Download EMS & Wilderness Emergency Care Training

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Welcome!
DOT National Standard
EMT-Intermediate/85 Refresher
ICEnAXES EMS & Wilderness Emergency Care Training
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Introduction
• Mary Koskovich
– EMT 1988 - 23 yrs
– Paramedic 1991- 20 yrs
– Educator 1997 - 14 yrs
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Course content
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• An approved 36-hour DOT National
Standard EMT-Intermediate/85 Refresher
– Specific topics are required for National
Registry recertification
• Drug therapies included in the NPS
Parkmedic protocols
• Pharmacology integrated into flexible
core topics
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• Go to mandatory core content
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• Go to:
– Intermediate Refresher Feb 21 22 Monday Tuesday
Schedule
ICEnAXES EMS & Wilderness Emergency Care Training
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• References
– Marx, John A. ed, Hockberger & Walls, eds et al.
Rosen’s Emergency Medicine Concepts and Clinical
Practice, 7th edition. Mosby & Elsevier, Philadelphia:
PA 2010.
– Tintinalli, Judith E., ed, Stapczynski & Cline, et al.
Tintinalli’s Emergency Medicine A Comprehensive
Study Guide, 7th edition. The McGraw-Hill
Companies, Inc. New York 2011.
– Wolfson, Allan B. ed. , Hendey, George W.; Ling,
Louis J., et al. Clinical Practice of Emergency
Medicine, 5th edition. Wolters Kluwer & Lippincott
Williams & Wilkings, Philadelphia: PA 2010.
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•
•
•
•
•
•
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•
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MEDICAL EMERGENCIES
Allergic reaction
Possible overdose
Near-drowning
ALOC
Diabetes
Seizures
Heat & cold emergencies
Behavioral emergencies
Suspected communicable disease
ICEnAXES EMS & Wilderness Emergency Care Training
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•
•
•
•
•
•
•
•
•
MEDICAL EMERGENCIES
Allergic reaction
Possible overdose
Near-drowning
ALOC
Diabetes
Seizures
Heat & cold emergencies
Behavioral emergencies
Suspected communicable
disease
•
•
•
•
•
•
•
Perspective
Pathophysiology
Epidemiology
Physical Exam Findings
Diagnostic Findings
Signs and Symptoms
Differential
considerations
• Scenario
• Treatment
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Allergic Reaction
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• Over millions of years, the human system has
evolved to become a highly complex, elegant
and efficient organ whose chief function is to
protect the human host (self) from harmful
offenders (nonself)
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Allergic Reaction
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• Antigens are foreign (or self) molecules
that will elicit an immune response.
• Immunologic responses to antigens in
humans are coordinated by two immune
systems
– The ancient innate immune system
– The adaptive system
ICEnAXES EMS & Wilderness Emergency Care Training
Allergic Reaction
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• The ancient immune
system
– Humans inherited it from
invertebrates
– Considered the 1st line of
defense
– Very fast
• Effector components
–
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Mast cells
Macrophages
Dendrites cells
Natural killer cells
Granulocytes
Antimicrobial peptides
Complements
Cytokines
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• The adaptive system
– Recent evolved which is
present in humans &
vertebrates
– Slow
• Must allow time for the
antigen-specific cells (B
and T cells) to amplify
through a process known
as clonal expansion
– Enormous diversity
• Capable of recognizing
the myriad antigens
through a vast library of
antibodies and receptorsup to (105)
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Allergic Reaction
• Despite the complexity, the 2 immune
systems work in concert and with great
fidelity to provide the human host
immunity
• However, they can overreact causing
allergic disease
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Allergic Reaction
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• Cases of allergy and
anaphylaxis have
historically been
documented to the
days of antiquity
• Pharaoh Menes died
of anaphylaxis in
2641 BCE from the
sting of an insect
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Allergic Reaction
• In 1902, Portier and
Richet discovered
that although a dog
tolerated an injection
of sea anemone the
1st time
• It died within minutes
when injected again
several weeks later
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Allergic Reaction
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• They coined the term anaphylaxis from
Greek
• (ana, against; phylax, guard or protect),
meaning “against protection”
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Allergic Reaction
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• Richet was awarded the Nobel Prize in
Medicine and Physiology in 1913
• Today, anaphylaxis refers to a lifethreatening allergic syndrome
characterized by multiorgan involvement
and rapid onset
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Allergic Reaction
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• Pathophysiology
– Mast cells (and basophils) and their contents
are the central effector cells and mediators
in allergy & anaphylaxis
– Exposure to an allergen leads to the synthesis
& release of allergen-specific
immunoglobulin E (IgE ) by plasma cells into
the circulation
• Immunoglobulin = antibodies
– Proteins that live in the body that are part of the
immune system. They neutralize foreign objects
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Allergic Reaction
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• Fixation of this allergen-specific IgE to surface
receptors on mast cells completes the process
known as sensitization
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In plain English:
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– The immune system creates disease-fighting
antibodies (called IgE) toward a substance
that is normally harmless, such as food.
