedic elects to intubate the Treatment v. With the failure of the naloxone, the paramedic elects to intubate the patient. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 116

Treatment v. Intubation is performed successfully, and the patient is bagged at 12 per Treatment v. Intubation is performed successfully, and the patient is bagged at 12 per minute with 100% oxygen. v. Tube placement in the trachea is confirmed by ØET CO 2 detector with positive waveform ØBilateral breath sounds ØOxygen saturation of 100% 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 117

Treatment v. A radio report is given to the ED attending. 16 March 2018 Treatment v. A radio report is given to the ED attending. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 118

ED Treatment and Beyond v. Patient placed on ventilator v. Repeat primary and secondary ED Treatment and Beyond v. Patient placed on ventilator v. Repeat primary and secondary exams confirm prehospital findings. v. Venous blood drawn for lab analysis v. Attending physician informs you that she also suspects GHB overdose. ØNo serum or urine tests available ØBased on clinical exam, history 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 119

ED Treatment and Beyond v. Radiographs of c-spine, chest, and abdomen obtained v. CT ED Treatment and Beyond v. Radiographs of c-spine, chest, and abdomen obtained v. CT scan of head performed v. Patient “wakes up” two hours later without any recollection of incident, admits to GHB ingestion, and would like something to eat. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 120

Epidemiology v. Gamma-hydroxybutyrate (GHB) first synthesized in 1962 for use as an anesthetic. v. Epidemiology v. Gamma-hydroxybutyrate (GHB) first synthesized in 1962 for use as an anesthetic. v. Popular with bodybuilders in the 1980 s ØThought to enhance muscle building v. Became “rave” drug in 1990 s ØProduces euphoric feeling 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 121

Epidemiology v. Sedative and hypnotic effects + colorless and odorless = date-rape drug ØBanned Epidemiology v. Sedative and hypnotic effects + colorless and odorless = date-rape drug ØBanned by FDA in 1990 ØIllegalized as Schedule I controlled substance in 2000 ØLegal version, Xyrem, introduced in 2002 § Schedule III controlled substance used for narcolepsy v. Low cost and ease of synthesis permit its continued prevalence. ØInstructions available on the Internet 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 122

Epidemiology v 9600 documented adverse reactions since 1992 v 71 GHB-related deaths; 15 with Epidemiology v 9600 documented adverse reactions since 1992 v 71 GHB-related deaths; 15 with GHB as the sole drug v. Emergency Department visits for GHBrelated complaints are up 100 -fold since 1994. ØAlthough a decline has begun in recent years v. Two-thirds of patients are male. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 123

A & P Review v. GHB is a naturally occurring neurotransmitter. ØBinds the GABA-B A & P Review v. GHB is a naturally occurring neurotransmitter. ØBinds the GABA-B receptor ØThis receptor is found throughout the brain, mostly in basal ganglia. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 124

A & P Review v. Exact function in body is unknown. ØPossible involvement with A & P Review v. Exact function in body is unknown. ØPossible involvement with § Sleep cycles § Temperature regulation § Cerebral glucose metabolism § Blood flow § Memory § Emotions 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 125

Pathophysiology v. GHB rapidly crosses blood-brain barrier following ingestion. v. Many observed effects are Pathophysiology v. GHB rapidly crosses blood-brain barrier following ingestion. v. Many observed effects are a result of the increased binding to GABA-B receptors in the brain by GHB. v. Alters the release of other neurotransmitters in the brain ØNoradrenalin: inhibition ØDopamine: stimulates high doses while inhibiting low doses 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 126

Pathophysiology v. Central nervous system effects are largely dose dependent. Ø 10 mg/kg: amnesia, Pathophysiology v. Central nervous system effects are largely dose dependent. Ø 10 mg/kg: amnesia, relaxation § Also decrease in heart rate and respiratory rate Ø 20– 30 mg/kg: drowsiness, sleep § Interference with motor and speech abilities Ø 50– 70 mg/kg: coma § Severe respiratory depression, up to arrest v. Death secondary to overdose is rare. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 127

Pathophysiology v. Typical street dose, 1– 5 grams ØOnset of effects within 5– 15 Pathophysiology v. Typical street dose, 1– 5 grams ØOnset of effects within 5– 15 minutes ØPeak effect in 30 minutes ØEffects can last 3– 6 hours v. Elimination occurs via respiration 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 128

Pathophysiology v. GHB withdrawal ØObserved in chronic GHB users ØSymptoms arise within 1– 6 Pathophysiology v. GHB withdrawal ØObserved in chronic GHB users ØSymptoms arise within 1– 6 hours of last use. ØSimilar presentation to opiate withdrawal ØExact pathophysiology is unknown. ØTypically self-resolving within 5– 15 days 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 129

