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The Victim of Drowning
Abused Drugs
February 2014 CE
Condell Medical Center
EMS System
Site Code: 107200E-1214
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Rev 2.14.14
1
Objectives
Upon successful completion of this module,
the EMS provider will be able to:

Discuss definition and circumstances of
drowning
 Describe the pathophysiology of drowning.
 Discuss the assessment and management of the
patient who has drowned.
 List the categories of drugs most commonly
abused.
2
Objectives cont’d





Describe the effects on the body systems
based on the drug abused.
Describe complications noted with abuse of
drugs
Discuss assessment and management of the
patient who has abused drugs.
Describe the benefits of using capnography in
patient assessment and in defining patient
care.
Actively participate in interpretation of
waveform capnography.
3
Objectives cont’d
 Actively
participate in review of
selected Region X SOP’s.
 Actively participate in case scenario
discussion.
 Review responsibilities of the preceptor
role.
 Successfully complete the post quiz with a
score of 80% or better.
4
Definition and Stats of Drowning

Drowning is death by suffocation due to
immersion in water

Death is within 24 hours of the incident

Near-drowning is survival past the 24 hour mark
from the incident
 Most likely victims are young and healthy
 3 likely victims




Toddlers
Adolescents
Elderly
Recovery dependent on prompt rescue and
resuscitation
5
Background on Drowning
 Toddlers
drown in bathtubs, toilets, and
buckets/pails of water
 Adolescents drown usually around larger
bodies of water

Males proportionately higher than females
areas – swimming pools most
likely site
 Alcohol involved in approximately 40% of
drownings
 Coastal

75% involves use in and around boats
6
Drowning
 Usually
occurs silently and quickly
 Often within reach of a rescuer

Near-by help do not recognize the situation
 Image
of person drowning is a movie
concept



Most people struggle to breathe and have no
breath left to yell for help
Most people do not wave their arms around;
they use their arms to try to lift themselves out
of the water
Most people drowning look like they’re “playing”
7
8
Potential Outcomes of Drowning
 Death
 Morbidity

Development of disability or injury related to
the incident
 Survival
with no morbidity
 Most
surviving children found within 2
minutes; most who die are found beyond
10 minutes
9
Definitions
 Morbidity


Development of disability or injury related to
the incident
State of being diseased or unhealthy related
to the incident
 Mortality

Incidence of death in a population
10
Pathophysiology of Drowning
 An
injury to primarily the pulmonary
system and central nervous system (CNS)
 Prognosis is linked/related to


Submersion time which directly affects the
severity and duration of hypoxia
Temperature of the water
11
Pathophysiology of Drowning
 Victim
initially holds their breath
 Involuntary laryngospasm triggered by
water in the airway
 Victim unable to breath causing decreased
oxygen levels and increased levels of
carbon dioxide
 With decreasing O2 levels, laryngospasm
releases, victim gasps, hyperventilates,
and possibly aspirates waterhypoxemia
12
Pathophysiology cont’d
 Water
enters lungs only if actively inhaled;
water does not passively infuse into lungs
 Developing hypoxemia and acidosis
contribute the most to morbidity and
mortality
13
Older Term: Dry Drowning
– airway closes due to laryngeal
spasms from the presence of water
 Definition

Hypoxemia is cause of death
 Includes
10-20% of submersions
 Sequence involves



Laryngospasm 
Hypoxia 
Loss of consciousness
14
Older Term: Wet Drowning
Definition – water inhaled which interferes with
respirations which affects cardiovascular system
 Water is aspirated
 Surfactant is diluted


Chemical covering alveoli that keeps them open
facilitating respirations

Decrease in transfer of gases
 Atelectasis develops
 Ventilation perfusion mismatch occurs

Blood pumped thru deoxygenated lungs causing a
decreased level of O2 in circulating blood volume
15
Mammalian Diving Reflex

Sudden exposure to cold water (<200C (680F))



Breathing stopped - apnea
Bradycardia
Vasoconstriction of nonessential vascular beds
• Blood shunted to heart and brain

Metabolic processes slowed down
 Noted especially in young children
 Patient may appear dead

Patient cannot be pronounced if cold & dead; must be
warm & dead
16
Pathophysiology of
Fresh Water Drowning
 Fresh
water moves across alveolarcapillary membrane into microcirculation

