toxicologic emergencies case studies and management ray taylor valencia community college department...
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Toxicologic Emergencies
Case Studies and Management
Ray Taylor
Valencia Community College
Department of Emergency Medical Services
April 19, 2023 Orange County EMS System 2
Notice All rights reserved. Slide show used with permission only for the
purposes of educating emergency medical providers (EMTs and Paramedics)
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
April 19, 2023 Orange County EMS System 3
Toxicologic EmergenciesObjectives
Review key prehospital management features of each of the following poisonings:Tricyclic AntidepressantsAnticholinergicsAcute Dystonic ReactionBeta BlockersCalcium Channel BlockersCarbon MonoxideCocaine / SympathomimeticsGamma-hydroxybutyrate (GHB)
April 19, 2023 Orange County EMS System 4
Drug Box
April 19, 2023 Orange County EMS System 5
2004 Therapy Provided in Human Exposure Cases
0
2
4
6
8
10
12
# of Cases
(X 103)
Specific Antidote
N-ACNaloxoneAlkalinizationFlumazenil
April 19, 2023 Orange County EMS System 6
Categories with Largest Numbers of Deaths (2004 TESS Data)
0
50
100
150
200
250
300
350
# deaths
Category
AnalgesicsAntidepressantsCV drugsStimulantsSed-hypAlcohols
April 19, 2023 Orange County EMS System 7
Patient Scenario #1
Dispatch data: “man down”
Scene: safe; Private house; Rural location
Victims: one, 25y/o male found unresponsive, with an empty pill bottle in his hand
Historians: victim’s girlfriend
April 19, 2023 Orange County EMS System 8
Patient Scenario #1
Empty pill bottle found in patient’s hand
Elavil®
50mg Tabs #50 3/2/14
April 19, 2023 Orange County EMS System 9
Patient Scenario #1
Hx: patient’s girlfriend states he has been depressed and ingested 50 x 50mg tabs 1 hr ago, and progressively became more somnolent until he “passed out” about ½ hr ago
April 19, 2023 Orange County EMS System 10
Patient Scenario #1 Primary Survey
LOC: unconscious, unresponsivenconscious, unresponsive Airway: open; Saliva accumulating; Gurgling open; Saliva accumulating; Gurgling Breathing: resp= 10/min; Sonorous; resp= 10/min; Sonorous; gag reflexgag reflex Circulation: pulse rapid & weak pulse rapid & weak
April 19, 2023 Orange County EMS System 11
Patient Scenario #1 Secondary Survey
V/S: BP=70/40, HR=140, RR=assisted, 02 sat=82%
SKIN: dry, flushed, no track marks HEENT: pupils fixed & dilated (6-7mm), no evidence of
head trauma LUNGS: clear & equal bilaterally COR: RRR ABD: soft, decreased bowel sounds NEURO: unresponsive, no gross focal deficits
April 19, 2023 Orange County EMS System 12
Patient Scenario #1Prehospital Secondary Interventions
Cardiac monitor:
What is the antidote?
April 19, 2023 Orange County EMS System 13
Tricyclic Antidepressant Toxicity
Specific Treatment NaHCO3 IS
THE TREATMENT OF CHOICE
April 19, 2023 Orange County EMS System 14
Tricyclic AntidepressantsDefine the Toxidrome
Anticholinergic
Hyperthermia, blurred vision, dry mouth, flushed skin, hallucinations, tachycardia, and seizures
Quinidine-like=Na channel blockade
Negative inotropy, prolonged Q-T, hypotension, and ventricular dysrhythmias
Alpha-adrenergic blockade
Hypotension
Antihistamine CNS sedation
April 19, 2023 Orange County EMS System 15
Tricyclic Antidepressant Toxicity
Clinical FeaturesMild-to-moderate toxicity Sinus tachycardia Slurred speech Dry mouth Drowsinesslethargy
Severe toxicity Coma Seizures Dysrrhythmias Hypotension
RAPID PROGRESSION OF SYMPTOMS IS
CHARACTERISTIC OF SEVERE TCA
TOXICITY
Can we predict who will go on to severe toxicity?