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In plain English:
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– When the body is 1st exposed to the
substance- the body does not react [but it
does produce the antibodies] = sensitization
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In plain English:
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– Then when the body is exposed to the
substance again, the antibodies spring into
action believing that the substance is a
dangerous foreign invader
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Allergic reaction
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• Essentially an allergic reaction is a
misunderstanding
– The body believes that a normally harmless
substance is dangerous
– The body creates a giant army upon
sensitization (antibody formation-IgE) & it
waits for the next exposure (attack)
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Allergic Reaction
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• An allergic reaction is triggered when an
antigen (e.g., foods, antibiotics, insect
stings) binds to IgE antibodies on mast
cells based in connective tissue
throughout the body, which leads to
degranulation of the mast cells (the
release of inflammatory mediators)
• These immune mediators cause many
symptoms
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Allergic Reaction
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Allergic Reaction
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The chemical mediators released from
mast cells exert their effect on target
organs to produce the clinical symptoms
of allergic reaction
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Allergic Reaction: Physical Exam Findings,
Diagnostic Findings, S/S
Severe
Anaphylaxis
Urticaria (itchy skin eruptions), angioedema (swelling
beneath the skin), rhinitis, conjunctivitis, diarrhea,
vomiting
•A&Ox4
•A&Ox4
•ALOC
•LS clear &
•LS with
•LS with
= bilaterally
wheezing
wheezing
•BP Normal
•BP Normal
•Low BP
or elevated
or elevated
Mild
Moderate
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Allergic Reaction: Physical Exam Findings,
Diagnostic Findings, S/S
• Pt’s are on a continuum
– Mild, moderate, severe
– Analogy - movie
• Progression
– Analogy drain
• Stable
• Fast
• Slow
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Allergic Reaction: Physical Exam Findings, Diagnostic
Findings, S/S
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• Urticaria (aka- hives)
= itchy skin eruption
characterized by
weals with pale
interiors & welldefined red margins
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Allergic Reaction: Physical Exam Findings,
Diagnostic Findings, S/S
• Increased capillary
permeability can
lead to:
–
–
–
–
–
Urticaria
Angioedema
Laryngeal edema
Nasal congestion
Gastrointestinal
swelling w/ abd
cramps & vomiting
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Allergic Reaction: Physical Exam Findings,
Diagnostic Findings, S/S
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• Angioedema = swelling, similar to hives, but the
swelling is beneath the skin rather than on the
surface.
• Hives = aka- welts - surface swelling
• It is possible to have angioedema without hives
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Allergic Reaction: Physical Exam Findings,
Diagnostic Findings, S/S
• Vasodilation can lead to:
–
–
–
–
–
Flushing
HA
Reduced peripheral vascular resistance
Hypotension
Syncope
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Allergic Reaction: Physical Exam Findings,
Diagnostic Findings, S/S
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• Contraction of smooth muscles can
cause:
–
–
–
–
Bronchospasms
Abdominal cramping
Diarrhea
Pulmonary vessel vasoconstriction can lead
to pulmonary HTN, pulmonary edema &
decreased cardiac filling pressures
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Allergic Reaction: Physical Exam Findings,
Diagnostic Findings, S/S
• Coronary vasoconstriction can lead to:
– Myocardial ischemia
– Decreased myocardial contractile force
(negative inotropy)
– Cardiac dysrhythmias
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Allergic Reaction: Physical Exam Findings,
Diagnostic Findings, S/S
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• Cardiovascular collapse in anaphylaxis
has classically been described as a result
of:
–
–
–
–
peripheral vasodilation
enhanced vascular permeability
leakage of plasma
intravascular volume depletion
(“empty ventricle syndrome”)
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Pathologic features identified at autopsy
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• In fatal cases of anaphylaxis
the most commonly observed
causes are in the respiratory &
cardiac system
–
–
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–
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Orolaryngeal edema
Pulmonary hyperinflation
Peribronchial vascular congestion
Intra-alveolar hemorrhage
Pulmonary edema
Increased tracheobronchial
secretions
– Esoinophilic infiltration of brochial
walls
– Death from asphyxia secondary
to angioedema of the epiglottis,
larynx, hypopharynx trachea
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Pathologic features identified at autopsy
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• Pts who die of
vascular collapse
show varying
degrees of
– Myocardial damage
– Visceral congestion
– & other findings
suggestive of a loss of
intravascular blood
volume
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Pathologic features identified at autopsy
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• Other autopsy findings:
–
–
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Urticarial eruptions
Angioedema
Visceral congestion
Submucosal edema
Hemorrhagic gastritis
• Notably- autopsy findings
may also be normal after
an anaphylactic death
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Review
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Epidemiology
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• It is estimated that 1% - 3% of the
population are at risk for anaphylaxis
during their lifetime
• 1% of these episodes will be fatal
• 1,000 - 1,500 anaphylactic deaths/yr U.S.