Electrolyte abnormality can occur
 Fresh



water exposure
Surfactant destroyed
Alveoli collapse
Ventilation-perfusion mismatch occurs
 Pneumonia
rare consequence but more
likely in stagnant warm water and fresh
water
17
Pathophysiology of
Salt Water Drowning
 Salt




water increases osmotic gradient
Fluid drawn into alveoli
Surfactant washed out
Membrane between alveoli and capillaries
damaged
Ventilation-perfusion mismatch
 Lungs
non-compliant and become filled
with fluid
18
Complications of Submersion
– major complication
 Water and bacteria enter the lungs
 Hypoxemia


Development of pneumonia
Development of ARDS
• Lung condition causing leaky pulmonary capillaries
and development of hypoxemia
 Hypothermia
if in cold water
 Cervical spine injury complicates the
capability of the victim to self-rescue
19
Pulmonary Injuries from Drowning
 Contaminated
foreign material
contaminates the pulmonary system
 Particulate matter present
 Bacteria has a portal of entry
 Vomitus increases risk of aspiration
 Pulmonary system exposed to chemical
irritants
 Surfactant destroyed/washed away
20
Obtaining a History









Age
Underlying medical problems
History drug/alcohol use/abuse
Length of time submerged/unattended prior to
finding
Potential trauma with drowning (i.e.: dive)
Change in level of consciousness
Change in behavior since removal from water
Prior or since any seizure activity or chest pain?
Vomiting
21
Assessment of the Patient Who
Has Drowned
 “CAB”
approach if found unresponsive
 “ABC” approach if alive
 Vital signs
 Neurological assessment

AVPU, GCS, PMS/SMV/CMS, pupils
 Lung
sounds
 Cardiac monitoring
 Consideration spinal immobilization/spinal
motion restriction
22
Management of the Patient Who
Has Drowned
 Typically
based on findings during the
assessment phase
 Closely monitor airway and apply
precautions against aspiration
 Rapid transport

All victims of drowning regardless of
presentation should be encouraged to be
evaluated by a physician
• Some problems are not immediately obvious
23
Region X SOP
Adult Near Drowning
 Adult
Routine Medical Care or Adult
Routine Trauma Care
 Spinal precautions
 Consider CPAP if condition indicates
 Determine patient stability

Stable? Treat signs and symptoms
Patient alert
Skin warm and dry
Systolic B/P >90 mmHg
24
Adult Near Drowning SOP cont’d
 Unstable?


Altered mental status
Systolic B/P <90 mmHg
Secure airway
Assess for hypothermia
If normothermic treat dysrhythmias per
protocol
If hypothermic follow hypothermic protocol
25
Adult Hypothermic Protocol
 Adult
Routine Medical Care
 Frostbite




Move to warm environment
Rapidly rewarm frozen areas with warm water
(if available)
OR
Use hot packs wrapped in towel
Handle skin like a burn
• Protect with light, dry sterile dressing
• Elevate and immobilize
• Do not let surfaces rub together

Manage pain appropriately
26
Adult Hypothermic SOP cont’d
 Systemic


Avoid rough handling and excess activity
Apply heat packs (as available) to axilla,
groin, neck, thorax
 Assess


hypothermia
pulse
Present? – Continue assessment
Absent?
• Withdrawal of Resuscitative Efforts policy does not
apply to these patients
27
Adult Hypothermic SOP cont’d

Pulse absent


Universal Adult Emergency Cardiac Care (CPR)
Evaluate flexion of extremities


Flexible?
• Follow cardiac protocol
• Extend time between medications to the max
• Repeat defibrillation as core temp rises
Not flexible?
• Follow cardiac protocol
• Limit shocks to 1
• Withhold IV medications
28
Pediatric Near Drowning SOP
 Routine
Pediatric Care
 Spinal Precautions
 Oxygenate at 100%
 Determine stability

