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QuickTime™ and a decompressor are needed to see this picture. Welcome! DOT National Standard EMT-Intermediate/85 Refresher ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Introduction • Mary Koskovich – EMT 1988 - 23 yrs – Paramedic 1991- 20 yrs – Educator 1997 - 14 yrs ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Course content QuickTime™ and a decompressor are needed to see this picture. • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. • Go to mandatory core content ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. • Go to: – Intermediate Refresher Feb 21 22 Monday Tuesday Schedule ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. • 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 QuickTime™ and a decompressor are needed to see this picture. • • • • • • • • • 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 QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. • • • • • • • • • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction QuickTime™ and a decompressor are needed to see this picture. • 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) ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction QuickTime™ and a decompressor are needed to see this picture. • 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 QuickTime™ and a decompressor are needed to see this picture. • The ancient immune system – Humans inherited it from invertebrates – Considered the 1st line of defense – Very fast • Effector components – – – – – – – – Mast cells Macrophages Dendrites cells Natural killer cells Granulocytes Antimicrobial peptides Complements Cytokines QuickTime™ and a decompressor are needed to see this picture. • 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) ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction QuickTime™ and a decompressor are needed to see this picture. • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction QuickTime™ and a decompressor are needed to see this picture. • They coined the term anaphylaxis from Greek • (ana, against; phylax, guard or protect), meaning “against protection” ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction QuickTime™ and a decompressor are needed to see this picture. • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction QuickTime™ and a decompressor are needed to see this picture. • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction QuickTime™ and a decompressor are needed to see this picture. • Fixation of this allergen-specific IgE to surface receptors on mast cells completes the process known as sensitization ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. In plain English: QuickTime™ and a decompressor are needed to see this picture. – The immune system creates disease-fighting antibodies (called IgE) toward a substance that is normally harmless, such as food. ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. In plain English: QuickTime™ and a decompressor are needed to see this picture. – When the body is 1st exposed to the substance- the body does not react [but it does produce the antibodies] = sensitization ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. In plain English: QuickTime™ and a decompressor are needed to see this picture. – Then when the body is exposed to the substance again, the antibodies spring into action believing that the substance is a dangerous foreign invader ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Allergic reaction QuickTime™ and a decompressor are needed to see this picture. • 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) ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction QuickTime™ and a decompressor are needed to see this picture. • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction QuickTime™ and a decompressor are needed to see this picture. The chemical mediators released from mast cells exert their effect on target organs to produce the clinical symptoms of allergic reaction ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S QuickTime™ and a decompressor are needed to see this picture. • Urticaria (aka- hives) = itchy skin eruption characterized by weals with pale interiors & welldefined red margins ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S QuickTime™ and a decompressor are needed to see this picture. • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S • Vasodilation can lead to: – – – – – Flushing HA Reduced peripheral vascular resistance Hypotension Syncope ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S QuickTime™ and a decompressor are needed to see this picture. • Contraction of smooth muscles can cause: – – – – Bronchospasms Abdominal cramping Diarrhea Pulmonary vessel vasoconstriction can lead to pulmonary HTN, pulmonary edema & decreased cardiac filling pressures ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S • Coronary vasoconstriction can lead to: – Myocardial ischemia – Decreased myocardial contractile force (negative inotropy) – Cardiac dysrhythmias ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S QuickTime™ and a decompressor are needed to see this picture. • 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”) ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Pathologic features identified at autopsy QuickTime™ and a decompressor are needed to see this picture. • In fatal cases of anaphylaxis the most commonly observed causes are in the respiratory & cardiac system – – – – – – 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Pathologic features identified at autopsy QuickTime™ and a decompressor are needed to see this picture. • Pts who die of vascular collapse show varying degrees of – Myocardial damage – Visceral congestion – & other findings suggestive of a loss of intravascular blood volume ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Pathologic features identified at autopsy QuickTime™ and a decompressor are needed to see this picture. • Other autopsy findings: – – – – – Urticarial eruptions Angioedema Visceral congestion Submucosal edema Hemorrhagic gastritis • Notably- autopsy findings may also be normal after an anaphylactic death ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Review ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Epidemiology QuickTime™ and a decompressor are needed to see this picture. • 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. ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Other causes QuickTime™ and a decompressor are needed to see this picture. • Iodinated contrast media • Foods – Peanuts, tree nuts, shellfish, milk, eggs, wheat • NSAID • Exercise-induced anaphylaxis – (usu. associated with prior food or drug ingestion) ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Onset QuickTime™ and a decompressor are needed to see this picture. • Symptoms of anaphylaxis usu. begin <30 mins post exposure & are often immediate • Oral antigens - may have a 2 hr delay ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Onset QuickTime™ and a decompressor are needed to see this picture. • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Onset • About 6% of pts with anaphylaxis experience a biphasic course with recurrent anaphylaxis within 8 hrs (despite earlier resolution!) ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Differential Considerations QuickTime™ and a decompressor are needed to see this picture. • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Scenario QuickTime™ and a decompressor are needed to see this picture. • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. 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. ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Scenario QuickTime™ and a decompressor are needed to see this picture. • 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 QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Question? QuickTime™ and a decompressor are needed to see this picture. • What initial management is indicated for this patient? ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. • Go to “Call Matrix Allergic Reaction” ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Question? QuickTime™ and a decompressor are needed to see this picture. • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Scenario • Is the pt stable or unstable? • What is your rationale? ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Scenario • What size IV catheter would you use? – Rationale? • What is the 1st appropriate pharmacological intervention? – Rationale? ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. 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) ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Scenario QuickTime™ and a decompressor are needed to see this picture. 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 EMS & Wilderness Emergency Care Training exhalation. QuickTime™ and a decompressor are needed to see this picture. Scenario QuickTime™ and a decompressor are needed to see this picture. • Further assessment of the pt reveals mild facial swelling. ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Scenario QuickTime™ and a decompressor are needed to see this picture. 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 ICEnAXES EMS & Wilderness Emergency Care Training illness QuickTime™ and a decompressor are needed to see this picture. Scenario • What is your field impression of this pt? – Give your rationale ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Scenario QuickTime™ and a decompressor are needed to see this picture. • 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. 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. ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Scenario • What specific treatment is required for this pt’s condition? ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Scenario • Diphenhydramine 50mg IV q 6hrs; – may utilize IM if no IV access ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. 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 QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. 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 QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Scenario QuickTime™ and a decompressor are needed to see this picture. 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 QuickTime™ and a decompressor are needed to see this picture. Scenario • Is further treatment required for this pt? ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. 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 ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. Scenario QuickTime™ and a decompressor are needed to see this picture. • Are there any special considerations for this pt? ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. Scenario QuickTime™ and a decompressor are needed to see this picture. • 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 QuickTime™ and a decompressor are needed to see this picture. Scenario QuickTime™ and a decompressor are needed to see this picture. • 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 QuickTime™ and a decompressor are needed to see this picture. Review Protocol QuickTime™ and a decompressor are needed to see this picture. • 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 QuickTime™ and a decompressor are needed to see this picture. • Pathophysiology • Epidemiology • Physical Exam Findings • Diagnostic Findings • Signs and Symptoms • Differential considerations • Scenario • Treatment ICEnAXES EMS & Wilderness Emergency Care Training QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. QuickTime™ and a decompressor are needed to see this picture. 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