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Epidemiology
• Penicillin 75% of fatal
reactions
• Hymenoptera stings
cause systemic reactions
in 1% of children & 3% of
adults
– 40-100 anaphylactic
deaths/yr in US
– 90% of stings are in
children, 90% of deaths
occur in adults
– Yellow jackets, honeybees,
wasps, hornets, fire ants,
harvester ants, bumblebees
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Other causes
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• Iodinated contrast media
• Foods
– Peanuts, tree nuts, shellfish, milk, eggs, wheat
• NSAID
• Exercise-induced anaphylaxis
– (usu. associated with prior food or drug
ingestion)
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Onset
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• Symptoms of anaphylaxis usu. begin <30
mins post exposure & are often
immediate
• Oral antigens - may have a 2 hr delay
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Onset
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• In general- the more immediate the
reaction, the more life-threatening
• Symptoms may last only a few minutes,
even w/o therapy, but on average they
persist for 2-4hrs
– With the exception of angioedema, which
often persists beyond 24 hrs
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Onset
• About 6% of pts with anaphylaxis
experience a biphasic course with
recurrent anaphylaxis within 8 hrs
(despite earlier resolution!)
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Differential Considerations
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• Go to dyspnea symptom bags
• As always a thorough hx & PE will guide
you to the correct diagnosis
– Features that suggest angioedema include
• Hx of the same or of a reasonable trigger
• Relatively rapid onset
• Asymmetirc distribution in nondependent areas
• Lack of symptoms that point to other etiologies
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Scenario
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• Dispatch info:
– You are dispatched to 9009 Ponderosa Lane
in Yosemite Valley for a 32 y/o female who is
experiencing an allergic reaction. The time
of call is 13:03 & your response time to the
scene is approximately 7 mins
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Scenario
• You arrive at the scene at 13:10 where
you find the pt sitting alongside the
driveway in front of her house. She is in
obvious respiratory distress & covered
with a rash.
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Scenario
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• As you perform an initial assessment the
pt tells you that she was stung by a
hornet 15 mins ago. Her respirations are
labored, however, she has adequate
tidal volume & is able to speak to you in
full sentences
ICEnAXES EMS & Wilderness Emergency Care Training
Scenario
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INITIAL ASSESSMENT
LOC
Conscious, but restless
Chief Complaint
“I was stung by a hornet & now I’m
having trouble breathing. I have an
Epi-Pen but it is expired.”
Airway is patent, audible wheezing is
heard, and respirations are labored
but with adequate tidal volume.
Pulse is weak & rapid; skin is
diaphoretic w/ a generalized rash.
Airway &
Breathing
Circulation
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Question?
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• What initial management is indicated for
this patient?
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• Go to “Call Matrix Allergic Reaction”
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Question?
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• What initial management is indicated for
this pt?
– After the scene size up & the initial
assessment
• Diagnostics, Monitoring & Mtg
• Verbal Survey that includes pertinent
positives/negatives & hx, meds, allergies
• Specific Protocol Treatments
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Scenario
• Is the pt stable or unstable?
• What is your rationale?
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Scenario
• After placing the pt on supplemental
oxygen, an IV line of NS is established &
set at a keep-vein-open rate
• Following the appropriate
pharmacological intervention, you
conduct a history and physical
examination
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Scenario
• What size IV catheter would you use?
– Rationale?
• What is the 1st appropriate
pharmacological intervention?
– Rationale?
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Scenario
• What size IV catheter would you use?
– Rationale?
• Large bore = 14 or 16ga
• What is the 1st appropriate
pharmacological intervention?
– Rationale?
• 1:1,000 Epinephrine IM 0.3ml (0.3mg)
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Scenario
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Verbal Survey & Physical Exam
Hx of allergies
“Yes, I’m allergic to hornets, bees & fire ants”
What were you exposed to?
“A hornet”
How were you exposed?
“It stung me”
Effects
“Shortly after I was stung, the rash developed.
Then I felt tightness in my throat & could not
breath. Since you gave me that medication,
I can breathe easier”
Progression
“Within a few minutes of being stung, the rash
developed, & then I began having trouble
breathing.”
Interventions prior to EMS
“Nothing. I did not use my EpiPen because it
was expired.”