April 19, 2023 Orange County EMS System 16
Review of Clinical Findings
2500 Cases of TCA Toxicity
21%
14% 8% 6%
51%
35%
tachycardiacomaincreased qrshypotensionseizuresarrhythmias
April 19, 2023 Orange County EMS System 17
2004 Poisoning Fatalaties
0
100
200
300
400
500
600
700
800
900
Fatalities
TotalAntidepressants
April 19, 2023 Orange County EMS System 18
Distribution of Poisoning Fatalities (2004) due to Antidepressants
0
20
40
60
80
100
120
Antidepressant
TotalAmitriptylineDoxepinBupropionNortriptyline
April 19, 2023 Orange County EMS System 19
Overdose And Poisonings – Overdose And Poisonings – General ApproachGeneral Approach
April 19, 2023 Orange County EMS System 20
Overdose And Poisonings – General Approach
General considerationsFor 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.
April 19, 2023 Orange County EMS System 21
Overdose And Poisonings – General Approach
Basic Life Support Secure airway while maintaining cervical spine
immobilization, as necessary. Administer supplemental oxygen (100%) Record and monitor vital signs Nothing by mouth (depending on agent, patient may be at
risk for seizure or rapid loss of consciousness with subsequent aspiration)
April 19, 2023 Orange County EMS System 22
Overdose And Poisonings – General Approach
Advanced Life Support Advanced airway/ventilatory management as needed Initiate cardiac monitoring, record and evaluate ECG strip
Record & monitor 02 saturation & end-tidal C02 (if
available by nasal cannula) IV NaCl 0.9% KVO or IV lock
If systolic BP remains < 90, administer boluses of 0.9% NaCl at 200-300 ml until systolic BP > 90 Contraindicated if evidence of congestive heart failure (e.g.
rales)
April 19, 2023 Orange County EMS System 23
Overdose And Poisonings – General Approach
Advanced Life Support If patient has an altered level of consciousness: Obtain a Glucometer reading. If hypoglycemic (reading 70 [< 60 in stroke]) with IV access:
Dextrose 25 gm, IV bolus. May repeat as needed q 5 or 10 minutes to blood glucose > 100 mg/dl Thiamine 100 mg, IV with initial dextrose
If hypoglycemic (reading 70 [< 60 in stroke]) without IV access: Glucose paste (Glutose) or other glucose agent (e.g. orange juice) if patient alert
enough to self administer oral agent, or Glucagon 1 mg, IM 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 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.
Refer to specific subprotocols when a specific agent has been identified or is strongly
suspected.
April 19, 2023 Orange County EMS System 24
Overdose And Poisonings – General Approach
Medical ControlContact Medical Control for further orders
April 19, 2023 Orange County EMS System 25
AntidepressantsAntidepressants
April 19, 2023 Orange County EMS System 26
Antidepressants
April 19, 2023 Orange County EMS System 27
Tricyclic and Tetracyclic Antidepressants
Basic Life SupportSecure airwayAdminister supplemental oxygen 100%Record and monitor vital signs
April 19, 2023 Orange County EMS System 28
Tricyclic and Tetracyclic Antidepressants
Advanced Life SupportAdvanced airway/ventilatory management as
neededBegin cardiac monitoring, record and evaluate ECG
stripRecord and evaluate 12-lead ECGRecord & monitor 02 saturation & end-tidal C02 (if
available by nasal cannulae)IV 0.9% NaCl KVO
April 19, 2023 Orange County EMS System 29
Tricyclic and Tetracyclic Antidepressants
Advanced Life Support If Altered Mental Status
See Altered Mental Status Protocol If Seizures
See Seizure Protocol If wide complex (QRS >0.12sec), hypotension, or any arrhythmias
Sodium Bicarbonate 1 meq/kg IV Repeat in 5 or 10 minutes
If Torsades de pointes Magnesium Sulfate 2 gm, IV in 100 ml NS bolus (if no renal
disease).