Clinical Assessment v. Scene clues ØMost common usage is in nightclubs, raves, and other Clinical Assessment v. Scene clues ØMost common usage is in nightclubs, raves, and other party environments. ØOften used in conjunction with alcohol or other drugs ØCommonly used in gyms by bodybuilders ØPrevalence as a “date-rape” drug 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 130

Clinical Assessment v. Airway ØSudden decreases in level of consciousness can place patient’s airway Clinical Assessment v. Airway ØSudden decreases in level of consciousness can place patient’s airway at risk. § Obstruction § Vomiting § Aspiration ØGag reflex may or may not be present. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 131

Clinical Assessment v. Breathing ØDecreased respiratory rate secondary to central nervous system depression v. Clinical Assessment v. Breathing ØDecreased respiratory rate secondary to central nervous system depression v. Circulation ØBradycardia found in one-third of cases. ØDysrhythmias are uncommon. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 132

Clinical Assessment v. Altered mental status ØVarying degrees, from euphoria to coma v. Patients Clinical Assessment v. Altered mental status ØVarying degrees, from euphoria to coma v. Patients tend to respond violently to arousal attempts. ØExercise caution when providing painful stimuli. v. Symptoms frequently spontaneously resolve, only to recur minutes later. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 133

Clinical Assessment v. Nausea and vomiting ØCommon finding ØPotential for airway complications v. Seizures Clinical Assessment v. Nausea and vomiting ØCommon finding ØPotential for airway complications v. Seizures ØUsually focal, rarely grand mal ØIntervention rarely required, typically selfresolving 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 134

Clinical Assessment v. Be alert for possible multiple drug interactions. v. GHB is rarely Clinical Assessment v. Be alert for possible multiple drug interactions. v. GHB is rarely the sole drug ingested when used recreationally. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 135

Treatment v. Airway management ØA priority in the GHB overdose patient ØLevel of consciousness Treatment v. Airway management ØA priority in the GHB overdose patient ØLevel of consciousness and presence of gag reflex dictates extent of management. § Test with OPA insertion. § Defer to nasopharyngeal airway (NPA) if needed. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 136

Treatment v. Airway management ØEndotracheal intubation § Laryngoscope introduction may arouse patient. § Failed Treatment v. Airway management ØEndotracheal intubation § Laryngoscope introduction may arouse patient. § Failed attempt may worsen situation. § RSI indicated if available 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 137

Treatment v. Provide high-flow oxygen. ØVentilate with BVM if respirations are inadequate. v. Monitor Treatment v. Provide high-flow oxygen. ØVentilate with BVM if respirations are inadequate. v. Monitor respirations. ØPulse oximetry v. ECG monitoring ØAdminister atropine for symptomatic bradycardia. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 138

Treatment v. Altered mental status (AMS) ØBlood glucose testing ØAdminister D-50 if patient is Treatment v. Altered mental status (AMS) ØBlood glucose testing ØAdminister D-50 if patient is hypoglycemic. ØFollow D-50 administration with thiamine. ØNaloxone is indicated if AMS is not resolved or if opiate coingestion is suspected. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 139

Treatment v. Seizures ØBenzodiazepines indicated for prolonged seizure activity § Diazepam § Lorezapam 16 Treatment v. Seizures ØBenzodiazepines indicated for prolonged seizure activity § Diazepam § Lorezapam 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 140

Treatment v. Suspected comatose patient can be suddenly aroused with painful stimuli. ØMovement of Treatment v. Suspected comatose patient can be suddenly aroused with painful stimuli. ØMovement of patient may awaken him. ØGHB patients often agitated, potentially violent when aroused ØCaution should be used during movement and transport. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 141

Treatment: Hospital v. Maintenance of ABCs is the priority. ØPerform RSI-facilitated intubation immediately if Treatment: Hospital v. Maintenance of ABCs is the priority. ØPerform RSI-facilitated intubation immediately if patient cannot protect his own airway. v. Continuous cardiac monitoring v. CT scan ØRule out a cerebrovascular accident (CVA). v. Lab studies ØNo standard blood or urine testing is available. ØForensic analysis is available for suspected date-rape cases. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 142

Treatment: Hospital v. Treatment is often palliative only. v. Effects typically self-resolve within six Treatment: Hospital v. Treatment is often palliative only. v. Effects typically self-resolve within six hours. 16 March 2018 Orange County EMS System © 2007 by Pearson Education, Inc. Pearson Prentice Hall, Upper Saddle River, NJ 143

Thank You I’M OUTTA HERE 16 March 2018 Orange County EMS System 144 Thank You I’M OUTTA HERE 16 March 2018 Orange County EMS System 144