Transcript EMS

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Taylor Ratcliff,
MD, FF, EMT-LP
Terminology
Anxiolysis, Sedation,
Anesthesia
Anxiolysis
Process of decreasing
anxiety or stress
related to a situation
Anxiolysis
Talk therapy
Distraction/
redirection
Medications
Sedation
Multiple different
levels recognized by
the American Society
of Anesthesiologists
(ASA)
Sedation
Light, moderate, deep
Anesthesia
Various stages based
on stimuli required to
obtain a response and
central nervous
system effects
Anesthesia
Emergency medical
services (EMS) usually
wants patients deeply
anesthetized, quickly
Risk/Benefit
Analysis
Risk/Benefit Analysis
Pain
›for some patients,
analgesia can be
provided to reduce
pain
Risk/Benefit Analysis
Pain
›is temporary. but
death is permanent
Risk/Benefit Analysis
What is the absolute
benefit of your
procedure...
Risk/Benefit Analysis
...versus the perceived
negative
consequences without
it, and the possible
complications?
Procedural
Sedation:
Applications For
EMS
Induction: Anesthesia
(Intubation)
Pharmaceutically-
assisted intubation
Perhaps the most
debated
Anxiolysis/Light
Sedation
Cardiac pacing,
cardioversion
Pleural
decompression,
intraosseous (IO)?
Applications for EMS
Premedication for
painful lifting,
moving, and
extrication
Applications for EMS
Psychotic patients
Excited delirium
Following Taylor Ratcliff
there will be a
presentation by Darrin
M. Batty touching on
excited delirium and
in-custody situations
Applications for EMS
Others
›radiological
procedures
Risks/Complications
Threat of death from
your medical director
Risks/Complications
Medication
intolerances/side
effects:
Risks/Complications
›each agent has its
own set of problems
and specific side
effects
Risks/Complications
›idiosyncratic/allergic
reactions
Risks/Complications
Oversedation/
respiratory
insufficiency:
Risks/Complications
›fast vs. long-acting
agents, reversibility
›ability to monitor
and ventilate your
patient
Risks/Complications
Loss of protective
airway reflexes
(aspiration)
Side Effect Matchup
Ketamine
Propofol
Etomidate
Benzodiazepines
Opiates
Ketamine
Tachycardia
Hypertension (HTN)
Emergence reaction
Propofol
Respiratory
depression
Hypotension
Egg/soy allergy
Etomidate
Vomiting
Fasciculations
Benzodiazepine
Somnolence
Decreased respiratory
drive
Opiates
Histamine release
Hypotension
Respiratory
depression
I Want a New Drug
Does the perfect
agent for sedation
exist?
I Want a New Drug
If so, what qualities
would it have?
I Want a New Drug
My perfect list:
Does it exist?
My Perfect List
Results reliable and
reproducible in
children and adults
My Perfect List
Able to give
intravenous (IV), IO,
intermuscular (IM)
My Perfect List
Quick onset and rapid
duration of action
My Perfect List
Minimal effects on
hemodynamic
parameters
My Perfect List
Applicable to wide
variety of situations
Does it exist?
Minimal side effect
profile
›vomiting
›myoclonus
Does it exist?
Reversible in
emergency
Does it exist?
Provides
›sedation
›anxiolysis
Does it exist?
Provides
›analgesia
›amnesia
Does it exist?
Use permitted by all
levels of responders
Does it exist?