April 19, 2023 Orange County EMS System 30
Tricyclic and Tetracyclic Antidepressants
Medical ControlContact medical control for further orders
April 19, 2023 Orange County EMS System 31
Patient Scenario #2
Dispatch data: “man in custody”
Scene: airport police station
Victims: one
Historians: patient and police
Hx: patient states he swallowed a handful of rocks, is now
extremely agitated, and is c/o feeling too shaky
April 19, 2023 Orange County EMS System 32
Patient Scenario #2
Primary SurveyLOC: alert, anxious and agitated
Airway: clear
Breathing: clear and equal
Circulation: bounding and rapid pulse
April 19, 2023 Orange County EMS System 33
Patient Scenario #2Secondary SurveyV/S: BP=180/120, HR=140, RR=30,
O2 sat=96%Skin: profusely diaphoreticHeent: clearLungs: clearCOR: rapid and regularABD: soft, nontenderNeuro: extreme psychomotor agitation
April 19, 2023 Orange County EMS System 34
Patient Scenario #2
Cardiac monitor: SINUS TACHYCARDIA,
RATE 140
What is the antidote?
April 19, 2023 Orange County EMS System 35
Patient Scenario #2
BenzodiazepinesDiazepam/ValiumLorezapam/AtivanMidazolam/Versed
April 19, 2023 Orange County EMS System 36
Hyperdynamic/Hyperadrenergic Agents
Cocaine (crack)Ketamine/phencyclidine (PCP)Amphetamine/methamphetamine
(ice, crystal meth)Ephedrine and derivatives, 2-agonists
Caffeine, nicotine, theophyllineDextromethorphan
April 19, 2023 Orange County EMS System 37
Adrenergic Agent OverdoseAdrenergic Agent Overdose
Toxidrome Tachycardia Hypertension Hyperthermia Agitation Diaphoresis
Complications Angina/infarction Dissecting aorta Seizures Intracranial bleed Rhabdomyolysis
What are critical acute problems?
April 19, 2023 Orange County EMS System 38
Cocaine and Sympathomimetic Overdose
Basic Life SupportSecure airwayAdminister supplemental oxygenRecord and monitor vital signs
April 19, 2023 Orange County EMS System 39
Cocaine and Sympathomimetic Overdose
Advanced Life Support 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 C02 (if
available by nasal cannulae) IV NaCl 0.9% KVO
April 19, 2023 Orange County EMS System 40
Cocaine and Sympathomimetic Overdose
Advanced Life Support If seizures, refer to Seizure Protocol For patients with sympathomimetic toxidrome (hypertension,
tachycardia, agitation): Diazepam (Valium) 5 mg, slow IV Or 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)
Repeat either medication in 5-10 minutes if signs and symptoms
continue
April 19, 2023 Orange County EMS System 41
Cocaine and Sympathomimetic Overdose
Medical ControlCall Medical Control for any additional
orders or questions
April 19, 2023 Orange County EMS System 42
Drug Induced TachycardiasManagement Considerations
Consider sodium bicarbonate for wide complex rhythms
Standard ACLS algorithms may not be effective
Utilize pressors if patient hypotensive
April 19, 2023 Orange County EMS System 43
Patient Scenario #3
Patient information:35 year-old farmer was working in his field
when it was unexpectedly crop-dusted by a confused pilot
1 hour later: he complains of difficulty breathing
April 19, 2023 Orange County EMS System 44
Patient Scenario #3
ROS:GI:+ N/V/D, abdominal crampsSkin: + profuse sweatingEye: + blurred visionCNS: +dizziness and restlessnessGU: + incontinence
April 19, 2023 Orange County EMS System 45
Patient Scenario #3
VS: T=100.8°F, BP=90/50 mm Hg,HR=42 bpm, RR=36/min, O2 sat=86%
PE:HEENT: profuse diaphoresis, BL constricted
pupils, visual acuity, copius tearingLungs: diffuse BL rales, rhonchi, and wheezesABD: hyperactive bowel sounds
April 19, 2023 Orange County EMS System 46
Patient Scenario #3
Cardiac monitor:
SINUS BRADYCARDIA, RATE 42
What is the antidote?
