Transcript 10 - Medical Emergencies

Medical Emergencies
Provincial Reciprocity Attainment Program
Diabetes
Diabetes
 The bodies inability to use sugar
properly
 Hypoglycemia
 Too much insulin or not enough sugar
 Hyperglycemia
 Too much sugar or not enough insulin
Hypoglycemia (Insulin Shock)
Signs and Symptoms
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Progresses quickly
Increased heart rate
Pale, cool and clammy skin
Dilated pupils
Lethargic
Slurred speech, confusion
Seizures, agitated
Combative, may appear intoxicated
Hyperglycemia (Diabetic
Coma)
Signs and Symptoms
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Progresses slowly
Excessive thirst, hunger
Frequent urination
Vomiting, ABD Pain
Musty odor (acetone) on breath
Fast, deep respirations (Kussmal’s)
Altered LOC
Dehydration
Allergies and Anaphylaxis
Anaphylaxis
 An immediate, systemic, lifethreatening allergic reaction
associated with major changes in the
cardiovascular, respiratory, and
cutaneous systems
 Prompt recognition and appropriate drug
therapy are important to patient survival
Antigens
 A substance that induces the formation
of antibodies
 Antigens can enter the body by injection,
ingestion, inhalation, or absorption
 Examples:
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Drugs (penicillin, aspirin)
Envenomation (wasp stings)
Foods (seafood, nuts)
Pollens
Antibodies
 Protective protein substances
developed by the body in response to
antigens
 Bind to the antigen that produced them
 Facilitate antigen neutralization and
removal from the body
 This normal antigen-antibody reaction
protects the body from disease by
activating the immune response
Immune Response
 Immune responses are normally
protective
 They can become oversensitive or be
directed toward harmless antigens to
which we are often exposed
 This response is termed “allergic”
 The antigen or substance causing the
allergic response is called an “allergen”
 Common allergens include drugs,
Immune Response
 The healthy body responds by a
defense system known as immunity
that may be:
 Natural
 present at birth
 Acquired
 resulting from exposure to a specific
antigenic agent or pathogen
 Artificially induced
 inoculation
Allergic Reaction
 Marked by an increased physiological
response to an antigen after a
previous exposure (sensitization) to
the same antigen
 Initiated when a circulating antibody (IgG
or IgM) combines with a specific foreign
antigen, resulting in hypersensitivity
reactions
 Or to antibodies bound to mast cells or
basophils (IgE)
Hypersensitivity Reactions
 Agents that may cause hypersensitivity
reactions (including anaphylaxis)
 Drugs and biological agents
 Insect bites and stings
 Foods
Localized Allergic Reaction
 Localized allergic reactions (type IV) do not
manifest multi-system involvement
 Common signs and symptoms of localized
allergic reaction include:
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Conjunctivitis
Rhinitis
Angioedema
Urticaria
Contact dermatitis
Anaphylaxis
 comes from Greek and means “against
or opposite of protection”
It is the most extreme form of an
allergic reaction
 Rapid recognition and aggressive
therapy are essential
Anaphylaxis
 Almost any substance can cause
anaphylaxis
 Most common:
 Penicillin (by ingestion or injection)
 Envenomation by stinging insects
Risk increases with the frequency of
exposure
Histamines
 Promote vascular permeability
 Cause dilation of capillaries and venules
 Cause contraction of nonvascular smooth
muscle, especially in the GI tract and
bronchial tree
 Increased capillary permeability allows
plasma to leak into the interstitial space
 The profound vasodilation that results further
decreases cardiac preload, compromising stroke
volume and cardiac output
Histamines
 These physiological effects lead to:
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Cutaneous flushing
Urticaria
Angioedema
Hypotension
 Onset of action is very rapid
 Effects are short lived because they are
quickly broken down by plasma enzymes
Other Chemical Mediators
 The remaining chemical mediators
(heparin…) exert varying effects that may
include:
 Fever, Chills, Bronchospasm
 Pulmonary vasoconstriction
 These chemical processes can rapidly lead
to:
 Upper airway obstruction and bronchospasm
 Dysrhythmias and cardiac ischemia
 Circulatory collapse and shock
Assessment Findings
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Respiratory effects
Cardiovascular effects
Gastrointestinal effects
Nervous system effects
Cutaneous effects
Assessment Findings
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Palpitations
Parasthesia
Pruritis (itching)
Erythema or urticaria
Throbbing in the ears
Coughing , wheezing and difficulty breathing
Difficulty swallowing because of swelling of the
tongue and throat
 In a severe reaction, patient may go into shock,
become incontinent, convulse, become
unconscious and die
Initial Assessment
 Airway and breathing
 Airway assessment is critical
 Evaluate the conscious patient for voice changes,
stridor, or a barking cough
 Complaints of tightness in the neck and dyspnea
suggest impending airway obstruction
 The airway of unconscious patient should be
evaluated and secured
Initial Assessment
 If airflow is impeded, endotracheal intubation
should be performed
 If there is severe laryngeal and epiglottic
edema, surgical or needle cricothyrotomy may
be indicated to provide airway access
 Monitor the patient closely for signs of
respiratory distress
 Circulation
 Assess pulse quality, rate, and location
frequently
History
 May be difficult to obtain but is critical
to rule out other medical emergencies
that may mimic anaphylaxis
 Question the patient regarding the chief
complaint and the rapidity of onset of
symptoms
 Signs and symptoms of anaphylaxis usually
appear within 1 to 30 minutes of introduction
of the antigen
Significant Past Medical
History
 Previous exposure and response to
the suspected antigen
 Not always reliable
 Method of introduction of the antigen
 Chronic or current illness and
medication use
 Preexisting cardiac disease or bronchial
asthma
 Prescribed Epi-Pen
Physical Examination
 Assess and frequently reassess vital signs
 Inspect the patient's face and neck for
angioedema, hives, tearing, and rhinorrhea,
and note the presence of erythema or
urticaria on other body regions
 Assess lung sounds frequently to evaluate
the clinical progress of the patient and to
monitor the effectiveness of interventions
 Monitor ECG
Drug Therapy
 Ventilatory support
 Epinephrine
 are the most specific interventions in the
management of anaphylaxis
 Fluid resuscitation
 in the presence of hypovolemia
 Additional pharmacological therapy:
 Benadryl, Ventolin, Corticosteroids
 Antidysrhythmics
 Vasopressors to manage protracted hypotension
Pathophysiology of
anaphylactic shock.