Nonaddictive
Drug Election
Five Major Drug
Classes and
Application
The Lineup
Drug class and
examples
Primary indications,
routes
The Lineup
Pharmacokinetics and
mechanism of action
Most common side
effects
Reversibility agents
Opiates (and Opioids)
Organic
Semisynthetic
Synthetic analgesic
Opiates (and Opioids)
 Fentanyl
 Methadone
 Morphine  Tramadol
 Dilaudid
 Heroin
 Oxycodone
Opiates (and Opioids)
Variety of routes
Opiates (and Opioids)
Binds opioid receptors
in central nervous
system:
Opiates (and Opioids)
›Mu (38%)
›Delta (16%)
›Kappa 3 (43%)
Opiates (and Opioids)
Onset of action -
variable
Opiates (and Opioids)
Side effects
›sedation
›respiratory
depression
Opiates (and Opioids)
Side effects
›hypotension
›nausea
›allergic reactions
Opiates (and Opioids)
Side effects
›allergic symptoms
common
(histamine), itching,
hives, etc.
Opiates (and Opioids)
Reversibility agents -
naloxone (can be dose
dependent)
Benzodiazepines
Drug class and
examples
›sedative hypnotic
Benzodiazepines
Drug class and
examples
›Valium®
›Versed®
Benzodiazepines
Drug class and
examples
›Ativan®
›Xanax®
Benzodiazepines
Primary indications
›anxiolysis
›sedation
›seizure control
Benzodiazepines
Primary indications
›muscle spasm
mitigation
›vertigo
Benzodiazepines
Routes
› by mouth (PO)
›IM
›IV
Benzodiazepines
Routes
›subcutaneous (SC)
›IO
Benzodiazepines
Most common side
effects
›sedation
›somnolence
Benzodiazepines
Most common side
effects
›hypoventilation
›hypotension
›coma
Benzodiazepines
Most common side
effects
›some patients are
sensitive to them
(idiosyncratic effect)
Benzodiazepines
Reversibility agents -
Flumazenil
®
(Romazicon )
Ketamine
Drug class
›dissociative
anesthetic
›hypnotic
Ketamine
Drug examples
›commonly used
illicitly
Ketamine
Drug examples
›street/slang names =
special K, K-hole,
etc.
Ketamine
Most common side
effects
›tachycardia
›hypertension
Ketamine
›“emergence
phenomenon”
secretions
increased
Ketamine
patients maintain
respiratory drive
Ketamine
Pharmacokinetics -
works on central
nervous system...
Ketamine
Pharmacokinetics
...N-Methyl-Daspartate (NMDA)
receptors
Ketamine
Research
›using for patients
with excited
delirium
Ketamine
Research
›use in patients that
are acutely
combative and
violent
Ketamine
Reversibility agents -
none
Ketamine
Emergence
phenomenon patients dissociated
when it starts to wear
off
Propofol
Propofol
Drug class and
example
›sedative hypnotic
›anesthetic
®
(Diprivan )
Propofol
Most common side
effects
›has antiemetic
properties
Propofol
›causes significant
hypotension
›respiratory
depression
Propofol
›cross-allergy to eggs
and soy problematic
Nitrous Oxide
Drug class and
examples
›inhalational
anesthetic
›anxiolytic
Nitrous Oxide
Drug class and
examples
›laughing gas
Nitrous Oxide
Most common side
effects
›nausea
›dysphoria
Nitrous Oxide
›hypoxia
›hypotension
›respiratory
depression
Nitrous Oxide
Must be mixed with
oxygen to avoid
making patient
hypoxic
Situational Choices
Ideal medication may
not exist, but the
situation may be
helpful
Situational Choices
Can be based on:
›patient condition
and vital signs
›needed duration of
action
Situational Choices
Can be based on:
›desired effect,
analgesia vs.
amnesia vs. sedation
Situational Choices
Local protocols and
accessibility
Scenarios
Pediatric Entrapment
Pediatric Entrapment
You are called to
scene where a
10-year-old male with
his arm stuck in a coke
machine slot:
Pediatric Entrapment
›no medical history
›normal
anatomy/exam
Pediatric Entrapment
›cannot access the
arm
Pediatric Entrapment
Extrication: fire
department advises
they will have to
“pull” on the arm
Child with Entrapped
Arm
Desired effect:
analgesia, axolysis
Child with Entrapped
Arm
Duration: short term
(<10 minutes)
Child with Entrapped
Arm
Delivery
route/available: all
available
Child with Entrapped
Arm
Anticipated
complications/side
effects
›difficulty in
controlling airway
Child with Entrapped
Arm
Anticipated
complications/side
effects
›vomiting
problematic
Child with Entrapped
Arm
Contraindications:
patient has an egg
allergy
Child with Entrapped
Arm
Justified
›risk of severe pain in
a child
›visible disfigurement
Best drug choices
for entrapped child?