April 19, 2023 Orange County EMS System 47
Patient Scenario #3
Atropine
April 19, 2023 Orange County EMS System 48
Mechanism of Action
Organophosphates and nerve agents inhibit acetylcholinesteraseThis allows acetylcholine to accumulate
Acetylcholine produces hyperstimulation of cholinergic nervous systemMuscarinic stimulation: smooth muscles contract (eg,
airway constriction); glands produce mega-secretionsNicotinic stimulation: skeletal muscles contract
(twitching)
April 19, 2023 Orange County EMS System 49
Cholinergic Toxidrome“SLUDGE”
SalivationLacrimationUrinationDefecationGastrointestinal (nausea, cramps)Emesis
Look for pinpoint pupils!
April 19, 2023 Orange County EMS System 50
Cholinergic Toxic Effects
General: sweating
Eye: lacrimation, miosis, blurred vision
Pulmonary: wheezing, rales, bronchorrhea
GI: salivation, n/v/d, cramps
CV: bradycardia, hypotension
GU: urinary incontinence
Muscle: fasciculations, cramps, weakness, twitchingSympathetic ganglia: tachycardia, hypertensionCNS: anxiety, restlessness, confusion, ataxia, coma, seizures, insomnia
April 19, 2023 Orange County EMS System 51
Anticholinergic Poisoning/Organophosphates
Basic Life Support Wear protective clothing including masks, gloves, and eye protection.
Toxicity to ambulance crew may result from inhalation or topical exposure.
Any traces of contamination must be removed from the vehicle prior to the next transport.
Secure airway Administer supplemental oxygen Record and monitor vital signs Decontaminate patient
Remove clothing Irrigate with normal saline – may also use soap and water
Contain run-off of toxic chemicals when flushing
April 19, 2023 Orange County EMS System 52
Anticholinergic Poisoning/Organophosphates
Advanced Life Support 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 C02 (if
available by nasal cannulae)
IV 0.9% NaCl KVO or IV lock
April 19, 2023 Orange County EMS System 53
Anticholinergic Poisoning/Organophosphates
Advanced Life Support If Altered Mental Status
See Altered Mental Status Protocol If Seizures
See Seizure Protocol 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.
April 19, 2023 Orange County EMS System 54
Anticholinergic Poisoning/Organophosphates
Medical ControlContact medical control for further orders
April 19, 2023 Orange County EMS System 55
Patient Scenario #4
Patient Information:28 year-old female c/o inability to open her
mouth, and tightness in the muscles of her jaw and face
Patient states she thought she was given a “valium” at a party earlier
April 19, 2023 Orange County EMS System 56
Patient Scenario #4
P.E. is unremarkable except for decreased range of motion of the jaw due to muscle contractions
VS: all within normal limits
What is the antidote?
April 19, 2023 Orange County EMS System 57
Patient Scenario #4
Benadryl
April 19, 2023 Orange County EMS System 58
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. Thorazine4. Prolixin5. Haloperidol
April 19, 2023 Orange County EMS System 59
Antipsychotics/Acute Dystonic Reaction
Basic Life SupportSecure airwayAdminister supplemental oxygen
Record and monitor vital signs
April 19, 2023 Orange County EMS System 60
Antipsychotics/Acute Dystonic Reaction
Advanced Life Support 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 C02 (if available by nasal
cannulae) IV 0.9% NaCl KVO or IV lock For dystonic reactions, administer Diphenhydramine (Benadryl) 25 mg, IV.
Repeat Diphenhydramine (Benadryl) 25 mg, IV if inadequate
response, in 10 minutes
April 19, 2023 Orange County EMS System 61
Antipsychotics/Acute Dystonic Reaction
Medical ControlCall Medical Control for any additional
orders or questions
April 19, 2023 Orange County EMS System 62
Patient Scenario #5
Patient Information:You respond to a basement apartment in
January. The apartment is being heated with a portable gas heater.