Stable? Treat signs and symptoms
• Awake, alert, normal respirations

Unstable? Abnormal respirations, altered
mental status
• Assess for gag reflex
29
Pediatric Near Drowning SOP
cont’d
 If

gag reflex absent
Intubate and assist ventilations via advanced
airway with BVM
• 1 breath every 6 - 8 seconds
 If

gag reflex present
Assist ventilations via BVM
• 1 breath every 3 – 5 seconds
 Assess


for hypothermia
Normothermic – treat dysrhythmias
Hypothermic – refer to hypothermic protocol
• Same as adult
30
Prognosis of Drowning Victim
 Often


poor
Related to multiple factors
Patients worse off
Initial presentation full arrest
Those remaining comatose
Those with fixed and dilated pupils
Those in respiratory arrest
 Duration
of hypoxemia impacts potential
for survival and for body system insult
31
Prognosis cont’d

Morbidity and death primarily from



Laryngospasm
Pulmonary insult
• Resulting hypoxemia and acidosis
Effects on the brain and other organ systems from
hypoxemia and acidosis

Secondary death risk from development of
ARDS
 Patients presenting awake and conscious have
best chance of full recovery
32
Patients with Altered Mental Status
Consider etiology – AEIOU-TIPPS
Trauma/temperature
 Epilepsy
Infection
 Insulin
Psychogenic
 Overdose/opiates Poisoning
 Uremia
Shock / seizure /
stroke / shunt
 Alcohol
33
Drugs Potentially Abused
– depresses CNS;
depresses ventilations, creates feeling of
euphoria
 Opioids/Narcotics



Synthetic – Tramadol, Propoxyphene
(Darvon), Fentanyl
Semisynthetic – dextromethorphan,
hydrocodone (Vicodin®, Lortab®), oxycodone
(oxycontin, Percodan®, Percocet)
Natural – codeine, morphine, paregoric,
heroin
34
Opioids/Narcotics cont’d
 Long





term effects
Restlessness
Muscle and bone pain
Insomnia
Vomiting
Cold flashes
35
Narcotic - Heroin









Harvested from opium poppy
3-6 months from planting to harvesting
Snorted, injected, smoked
Constricted pupils
Droopy, watery eyes
Dry mouth
 Nausea/vomiting
Slow slurred speech
Mental clouding
Loss of coordination
 pulse
 pain sensitivity
 appetite
 sexual drive
36
Heroin cont’d
 Long





term effects
Physical and psychological dependence
Tolerance
Mood swings
Seizures
Coma
37
Definitions

Physical dependence


Psychological dependence



Perceived “need” or “craving” for a drug
Can last a long time even after use stops
Addiction


Changes in the body after repeated use of drug that
requires continued administration of drug to prevent
withdrawal symptoms
Compulsive drug-seeking behavior; loss of control in
use of drug; drug most important thing for user
Physical tolerance

Shortened duration and  intensity of effects creating
need for increasingly larger doses to attain desired
effect
38
Drugs Potentially Abused
 Stimulants

Chemical substances (natural or synthetic)
that affect the CNS and accelerates activities
Caffeine
Nicotine
Adrenalin
Cocaine
Amphetamines
39
Stimulant - Cocaine








Euphoria then depression
Dilated pupils
Nasal tissue irritation, perforated septum
Tooth decay – anesthetic effect on gums
Vasoconstriction at point of injection
Increased heart rate
Severe chest pain
AMI – most common in 18-45 year-old;

Coronary artery spasm and platelet activation
contribute to coronary occlusion; may have no
evidence noted on angiogram inspection
40
Stimulant – Cocaine cont’d
 Long






term effects
Strong psychological dependence
Physical tolerance
Eating disorders
Impotence
Seizures
Strokes
41
Stimulant - Cocaine
 Smoked



Effects quicker/stronger
Onset 7 seconds; duration 15 minutes
Short period of high
 Injected


Highly water soluble – dissolves easily in
water
Onset 15-30 seconds; duration 15-20 minutes
42
Stimulant - Cocaine

Crack cocaine



Process of converting cocaine hydrochloride (HCl)
back to cocaine base for smoking
Ingredients added to cocaine, heated, then cooled,
then filtered to collect crystals
Free basing




Process of converting cocaine HCl back to cocaine
base for smoking
Onset 8 - 10 seconds
Effects 5 - 10 times more intense than snorting
• Theory that freebasing removes contaminants
making a purer product
Requires adding a solvent in process which  risk of
explosion and fire
43
Stimulant - Methamphetamine