Ketamine would
have been an
excellent choice
Elderly Person with
Fractured Hip
Elderly with Fractured
Hip
85-year-old female;
fall and hip injury:
Elderly with Fractured
Hip
›severe pain with any
movement
›begs you not to
“move her” and
screams
Elderly with Fractured
Hip
›history of
hypertension,...
Elderly with Fractured
Hip
...coronary artery
bypass graft (CABG),
diabetes mellitus
(DM)
Elderly with Fractured
Hip
›vital signs (V/S)
blood pressure (BP)
106/70
heart rate (HR) 110
Elderly with Fractured
Hip
›vital signs (V/S)
respiratory rate
(RR) 24
Elderly with Fractured
Hip
Desired effect:
analgesia
Duration: long term
Elderly with Fractured
Hip
Delivery
route/available:
IV/IO/IM
Elderly with Fractured
Hip
Anticipated
complications/side
effects:
›airway modifications
Elderly with Fractured
Hip
Anticipated
complications/side
effects:
›respiratory
depression
Elderly with Fractured
Hip
Contraindications:
hypotension (relative)
Elderly with Fractured
Hip
Audience electronic
response
›opiates
›demerol
Elderly with Fractured
Hip
Audience electronic
response
›etomidate
Elderly with Fractured
Hip
Audience electronic
response
›propofol
›benzodiazepine
Elderly with Fractured
Hip
Audience electronic
response
›nitrous oxide
›succinylcholine
Patient Needing
Cardioversion
Cardioversion
35-year-old male with
chest pain
›supraventricular
tachycardia (SVT),
hypotensive
Cardioversion
35-year-old male with
chest pain
›long history, knows
when he “goes into
it”, 30 minutes ago
Cardioversion
35-year-old male with
chest pain
›says, “don’t you
shock me while I’m
awake again”
Cardioversion
›history of WolffParkinson-White
(WPW) syndrome,
SVT,...
Cardioversion
...hypertrophic
cardiomyopathy
(HCM), ablation 1
year ago
Cardioversion
›exam reveals anxious
patient, poor pulses
BP 86/48
HR 176
RR 30
Cardioversion
Desired effect
›analgesia and
amnesia
›axiolysis
Cardioversion
Duration; very short
term
Delivery
route/available;
IV/IO/IM
Cardioversion
Contraindications;
hypotension
Cardioversion
Justified; cases of
documented
post-traumatic stress
disorder
Cardioversion
Audience electronic
response
›Versed®
›Ativan®
›Valium®
Cardioversion
How about
Etomidate?
Cardioversion
Ketamine
Pediatric Asthma:
Intubated
Pediatric Asthma:
Intubated
You arrive to transfer
a 6-year-old male with
asthma:
Pediatric Asthma:
Intubated
›patient already
intubated
Pediatric Asthma:
Intubated
›not well sedated,
difficult to bag (very
“tight”, fighting the
vent)
Pediatric Asthma:
Intubated
›no other medical
history
Pediatric Asthma:
Intubated
›V/S
BP 132/90
HR 100
Pediatric Asthma:
Intubated
›V/S
RR 32 spontaneous
oxygen saturation
(hemoglobin) or
SaO2 90%
Pediatric Asthma:
Intubated
Desired effect?
›analgesia
›amnesia
›decreased
respiratory drive
Pediatric Asthma:
Intubated
Desired effect?