You find an elderly male who is confused and c/o headache associated with general malaise and nausea
You note an extremely strong gas odor
April 19, 2023 Orange County EMS System 63
Patient Scenario #5
V/S: BP=110/50, HR=102, RR=30, O2 sat=95%Mucous membranes: “cherry red”Lungs: clearNeuro: no focal findings
What is the antidote?
April 19, 2023 Orange County EMS System 64
Carbon MonoxideSerious CO Toxicity
LOC or near syncopeConfusionFocal neurologic changesMyocardial ischemiaHypotensionAcidosis
April 19, 2023 Orange County EMS System 65
Carbon Monoxide
Type of Air T ½ (minutes)
Room 320
100% oxygen 60
Hyperbaric 02 20
April 19, 2023 Orange County EMS System 66
Carbon MonoxideBasic Life SupportRemove the patient from the contamination sourceSecure airwayAdminister supplemental oxygen (100%) and
note time oxygen started
Record and monitor vital signs
April 19, 2023 Orange County EMS System 67
Carbon Monoxide
Advanced Life SupportAdvanced airway/ventilatory management as neededBegin cardiac monitoring, record and evaluate ECG
stripRecord and evaluate 12-lead ECG
Record & monitor 02 saturation & end-tidal C02 (if
available by nasal cannulae)
IV NaCl 0.9% KVO
April 19, 2023 Orange County EMS System 68
Carbon Monoxide
Medical ControlContact Medical Control for further orders
April 19, 2023 Orange County EMS System 69
Patient Scenario #6
Patient Information:75 y/o is dropped off at the station and is
c/o of “weakness and dizziness”PMH: hypertension
After probing several family members who arrive, you discover she has actually been taking Calan 240 mg TID instead of QD
April 19, 2023 Orange County EMS System 70
Patient Scenario #6
Primary SurveyLOC: waxing and waning
Airway: clear
Breathing: clear and equal
Circulation: slow weak pulse
April 19, 2023 Orange County EMS System 71
Patient Scenario #6
Secondary SurveyV/S: BP=80/50, HR=35, RR=16, O2
sat=88%Skin: pale and diaphoreticCOR: slow and weakNeuro: no focal findingsGlucose check: 280 mg/dl
April 19, 2023 Orange County EMS System 72
Patient Scenario #6
Cardiac monitor:
What is the antidote?
April 19, 2023 Orange County EMS System 73
Ca++ Channel Blockers and -Blockers
Define the toxidrome (signs and symptoms)Does it fit with the clinical picture?
Bradycardia (± AV block)HypotensionAltered level of consciousnessHyperglycemia/hypoglycemia
April 19, 2023 Orange County EMS System 74
Ca++ Channel Blockers and -Blockers: Specific Therapy
Standard ACLS Atropine — often not
effective TCP Dopamine Epinephrine
Toxicologic Approach High-dose pressors Glucagon: 5 to 10 mg IV
bolus: 3 to 5 mg/h drip
Calcium: 1 to 3 g, slow IV bolus
April 19, 2023 Orange County EMS System 75
Calcium Channel Blockers
Calcium Channel Blockers include:Amlodipine (Norvasc)Felodipine (Plendil, Renedil) Isradipine (DynaCirc)Nicardipine (Cardene)Nifedipine (Procardia, Adalat)Verapamil (Calan)Diltiazem (Cardizem)
April 19, 2023 Orange County EMS System 76
Calcium Channel Blockers
Basic Life SupportSecure airwayAdminister supplemental oxygen
Record and monitor vital signs
April 19, 2023 Orange County EMS System 77
Calcium Channel Blockers
Advanced Life Support 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 C02 (if
available by nasal cannulae) IV 0.9% NaCl KVO or IV lock
April 19, 2023 Orange County EMS System 78
Calcium Channel BlockersAdvanced Life Support 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 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
If hypotension 300 ml NaCl 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
April 19, 2023 Orange County EMS System 79
Calcium Channel Blockers
Medical ControlDopamine IV infusion, titrate
April 19, 2023 Orange County EMS System 80
Patient Scenario #7
Patient Information:“48 year-old man-suicidal OD-looks bad”Friend states: “overdosed on some pills, got
weak and drowsy, called 911”Happened: 2 hours ago
Friend presents empty bottle of Propranolol (prescription filled yesterday for 20 mg tabs, #60)
April 19, 2023 Orange County EMS System 81
Patient Scenario #7
Primary SurveyLOC: obtunded, minimal response to
stimuliAirway: clearBreathing: clear and equalCirculation: slow weak pulse
April 19, 2023 Orange County EMS System 82
Patient Scenario #7
Secondary SurveyV/S: HR=30 bpm, BP=50 mm Hg/palp,
RR=10/min (shallow), O2 sat=78%Skin: pale and diaphoreticCOR: slow and weakNeuro: no focal findingsGlucose: 40 mg/dl
April 19, 2023 Orange County EMS System 83
Patient Scenario #7
Cardiac monitor:
What is the antidote?