Powder, liquid, tablets
Injected, inhaled, smoked, oral
Smoked – in bloodstream 5-10 seconds
High lasts 80
More potent than amphetamine
Physical & psychological dependency
Tolerance develops quickly
Users volatile, paranoid, unreliable
Intense tremendous energy; impulsive
44
Meth cont’d





 attention span
Intense itching – “bugs”
Tremors
Euphoria
Rapid speech
Hallucinations
Violence
Stages: Rush up to 30 min High 4-160 Binge-3-15
days; ingest more to continue high Tweaking (end of
binge)– psychotic state; paranoia, depression,
aggression Crash – body shuts down, deep sleep 1-3
days  meth hangover – lasts 2-14 days; deteriorated
state, exhausted; starts over to feel better  withdrawal
– painful & difficult; lasts 30-90 days; depressed,
energy, no pleasure, crave the drug
45
Drugs Potentially
Abused

Bath salts – outlawed in most States



Strong stimulant that creates aggression &
hallucinations


So named due to resemblance to bath salts
Labeled “not for human consumption” to avoid much
oversight
Synthetic similar to amphetamines
Unable to identify exact chemical composition so
treatment can be hampered/ difficult

3 most common chemicals: mephedrone,
pyrovalerone, methylenedioxyprovalerone (MPDV)
46
Bath Salts cont’d
 Snorted,
injected, ingested with food/drink
 Strongly addictive; triggers intense cravings
 Agitation
Paranoia
 Hallucinations
Chest pain
  heart rate
High B/P
 Kidney pain
Muscle tension
 temp or chills
Nausea
 Confusion
47
 May overheat and tear off clothes
Bath Salts cont’d
 Pt
often reports they thought they were
going to die; heavy drug users swear they
will never use this again
 Paranoia  aggressive, uncontrollable
attacks on others, self-destructive with
complete disassociation with reality
 Probably won’t respond to requests
 Pepper spray and tasers not likely to be
effective
 Effects last 3-4 hours or longer
48
Drugs Potentially Abused
 Depressants

Tranquilizers – used medically for anxiety,
depression, sedation, seizures, anesthesia,
sleep control, as antipsychotics
• Anti-anxiety – Rohypnol, Valium, Xanax


Barbiturates – seconal, Phenobarbital
Non-barbiturate – haldol, Quaaludes
49
Depressants – Rohypnol - Roofies







Intended as pre-med for anesthesia and
treatment for insomnia
Left no taste, odor, or visible effect in drinks
(changed in 1977 to be visible in drinks)
Onset 20-30 min; duration 8-120; detectable 720
Impairs judgment
inhibitions
Blackout/amnesia
Dizziness
Drunk like behavior
Gait ataxia
Slurring & stuttering
pulse, B/P
50
Common Over-The-Counter (OTC)
Products
 ASA and
Tylenol commonly added to
many over-the- counter products
 Inadvertent overdosing can be common
51
Drugs Commonly Abused
– Tylenol®
 Most common poisoning
 Suppository, tablet, liquid, drops, caplets
 Max dose 4000 mg/day (8 extra strength;
12 regular)
 >7000 mg/day could be severe OD
 Acetaminophen

(14 extra strength; 22 regular)
 Symptoms
start approximately 120 post
ingestion
52
Acetaminophen – Tylenol® cont’d
1st 24 hours
 Abdominal pain
 Sweating
 Pale, tired
 24 – 72 hours
 Pain RUQ
 Dark colored urine
 72 - 96 hours




•appetite
•Nausea//vomiting/diarrhea
•Jaundice
• urine production
Blood in urine
•Hungry, shaky, weak & tired
Blurred vision
•Fever
Tachypnea, tachycardia •Confusion, coma
53
Acetaminophen – Tylenol® cont’d
 Good
recovery if treated within 8 hours of
overdose

Improvement within 7 days
 Liver
failure and death in few days without
rapid treatment
 Increased risk



Alcoholic intake >3/day
Smoker
Known liver disease
54
OTC Drugs Commonly Abused
acid – Aspirin
 Availability makes it a common source of
unintentional and suicidal ingestion
 Acetylsalicylic

Found in multiple OTC products
 Tablet,
capsules, liquid, topical
 Affects multiple systems:



Central nervous
Pulmonary
Metabolic
• Cardiovascular
•Hepatic
•Renal
55
Acetylsalicylic acid – Aspirin
 Earliest