›increased pulmonary
compliance (ease of
ventilation)
Pediatric Asthma:
Intubated
Audience electronic
response
›opiates
›ketamine
Pediatric Asthma:
Intubated
Audience electronic
response
›propofol
®
›Versed
Pediatric Asthma:
Intubated
Caregiver precautions
›approved use
›appropriate age
›authorization to use
General Summary
Thoughts
General Summary
Thoughts
Use pain medication
for most pain
General Summary
Thoughts
Quick procedures
should merit a
quick-acting agent
General Summary
Thoughts
Take advantage of the
known side effects of
different medications
General Summary
Thoughts
Know the specific
contraindications to
specific agents
Extenuating
Circumstances
Extenuating
Circumstances
Should we ever
intubate patients for
severe pain?
Extenuating
Circumstances
›going to the
operating room
anyway
›risks/complications
Extenuating
Circumstances
What about sedation
for violent or
combative patients?
Extenuating
Circumstances
Following this part of the
program, Darrin M. Batty
presents
Positional Asphyxia:
An In-Custody
Phenomenon
Partner with Law
Enforcement
Some noncompliant
citizens may actually
be people in the
throws of a medical
emergency
Partner with Law
Enforcement
EMS can help mitigate
the issue
Sudden In-Custody
Death
Positional/postural
asphyxia - is a form of
asphyxia which occurs
when someone's...
Sudden In-Custody
Death
...position prevents
them from breathing
adequately
Sudden In-Custody
Death
Excited delirium or
"acute exhaustive
mania,” is a state of
extreme...
Sudden In-Custody
Death
...mental and
physiological
excitement
Sudden In-Custody
Death
A misunderstood
phenomenon
Sudden In-Custody
Death
Police procedures,
techniques, and tools
have been blamed:
Sudden In-Custody
Death
›1980 - "choke holds“
Sudden In-Custody
Death
›“Hogtie" hobble
device
Sudden In-Custody
Death
›intermediate tools chemical agents and
electronic weapons,
®
such as Tasers
Sudden In-Custody
Death
None of these tools or
techniques are the
causes in and of
themselves
Excited Delirium
50 to 105 in-custody
deaths every year:
Excited Delirium
›police department
(PD) sees as detain
and arrest scenarios,
not serious medical
issues
Excited Delirium
›similar deaths also
occur in psychiatric
and geriatric care
facilities
Excited Delirium
People with a mental
illness, (bipolar
disorder or
schizophrenia)
Excited Delirium
Chronic, illicit
stimulant (cocaine,
methamphetamine,
phencyclidine [PCP])
abusers...
Excited Delirium
...and ecstasy,
marijuana, or alcohol
abusers
Excited Delirium
Combination of
mental illness and
substance abuse
Excited Delirium
Most subjects police
encounter with
excited delirium are
males...
Excited Delirium
...between the ages of
30 and 40 (rarely seen
in females)
The Perfect Storm
Pathology/physiology
Illicit substances
Law enforcement
Pathology/Physiology
Predisposed to
sudden death
Pathology/Physiology
Organic disease:
Pathology/Physiology
›preexisting cardiac
abnormality
(cardiomyopathy)
›obesity
Pathology/Physiology
›chronic alcohol
abuse
Pathology/Physiology
Mental illness
›bizarre behavior
›anxious
Pathology/Physiology
Mental illness
›irrational
›violent
Pathology/Physiology
›not communicating
or communication is
incomprehensible or
repetitive
Pathology/Physiology
›exhibit extreme
paranoia
›screaming for no
reason or at no one
Pathology/Physiology
›may shed clothing or
be naked
›hallucinating
Pathology/Physiology
Metabolic acidosis
Hyperthermia
Dehydration
Illicit Substances
Under the influence of
something (with
alcohol)
Illicit Substances
Also under the
influence of illicit
drugs such as:
Illicit Substances
›cocaine
›methamphetamine
›PCP
Illicit Substances
May be sweating
profusely
Illicit Substances
No apparent
sensitivity to pain
stimuli
Illicit Substances
Display superhuman
endurance and
strength
Illicit Substances
Body temperature is
elevated (face, head,
and neck appear
reddened or flushed)
Law Enforcement
Able to violently resist
several officers and
application of
restraints
Law Enforcement
After control is
achieved, the person
continues to struggle
Law Enforcement
May exhibit muscle
rigidity
Law Enforcement
Breathing may
become impaired or
restricted by control
and restraint
techniques...