April 19, 2023 Orange County EMS System 84
Common NamesPropranolol (Inderal)Atenolol (Tenormin)Metoprolol (Lopressor)NadololTimololLabetololEsmololAcebutolol
April 19, 2023 Orange County EMS System 85
Common Namesß ß Combination Drugs
Corzide (nadolol/thiazide)Inderide (inderal/HCTZ)TenoreticLopressor HCTTimolideZiac
April 19, 2023 Orange County EMS System 86
Beta Blocker Toxicity
Basic Life Support Secure airway Administer supplemental oxygenRecord and monitor vital signs
April 19, 2023 Orange County EMS System 87
Beta Blocker Toxicity
Advanced Life Support 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 C02 (if
available by nasal cannula)
IV 0.9% NaCl KVO or IV lock
April 19, 2023 Orange County EMS System 88
Beta Blocker Toxicity
Advanced Life Support 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 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
If hypotension 300 ml NaCl 0.9% bolus, repeat as needed Glucagon 3 mg IV, may repeat X 1
April 19, 2023 Orange County EMS System 89
Beta Blocker Toxicity
Medical ControlDopamine infusion
April 19, 2023 Orange County EMS System 90
Drug Induced Bradycardia
Beta blockersCalcium channel blockersDigoxinOrganophosphatesMushroomClonidine (Alpha 2 agonist)
April 19, 2023 Orange County EMS System 91
Dispatch
It’s 3 a.m. and you and your partner, both paramedics, are dispatched to an “unknown problem” in an alley behind a popular nightclub.
As you pull up, you see a police unit already on scene.
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 92
Initial Assessment
Patient presentation20 y/o maleRight lateral recumbent
positionAppears to be
unconsciousSnoringVomit on ground
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 93
Discussion
How would you describe the patient’s status?
What are your immediate concerns?
What are your next, most immediate actions?
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 94
Assessment
Your partner opens the patient’s airway and prepares the suction unit and airway equipment.
You cut the patient’s clothes down his back.
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 95
Assessment
You note:Patient unresponsive to painful stimuliAirway open, some vomit visible
Your partner suctions the vomit from the airway.Respiratory rate slow, shallow
Lung sounds bilaterallyPulse rapid, full, regularNo gross bleeding or trauma apparent
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 96
Discussion
Have your concerns changed?If so, how?
Does this patient require spinal immobilization?
What are your next, most immediate actions?
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 97
Assessment/Treatment
Your partner holds c-spine while you continue your exam
You perform a rapid exam of the patient’s posterior chest, back, and buttocks.You note that lung sounds are clear in all
posterior fields.
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 98
Assessment/Treatment
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
With the police officer’s assistance, the patient is rolled onto a backboard.
April 19, 2023 Orange County EMS System 99
Treatment
Your partner inserts an oropharyngeal airway (OPA) into the patient’s airway, which he accepts.
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 100
Discussion
What does this indicate?
Does this change your assessment of the situation?How?