Nausea & vomiting (common)
Diaphoresis
•Tinnitus
Vertigo
•Tachycardia
Hyperventilation (common)
 As



signs & symptoms
toxicity progresses
Agitation
Hallucinations
Lethargy
•Delirium
•Convulsions
•Stupor
56
Acetylsalicylic acid – Aspirin
– indicates severe toxicity
especially in young children
 Patient becomes severely hypoxic
 Dehydration due to vomiting, increased
respiratory rate, hyperthermia
 GI hemorrhage more likely in chronic
intoxication
 Field care is supportive
 Hyperthermia
57
Acetylsalicylic acid – Aspirin
Sample Ingestion for 166# / 75 kg Adult
 <150

mg/kg – no toxicity
11,250 mg – 35 adult ASA
 150-2300
mg/kg – mild to moderate
toxicity

22,500 mg – 69 adult ASA
 301

– 500 mg/kg – serious toxicity
37,500 mg – 116 adult ASA
 >500

mg/kg – potentially lethal toxicity
>37,500mg
58
Product Potentially Abused
glycol – Antifreeze
 Colorless, odorless, sweet tasting liquid
 120 ml (4 oz) could be fatal to average
sized man
 1st symptom similar to drinking alcohol
(ethanol)
 Within few hours
 Ethylene

Nausea & vomiting, convulsions, stupor, coma
59
Ethylene glycol – Antifreeze
 Overdose





Damage to brain, lungs, liver, kidneys
Metabolic acidosis
Shock
Organ failure
Death
 Outcome
depends on time treatment
started
60
Drugs Accidentally Ingested
 Nicotine

ingestion
1 full cigarette, 3 butts, one piece of nicotine
chewing gum swallowed can be toxic to a
toddler
 Product
can be tempting smelling like
mint, vanilla, and cherry
 Patient needs a medical evaluation
61
Nicotine Ingestion
 Mild


poisoning
Vomiting
Lethargy
 Severe



•Sweating
•Tremors
poisoning
Confusion
Paralysis
Seizures
 Field
care is supportive
62
Paraphernalia Expected in
Environment
 Syringes,
needles
 Scales
 Baggies
 Pipes
for smoking
 Coffee filters
 Glass vials
 Spoons
 Hemostats
63
Paraphernalia cont’d
– prevents teeth grinding
 Vicks inhaler – opens nasal passages
allowing for bigger “hit” snorted
 Glow sticks – to be amused by light show
when waving stick around
 Pacifiers
64
Complications of Drug Abuse
 Destruction
of nasal septum due to
snorting cocaine
65
Complications of Drug Abuse

Abscess at injection site and infection from
intense scratching of
imaginary “bugs”

“Meth mouth”
 Enamel eroded away
due to corrosive
chemicals in product
66
Complications of Drug Abuse
 Brain


changes from use of ecstasy
Left side is a normal
brain scan
Right side is 3 weeks
since last use of drug
67
Complications of Drug Abuse
indicates use of glucose – the energy
source for brain function
 Decreased red = decreased glucose use =
decreased brain activity
 Red
68
Assessment of Patients Abusing
Drugs
 Having
high index of suspicion important
 Assess thoroughly to identify the product
to determine measures to control it
 Rescuer risk



Exposure risk during hands-on assessment
Disease transmission – hepatitis C, HIV
Injury due to violent patient
69
Assessment of the Patient With
Abusive Behavior with Drugs
 Start

with ABC’s
CAB if patient is in arrest
 Frequently
monitor for changing vital signs
 Frequently monitor for change in
respiratory status
 Usually perform routine medical
assessments and possible trauma
assessments
70
Management of Patients Abusing
Drugs
 Protect
rescuer safety first then patient
 Most field care is supportive and based on
signs and symptoms evident
 Consider use of law enforcement support
for violent patients
 Violent patient may need sedation as soon
as possible

Agitation and increased activity could worsen
the patient condition
71
Adult Altered Mental Status SOP
 Consider





etiology
Diabetes
Drug Overdose
Poisoning
Alcohol related
Stroke
 Adult
Routine Medical Care
 Immobilize C-spine as indicated
72
Adult Altered Mental Status SOP
 Obtain


blood glucose level and record
If <60 administer D50% - 50 ml IVP/IO OR
Glucagon 1 mg IM/IN
 If
not alert, respirations decreased or
narcotic overdose suspected