Urticaria as a result of an allergic
reaction.
Urticaria
Toxicology
Poisonings
 Poison
 Any substance that produces harmful
physiological or psychological effects
Routes of Absorption
 Poisons may enter the body through:
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Ingestion
Inhalation
Injection
Absorption
Types of Toxicological
Emergencies
 Accidental poisoning
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Dosage errors
Idiosyncratic reactions
Childhood poisoning
Environmental exposure
Occupational exposure
 Drug/alcohol abuse
 Intentional poisoning/overdose
 Chemical warfare
 Assault/homicide
Types of Toxicological
Emergencies
 Statistics from the grand ole USA
 80% of suicidal gestures are from OD
 28,000 suicidal deaths/yr from OD
 Peak age for accidental OD is 2 years old
 Chance of reoccurrence post poisoning is 25%
in within one year
General Guidelines
 Most poisoned patients require only
supportive therapy to recover
 Airway:
monitor and clear if req’d
 Breathing:
support as req’d
 Circulation: support as req’d
 Oxygen (100%), IV, Monitor and Blood
glucose
 Consider other causes in the Unconscious
or seizing patient
 Obtain a thorough history and perform a
focused physical examination
General Guidelines
 If overdose is suspected, obtain an overdose
history from the patient, family, or friends
 Consult with OLMC/poison control center for
specific treatment to prevent further absorption of
the toxin (or antidote therapy)
 Frequently reassess the patient; monitor vital signs
and ECG
 Safely obtain any substance or substance container
of a suspected poison and transport it with the
patient
 Transport the patient for physician evaluation
Assessment
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Consider ICP
Watch for seizures
Watch for changes in condition (ABC’s)
Expose the patient
History………………………….
General Management
Principles
 Vitals
 Evaluate skin for perfusion status
 Monitor
 Head to Toe (rule out old trauma)
 Neuro
 Pupils
 LOC (GCS, AVPU)
 Symmetry of motion, ataxia
Poisoning by Ingestion
 About 80% of all accidental ingestions of
poisons occur in children 1 to 3 years of age
 Most result from household products
 Poisoning in adults is usually intentional,
although accidental poisoning from
exposure to chemical in the workplace also
occurs.
 Toxic effects of ingested poisons may be
immediate or delayed, depending on the
substance ingested
Poisoning by Ingestion
 Early management focuses on:
 Removing the toxin from the stomach
or
 Binding the toxin to prevent absorption
before the poison enters the intestines
Assessment and Management
 The primary goal of physical
assessment of poisoned patients is to
identify the poison’s effects on the
three vital organ systems most likely to
produce immediate morbidity and
mortality:
 Respiratory system
 Cardiovascular system
 Central nervous system
Assessment and Management
 Five signs of major toxicity
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Coma
Cardiac dysrhythmias
GI disturbances
Respiratory depression
Hypotension or hypertension
History
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What was ingested?
When was the substance ingested?
How much of the substance was ingested?
Was an attempt made to induce vomiting?
Has an antidote or activated charcoal been
administered?
 Does the patient have a psychiatric history
pertinent to suicide attempts or recent
episodes of depression?