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April 19, 2023 Orange County EMS System 101
Treatment
Your partner assists the patient’s respirations while continuing to hold c-spine.
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 102
Initial Assessment
You note equal breath sounds bilaterally.Vital signs
HR = 72 regularRR = 12 shallowBP = 116/72SaO2 = 100% with oxygen
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 103
Discussion
What additional information would you like to have?
More importantly, how do you get it?
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 104
Assessment
You ask the officer for any information he may have, and he says:Patient was alone when the officer arrived.9-1-1 caller is not on scene.No one in area admits to knowing patient.It’s “rave night” at the club, and “there have
been problems with ODs before.”
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 105
Detailed Assessment
Your physical exam revealsNo smell of alcohol on patient’s breathSkin cool, dry, slightly paleNo signs of trauma anywhere on bodyPEARLNo “track marks” or tattoosNo burns to fingers or lipsNothing in patient’s pockets
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April 19, 2023 Orange County EMS System 106
Detailed Assessment
Blood glucose = 80 mg/dL
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April 19, 2023 Orange County EMS System 107
Discussion
Based on the information you have, what do you think is wrong with the patient?
What are the various substances of abuse that may be involved? How do they compare to your physical exam findings?
What are your next, most immediate actions?
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 108
Treatment
Patient is moved to the ambulance
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 109
Ongoing Assessment
Patient is placed in the ambulance, and you begin transport to the ED.
Repeat vital signsHR = 78 regularRR = 12 shallowBP = 122/74SaO2 = 100% with oxygen
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 110
Discussion
As a paramedic, what are your next, most immediate actions?
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 111
Ongoing AssessmentTransport to the ED is started.Patient is placed on the cardiac monitor,
and a large-bore IV is started.
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April 19, 2023 Orange County EMS System 112
Detailed Assessment
Cardiac rhythm
© 2007 by Pearson Education, Inc.Pearson Prentice Hall, Upper Saddle River, NJ
April 19, 2023 Orange County EMS System 113
Discussion
Do you administerIV glucose?
Why or why not?IV naloxone?
Why or why not?
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Treatment
The paramedic decides not to administer D50, since patient’s blood glucose is 80 mg/dL.
IV naloxone (2mg) is administered without effect.
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Discussion
Based on all the information you have, what do you think may be wrong with the patient?
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TreatmentWith the failure of the naloxone, the
paramedic elects to intubate the patient.
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Treatment
Intubation is performed successfully, and the patient is bagged at 12 per minute with 100% oxygen.
Tube placement in the trachea is confirmed byET CO2 detector with positive waveformBilateral breath soundsOxygen saturation of 100%
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Treatment
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A radio report is given to the ED attending.
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ED Treatment and Beyond
Patient placed on ventilatorRepeat primary and secondary exams
confirm prehospital findings.Venous blood drawn for lab analysisAttending physician informs you that she
also suspects GHB overdose.No serum or urine tests availableBased on clinical exam, history
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ED Treatment and Beyond
Radiographs of c-spine, chest, and abdomen obtained
CT scan of head performedPatient “wakes up” two hours later
without any recollection of incident, admits to GHB ingestion, and would like something to eat.
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Epidemiology
Gamma-hydroxybutyrate (GHB) first synthesized in 1962 for use as an anesthetic.
Popular with bodybuilders in the 1980sThought to enhance muscle building
Became “rave” drug in 1990s Produces euphoric feeling
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Epidemiology
Sedative and hypnotic effects + colorless and odorless = date-rape drugBanned by FDA in 1990Illegalized as Schedule I controlled substance in
2000Legal version, Xyrem, introduced in 2002
Schedule III controlled substance used for narcolepsyLow cost and ease of synthesis permit its
continued prevalence.Instructions available on the Internet
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Epidemiology
9600 documented adverse reactions since 1992
71 GHB-related deaths; 15 with GHB as the sole drug
Emergency Department visits for GHB-related complaints are up 100-fold since 1994.Although a decline has begun in recent years
Two-thirds of patients are male.