Narcan 2 mg IN/IVP/IO every 5 minutes as
needed to achieve desired effect
Improvement in ventilatory status
Max total 10mg
73
Adult Altered Mental Status SOP
 Note:



Attempt to identify substance(s) involved
Transport with patient any containers of
medications found at scene if not a safety risk
Consider use of restraints prior to
administration of Narcan
74
Pediatric Altered Mental Status
 Same

as Adult SOP except
IV fluid challenge listed
• 20 ml/kg
Remember frequent reassessment to note how
patient is handling the fluid challenge

Medication dosing based on pediatric weight
75
Narcan® (Naloxone)
 Narcotic/opioid
antagonist
 Can reverse respiratory depression
induced by exposure to narcotics







Morphine
Hydromorphine
Oxycodone
Demoral
Heroin
Paregoric
Dilaudid
Codeine
 Percodan
Fentanyl
Darvon
Methadone
Talwin
Nubain
76
Narcan® (Naloxone) cont’d
 Onset


within 2 minutes
Reversal effects dependent on amount of
narcotic taken
Be prepared to repeat dosage as needed to
max 10 mg IN/IVP/IO
 Use
cautiously in patients with cardiac
irritability and narcotic addiction
 May cause nausea, vomiting, withdrawal
symptoms, seizures
77
Opioid Withdrawal
 Tachycardia
 Hypertension
 Anxiety
 Dilated
Rare but possible:
seizures
stroke
dysrhythmia
pupils
 Sweating
 Vomiting/diarrhea
 Rhinorrhea – runny nose
 Piloerection - goose bumps
 Yawning
78
Region X SOP – Behavioral
Emergencies
 Establish
scene & personal safety
 Call law enforcement as appropriate
 Determine & document if patient threat to
self/others/unable to care for self
 Attempt to verbally calm patient
 Restrain as necessary and document

Reason, type, time, response
79
Region X SOP - Behavioral
Emergencies
 Consider





medical etiology
Hypoxia
Substance abuse/overdose
Excited delirium/Hyperthermia
Neurological disease (CVA, bleed)
Metabolic problem (hypoglycemia)
 Adult/Pediatric
Routine Medical Care
 If pediatric patient, contact Medical
Control for med orders
80
Region X SOP - Behavioral
Emergencies
Note:
 All ED’s in Region X are able to accept
patients with behavioral issues

All patients must be medically screened prior
to admission to psych unit
 Bring
to ED any containers found at scene
that do not pose a risk
 Contact Medical Control in all instances
where a refusal of transport is being
considered
81
Region X SOP - Behavioral
Emergencies
 For




Versed 2 mg IN
May repeat 2 mg IN every 2 minutes
Titrate to desired effect
Max up to 10mg
 For



severe anxiety/agitation
additional sedation if required
Valium 5 mg IVP over 2 minutes
Repeat as needed to max total 10 mg
Or Valium 10 mg IM
82
Capnography – A Useful Tool
 Carbon
dioxide (CO2) is a trace gas
 Produced as a by-product in the body and
delivered to the lungs
 Detectable in exhaled air
 Measured as a partial pressure in mmHg

PETCO2
 In
normal conditions, PETCO2 35-40mmHg
 Correlates with cardiac output
83
ETCO2 vs PETCO2
 ETCO2

detectors
Colormetric qualitative devices
• Indicates presence/absence of CO2
exhaled at end of the breath

CO2 is present or not
 PETCO2

Quantitative device
• Indicates a precise level of
measurable CO2 exhaled
at the end of the breath
84
Capnography Usefulness in Patient
Assessment

Monitors quality of CPR


Can optimize the compression depth and rate
If PETCO2 drops below 10mmHg, evaluate to improve
CPR technique

Indicates correct placement of endotracheal
tube
 Can detect return of spontaneous circulation
(ROSC)

If PETCO2 abruptly increases toward the norm of 3540mmHg, reassess the patient for ROSC (pulse)
85
Capnography in Patient
Assessment

What is your interpretation?


Normal waveform; CO2 exhaled at levels of 3545mmHg
Is intervention required?

No
86
Capnography in Patient
Assessment

What is your interpretation?


Hyperventilation – blowing off CO2 therefore CO2
Is intervention required?