Scattered
wheezing
is heard
on inhalation &
BreathICEnAXES
sounds
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Emergency
Care
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exhalation.
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Scenario
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• Further assessment of the pt reveals mild
facial swelling.
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Scenario
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Baseline VS & SAMPLE Hx
BP, Pulse, Respirations
100/70, HR 132, 22 & slightly labored
Oxygen Saturation
95% (on 100% oxygen)
S/S
Respiratory distress, hives, facial swelling,
all of which have improved since you
administered epinephrine
allergies
“I’m not allergic to any medications.
Just hornets, bees, and fire ants.”
Medications
“I have a prescribed Epi-Pen but it is
expired.”
Pertinent Past Hx
“I do not have any other medical
problems.”
Last Oral Intake
“I ate lunch about 2 hrs ago.”
“I was stung by a hornet.
Events leading to present
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illness
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Scenario
• What is your field impression of this pt?
– Give your rationale
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Scenario
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• This pt is suffering from anaphylactic shock.
• The following assessment findings support the
field impression:
– Known allergy to hornets, exposure to which the pt
has confirmed
– Generalized rash (urticaria), which is a hallmark
finding in allergic reaction
– Labored breathing & wheezing- which indicates
bronchoconstriction consistent w/ anaphylaxis
– Tachycardia & restlessness are signs of shock & are
typically not present during a mild or moderate
allergic reaction
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Scenario
• The pt’s condition has improved
significantly, but she still has a fine rash
covering her body & complains of
itching. You reach for the drug box in
preparation for your next intervention.
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Scenario
• What specific treatment is required for
this pt’s condition?
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Scenario
• Diphenhydramine 50mg IV q 6hrs;
– may utilize IM if no IV access
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Scenario
• You administer the diphenhydramine
indicated for the pt’s condition, after
which you note that the rash is
diminished. You continue oxygen
therapy & load the pt into the
ambulance for transport to the ED
ICEnAXES EMS & Wilderness Emergency Care Training
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Scenario
• En route to the ED, the pt’s condition
continues to improve. You perform an
ongoing assessment & then call your
radio report to the receiving facility
ICEnAXES EMS & Wilderness Emergency Care Training
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Scenario
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Ongoing Assessment
LOC
Conscious & alert to person,
place & time, but appears
drowsy
Airway & Breathing Respirations 18; unlabored
Oxygen Saturation 98% (on 100% oxygen)
BP, Pulse
118/78, HR 104
LS clear & = bilaterally, scattered
wheezing
Skin is somewhat flushed, rash
Integumentary
ICEnAXES EMS & Wilderness
Emergency Care Training
has dissipated
Breath sounds
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Scenario
• Is further treatment required for this pt?
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Scenario
• At this point, the pt
requires continuous
monitoring to ensure
complete resolution of
her s/s
• Wheezing or Stridor still
present? - Yes
Albuterol 2.5mg/3mL
via nebulizer
or
4 puff via MDI
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Scenario
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• Are there any special considerations for
this pt?
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Scenario
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• Are there any special considerations for
this pt?
– Although the pt does not have a cardiac hx,
you should monitor her BP & HR, both of
which have been increased by the
epinephrine that you gave her.
– Catecholamines (e.g., Epi & Norepi) cause
an increase in oxygen demand, which could
exacerbate any underlying medical
problems that the pt may have & be
unaware of.
ICEnAXES EMS & Wilderness Emergency Care Training
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Scenario
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• The pt is delivered to the hospital in
stable condition, and you give your
verbal report to the MD. The pt’s s/s
have completely resolved.
• Following additional assessment in the
ED, she is given a new prescription for an
EpiPen & discharged home.
ICEnAXES EMS & Wilderness Emergency Care Training
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Review Protocol
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• Go to allergic reaction -mild, moderate,
severe adult protocol
• Go to allergic reaction -mild, moderate,
severe pediatric protocol
• Discuss IM versus IVP epinephrine
ICEnAXES EMS & Wilderness Emergency Care Training
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• Pathophysiology
• Epidemiology
• Physical Exam Findings
• Diagnostic Findings
• Signs and Symptoms
• Differential considerations
• Scenario
• Treatment
ICEnAXES EMS & Wilderness Emergency Care Training
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Questions?
• References
– Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s
Emergency Medicine Concepts and Clinical Practice, 7th
edition. Mosby & Elsevier, Philadelphia: PA 2010.
– Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s
Emergency Medicine A Comprehensive Study Guide, 7th
edition. The McGraw-Hill Companies, Inc. New York 2011.
– Wolfson, Allan B. ed. , Hendey, George W.; Ling, Louis J., et al.
Clinical Practice of Emergency Medicine, 5th edition. Wolters
Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.
ICEnAXES EMS & Wilderness Emergency Care Training