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A & P Review
GHB is a naturally occurring neurotransmitter.Binds the GABA-B receptorThis receptor is found throughout the brain,
mostly in basal ganglia.
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A & P Review
Exact function in body is unknown.Possible involvement with
Sleep cycles Temperature regulation Cerebral glucose metabolism Blood flow Memory Emotions
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Pathophysiology
GHB rapidly crosses blood-brain barrier following ingestion.
Many observed effects are a result of the increased binding to GABA-B receptors in the brain by GHB.
Alters the release of other neurotransmitters in the brainNoradrenalin: inhibitionDopamine: stimulates high doses while
inhibiting low doses
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Pathophysiology
Central nervous system effects are largely dose dependent.10 mg/kg: amnesia, relaxation
Also decrease in heart rate and respiratory rate20–30 mg/kg: drowsiness, sleep
Interference with motor and speech abilities50–70 mg/kg: coma
Severe respiratory depression, up to arrest
Death secondary to overdose is rare.
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Pathophysiology
Typical street dose, 1–5 gramsOnset of effects within 5–15 minutesPeak effect in 30 minutesEffects can last 3–6 hours
Elimination occurs via respiration
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Pathophysiology
GHB withdrawal Observed in chronic GHB usersSymptoms arise within 1–6 hours of last use.Similar presentation to opiate withdrawalExact pathophysiology is unknown.Typically self-resolving within 5–15 days
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Clinical Assessment
Scene cluesMost common usage is in nightclubs, raves,
and other party environments.Often used in conjunction with alcohol or
other drugsCommonly used in gyms by bodybuildersPrevalence as a “date-rape” drug
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Clinical Assessment
AirwaySudden decreases in level of consciousness can
place patient’s airway at risk. Obstruction Vomiting Aspiration
Gag reflex may or may not be present.
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Clinical Assessment
BreathingDecreased respiratory rate secondary to central
nervous system depression
CirculationBradycardia found in one-third of cases.Dysrhythmias are uncommon.
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Clinical Assessment
Altered mental statusVarying degrees, from euphoria to coma
Patients tend to respond violently to arousal attempts.Exercise caution when providing painful
stimuli.
Symptoms frequently spontaneously resolve, only to recur minutes later.
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Clinical Assessment
Nausea and vomitingCommon findingPotential for airway complications
SeizuresUsually focal, rarely grand malIntervention rarely required, typically self-
resolving
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Clinical Assessment
Be alert for possible multiple drug interactions.
GHB is rarely the sole drug ingested when used recreationally.
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TreatmentAirway management
A priority in the GHB overdose patientLevel of consciousness and presence of gag reflex
dictates extent of management. Test with OPA insertion. Defer to nasopharyngeal airway (NPA) if needed.
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Treatment
Airway managementEndotracheal intubation
Laryngoscope introduction may arouse patient. Failed attempt may
worsen situation. RSI indicated if
available
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Treatment
Provide high-flow oxygen.Ventilate with BVM if respirations are
inadequate.Monitor respirations.
Pulse oximetry ECG monitoring
Administer atropine for symptomatic bradycardia.
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Treatment
Altered mental status (AMS)Blood glucose testingAdminister D-50 if patient is
hypoglycemic.Follow D-50 administration
with thiamine.Naloxone is indicated if AMS
is not resolved or if opiate coingestion is suspected.
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Treatment
SeizuresBenzodiazepines indicated for
prolonged seizure activity Diazepam Lorezapam
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Treatment
Suspected comatose patient can be suddenly aroused with painful stimuli.Movement of patient may awaken him.GHB patients often agitated, potentially
violent when arousedCaution should be used during movement and
transport.
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Treatment: Hospital
Maintenance of ABCs is the priority.Perform RSI-facilitated intubation immediately
if patient cannot protect his own airway.Continuous cardiac monitoringCT scan
Rule out a cerebrovascular accident (CVA).Lab studies
No standard blood or urine testing is available.Forensic analysis is available for suspected
date-rape cases.
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Treatment: Hospital
Treatment is often palliative only.Effects typically self-resolve within six
hours.
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