Talk patient through slowing down their rate
If bagging, slow down your rate – you are
hyperventilating the patient!
87
Capnography in Patient
Assessment

What is your interpretation?


Hypoventilation, CO2 levels, is present possibly due
to CNS depression, narcotic overdose or heavy
sedation
Is intervention required?

Yes, assist the patient’s ventilations
88
Capnography in Patient
Assessment

What is your interpretation?



“Shark fin” appearance indicating obstruction during
exhalation
Seen in asthma, COPD, airway obstruction
Is intervention required?

Yes, bronchodilators or suctioning may be required
89
Capnography in Patient
Assessment

Pt is intubated. What is your interpretation?


Flattening waveform indicates esophageal intubation;
no measurement of exhaled CO2
Is intervention required?

Yes, extubate, hyperventilate, and reintubate
90
Case Scenario Discussion
 Review
the following cases
 Determine your general impression
 Determine appropriate course of action
 Discuss anything unique to the type of call
encountered
91
Case Scenario #1
 EMS
called to the scene for a 2 year-old
found floating in the bathtub
 They were only out of sight “a few seconds”
 Pediatric assessment triangle



Limp, flaccid, no activity
No respiratory movement noted
Cyanotic
 Consider
c-spine precautions
92
Case Scenario #1 cont’d
 CAB



Circulation-airway-breathing
5-10 second pulse check- pulse rapid, regular,
weak
Respirations absent
 What

assessment
intervention is required now?
Support ventilations via BVM
• 1 breath every 3-5 seconds (12-20/minute) in peds
patient
• Auscultate breath sounds
93
Case Scenario #1 cont’d
 Assess
for possible trauma
 Place on the monitor

Interpretation?
• Sinus tachycardia
94
Case Scenario #1 cont’d
 What

is the rate of ventilation via BVM?
1 breath every 3- 5 seconds (12 - 20/minute)
 What
is the rate of ventilations via an
advanced airway (ie: ETT or King airway)?

One breath every 6-8 seconds (8 – 10 / minute)
 How

is ETT placement confirmed?
Direct visualization, bilateral rise & fall of chest,
5 point auscultation, ETCO2 yellow, waveform
capnography
• PETCO2 35 – 45 mmHg noted in perfusing patient
95
Case Scenario #2
 EMS
called to a private residence for a 32
year-old found unresponsive.
 Last seen 4-6 hours ago
 Found lying on the floor pale, dry, vomitus
evident
 Pulse present but weak
 Respirations 4/minute with gasping
 Start thinking causes – AEIOU-TIPS

Hx: Valium, Tylenol, ETOH overdose today
96
Case Scenario #2
 What

720 – 1240 mg/kg
 150#

constitutes an overdose of Valium?
= 68 kg
68kg x 720mg = 49,090 mg
• Or 9,818 - 5 mg tablets

68kg x 1240 mg = 84,320 mg
• Or 16,864 – 5 mg tablets
 Hard
to OD on valium alone
 Mixing Valium with alcohol becomes the
hazard
97
Case Scenario #2 cont’d
 Assessments/interventions

Clear airway
• Suction, positioning, document presence of
vomitus – aspiration likely

Support ventilations
• BVM 1 breath every 5-6 seconds in adults

Prepare to protect airway
Suctioning
Positioning
Advanced airway
98
Case Scenario #2 cont’d
 IV

access
If unable to establish peripheral, then what?
• IO – pre-tibial site initial preferred site

How do you confirm IO placement?
• Needle stands up
• Flushes easily and without infiltration
• Fluid flows with pressure bag
 Obtain

blood glucose level
72
99
Case Scenario #2 cont’d
 Administer

2mg IN/IVP/IO every 5 minutes; max 10 mg
 What



Narcan
is the desired effect of Narcan?
Improve ventilations
Don’t necessarily need patient fully awake
Consider application of restraints prior to
administration of Narcan
 If
the patient is tubed, what is ventilation
rate?

1 breath every 6-8 seconds (all ages)
100
Case Scenario #2 cont’d
 After
IO insertion and fluid infusion begun,
patient becoming more restless and
moving leg around; pulse rate up; facial
grimacing present


What might be the problem?
Pain due to infusion via IO route
 Intervention?