Poisoning by Inhalation
 Accidental or intentional inhalation of
poisons can lead to a life—threatening
emergency
 The type and location of injury caused by toxic
inhalation depend on the specific actions and
behaviors of the chemical involved
 Toxic gases can be classified in three
categories: simple asphyxiants, chemical
asphyxiants, and irritants/corrosives
General Management—
Inhaled Poisons
 Scene safety
 Personal protective measures
 Rapidly remove the patient from the poison
environment
 Surface decontamination
 Adequate airway, ventilatory, and circulatory
support
 Initial assessment and physical examination
 Irrigation of the eyes (as needed)
 IV line with a saline solution
 Regular monitoring of vital signs and ECG
 Rapid transport to an appropriate medical facility
Carbon Monoxide Poisoning
 A colorless, odorless, tasteless gas
produced by incomplete combustion of
carbon-containing fuels
 Does not physically harm lung tissue
 Its affinity for hemoglobin is 250 times that
for oxygen
 Small concentrations of carbon monoxide can
result in severe physiological impairments
 Physical effects of carbon monoxide poisoning
are related to the level of COHb in the blood
 Treatment
Poisoning by Injection
 Human poisonings from injection may result
from:
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Drug abuse
Arthropod bites and stings
Reptile bites
Hazardous aquatic life
 Injected poisons are often mixtures of many
different substances, which may produce
several different toxic reactions
 Be prepared to manage reactions in many organ systems
simultaneously
Arthropod Bites and Stings
 Hymenoptera (bees, wasps, and ants)
and Arachnida (spiders, scorpions, and
ticks) cause the highest incidence of
need for emergency care
 Reactions to venoms are classified as
local, toxic, systemic, and delayed
Poisoning by Absorption
 Many poisonings by absorption result from
exposure to organophosates and
carbamates that are available for
commercial and public use as flea collars
and home and commercial insecticides
 Organophosphates and carbamates are among the most
toxic chemicals currently used in pesticides
 They are well absorbed by ingestion, inhalation, and
dermal routes
Toxidromes
 A collection of clinical clues to a
particular poison
 5 Major:
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Sympathomimetic
Anticholinergic
Cholinergic (muscarinic)
Cholinergic (nicotinic)
Narcotic (and withdrawal)
Toxidromes
 For each toxidrome identify:
 Signs and symptoms
 Typical toxins
 Treatment
Sympathomimetic
 S/S:
 agitation, psychosis, seizures,
tachycardia, hypertension, hyperthermia,
diaphoresis, ECG changes
 Toxins:
 Epi, Norepi, amphetamines, cocaine,
ephedrine, pseudoephedrine, PCP, LSD,
caffeine
Anticholinergic
“DRY” patient
 S/S:
 Red as a beet, Dry as a bone, Mad as a
hatter, Hot as a stone, Blind as a bat,
Bladder and Bowel lose their tone while
the heart runs alone
 Toxins:
 Atropine, TCA’s, antihistamines,
mushrooms
Cholinergic – Muscarinic
“WET” patient
 S/S:
 “SLUDGE”
 Salivation, lacrimation, urination, deification,
GI upset, emesis
 bradycardia, wheezing,
bronchoconstriction, miosis, confusion,
coma, convulsion, diaphoresis, seizures
 Toxins:
 Organophosphates, insecticides, nerve
gas, carbamates
Cholinergic - Nicotinic
 S/S:
 Biphasic response
 excitation followed by depression,
tachycardia/bradycardia,
hyper/hypotension,
fasciculations/paralysis, coma seizures
 Toxins:
 tabacco, nicotinic insecticides, nicotine
patches and gum
Narcotic
 S/S:
 CNS depression, miosis, hypothermia,
hypoventilation, hypotension, pinpoint
pupils
 Toxins:
 opiates, opiodes
Withdrawal
 S/S:
 Tachycardia, hypertension, N/V, DT,
seizures, hallucinations, insomnia,
diarrhea, piloerection, cramps, mydriasis
 Toxins:
 withdrawal from ETOH, barbs, benzos,
narcotics
Common Toxins and
Management
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Acetaminophen
Salicylate
Methanol
Digoxin
Lithium
Organophosphate
Phenytoin
CO
mucomist
charcoal
ETOH
Charcoal
Dialysis
Atropine
Charcoal
hyperbaric chamber
Common Toxins and
Management
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Anticholinergic
Beta blockers
Ca Channel blocker
Cyanide
Dystonias
Opiates
physostigmine
glucagon
Calcium
Nitrate
Benadryl
Naloxone
Methods to decrease
absorption
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#1 RULE: DO NOT POISON YOURSELF
Eyes: Remove contacts, flush for 20 min
Skin:
Remove clothes and wash
GI:
Don’t empty corrosives
GI
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Optimal time:
< 10 min
After 1 hour charcoal has less effect
Stay away from ipecac
Lavage: Best for adult
Charcoal:
 Large surface area, absorbs most toxins
effectively
 Doesn’t work with etoh, petroleum,
metals
Wrapping it Up
 Know common poisons in your area
 Remember anything is a potential poison
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Manage ABC’s as before
HISTORY!!!!
Identify toxidrome
Remember patient may be mixing
toxidromes
Poison Control Centers
 Poison control centers exist across the
Canada to help manage poisoning
emergencies
 Most are based in major medical centers
or teaching hospitals
 IWK houses Nova Scotia’s
1-800-565-8161