Slow down fluid rate; Lidocaine 50 mg over 60
seconds, wait 60 seconds then begin infusion
101
Case Scenario #3
 EMS
called for adult found by friends
floating in the lake; unknown submersion
time
 0-0-0
 Assessment/treatment required?



Spinal immobilization
Immediate CPR – Perform CAB assessment
Place patient on monitor
102
Case Scenario #3
 What

VF
 What

is the rhythm?
do you do?
Administer 1st shock and finish assessing
patient to determine further course of action
103
Case Scenario #3 cont’d
 Decision

Is patient normothermic or hypothermic?
• If normothermic, treat dysrhythmia
• If hypothermic, determine if extremities flexible

If hypothermic, place warm packs
• Axilla, groin, neck, thorax
• If extremities can be flexed, administer medications
but extend time between to longest available
 Repeat defibrillation as core temp rises
• If extremities cannot be flexed, then hold meds
 Limit defibrillation to 1 attempt
104
Case Scenario #3 cont’d
 Cannot
withdraw resuscitative efforts until
patient warmed
 Adult CPR ratios?


1 & 2 man CPR – 30:2
If pulse present but not breathing, support
ventilations 1 every 5 - 6 seconds via BVM
• 1 every 6-8 seconds if via advance airway

If no pulse and advanced airway placed,
ventilate 1 every 6 - 8 seconds
105
Case Scenario #4
 EMS
called for 18 year old running thru
streets naked and screaming
 PD on scene
 What kind of restraints do you have?




Verbal de-escalation
Manual control
Soft restraints
Handcuffs only used by PD
• If handcuffs used, PD must accompany EMS in the
ambulance to the hospital
106
Case Scenario #4
 Consider





etiology
Hypoxia
Substance abuse / OD
Excited delirium / hyperthermia
Neuro disease ( i.e.; CVA, intracerebral bleed)
Metabolic problems (i.e.: hypoglycemia)
 If
peds patient contact Medical Control for
medication orders
107
Case Scenario #4 cont’d
 For


 If




severe anxiety / agitation
Versed 2 mg IN
Can repeat every 2 min until a max of 10 mg
additional sedation is required
Valium 5 mg IVP over 2 minutes
Repeat as needed
Max total dose 10 mg
Or give Valium 10mg IM
108
Reminder: Preceptor Role
 Your
role is to nurture, guide, grow the
student in their role
 Provide constant feedback and support
 Student expected to increase their
knowledge and skill level over time
increasing their independence
 Dynamic process changing over time
 Student can only improve with appropriate
direction and guidance
109
Review of Ventilation Rates
 Inadequate

breathing with pulse
Infant & child rescue breaths via BVM
• 1 every 3-5 seconds (12 - 20 / minute)

Adult
• 1 every 5 -6 seconds (10 – 12 / minute)
 Ventilations

with advanced airway in place
Infant, child, adult
• 1 breath every 6 -8 seconds (8 – 10 / minute)
• If during CPR, asynchronous with chest
compressions
110
Hazards of Hyperventilation
 As
respiratory rates increase above
recommended, the patient will be
hyperventilating
 Hyperventilation blows off CO2 decreasing
levels
 Vessels reflexively vasoconstrict

Impeded blood flow decreases cerebral
perfusion
 Cell
death becomes secondary insults
111
Bibliography
Aehlert, B. ECG’s Made Easy. 4th Edition. Mosby Jems.
2011.
 Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles & Practices, 4th edition. Brady. 2013.
 Region X SOP’s; IDPH Approved January 6, 2012.
 2010 American Heart Association Guidelines for CPR
and ECC
 http://www.sgna.org/issues/sedationfactsorg/medications
.aspx
 http://www.tustinca.org/weblink8/0/doc/218449/Page1.as
px
 http://www.who.int/water_sanitation_health/diseases/dro
wning/en/

112
Bibliography







http://emedicine.medscape.com/article/772753-overview
www.illinoispoisoncenter.org
Poison Control – 1-800-222-1222
Abcpoolsafety.org
Swimforlife.com
http://www.nlm.nih.gov/medlineplus/ency/article/000774.
htm
http://www.dentalgentlecare.com/drug_use_&_oral_clues
.htm

http://www.drugfreeworld.org/drugfacts/crystalm
eth/the-stages-of-the-meth-experience.html

http://www.huffingtonpost.com/2013/11/07/bath-saltszombies-video_n_4234691.html
113