Law Enforcement
...or due to
overexertion or
exhaustion
Law Enforcement
After sustained and
extreme exertion, the
person suddenly
becomes still and
quiet
Law Enforcement
Death may occur
What do police
do to gain
compliance?
Chemical Agents
Chemical Agents
Deployment of
chemical agents
›direct application
›space deprivation
Chemical Agents
Decontamination
›tincture of time and
fresh air
› cool water
Chemical Agents
Decontamination
›folk remedies (baby
shampoo, milk)
Chemical Agents
(Medical Concerns)
Respiratory irritation
(worsen preexisting
conditions such as
asthma)
Chemical Agents
(Medical Concerns)
Anxiety
High blood pressure
Chemical Agents
(Medical Concerns)
Lasts longer time than
expected
Medical conditions
Oleoresin Capsicum
Oleoresin capsicum
®
(OC), Cap-Stun ,
or
pepper spray - causes
swelling of eyes and
respiratory distress
Oleoresin Capsicum
Inflicts pain on skin
that can outlast other
symptoms
Oleoresin Capsicum
Symptoms can
reoccur hours later
OC - Pepper Spray
Chemical Agents
Orthochlorbenzalmalononitrile
(CS)
“Tear Gas”
Tear Gas
Causes uncontrolled
blinking and excessive
discharge from the
nose
Tear Gas
Heavy coughing and
sneezing is a common
result
Syncope is rare
CS - Tear Gas
Conducted Energy
Weapons
Taser®
Electro-muscular
Disruption Weapon
Taser®
Range of up to 21
feet; 24 feet for
tactical operations
Taser®
50,000 volts, 26 watts,
and 3.5 milliamps; 60
muscular contractions
per second
Taser®
Probes penetrate less
than quarter inch
One of the most
researched, less lethal
weapons (LLW)
Taser® Injuries
Small metal probes:
›enter skin only
5-7 mm
Taser® Injuries
Small metal probes
›standard operating
procedure: leave in
place, cut the wires
Taser® Injuries
Small metal probes
›tasered subjects go
to emergency
department
Taser® Injuries
Falls
›standing height - not
much risk
›What might they
hit?
Taser® Injuries
Falls
›treat injuries
®
(remove Taser
hooks)
Taser®
Positional
Asphyxia
Three-point Landing
Three-point Landing
Struggle/resistance
OC
®
or Taser used
create window of
opportunity
to
Three-point Landing
Restraint technique
Restriction of chest
wall may prevent full
breaths
Positional
Asphyxia
Three-point Landing
Three-point Landing
Officer’s
weight
Obesity
Three-point Landing
Hand
Cuffs
Arms
restrict
chest
movement
Three-point Landing
Hobbled
Legs
Pull arms;
restricting
the chest
Three-point Landing
Do NOT leave
restrained prone
Three-point Landing
Do NOT leave
restrained prone
Do NOT leave alone
Three-point Landing
Continued struggle =
excited delirium
Three-point Landing
EMS called for
assessment and
evaluation, if in doubt
Management of
Excited Delirium
Management
Tranquilizer/sedative
®
›Haldol
›Valium®
›Versed®
Management
Reduce temperature
Manage acidosis and
dehydration
Management
Ventilation
Management
Sedation decreases
exertion/agitation
Management
Re-restraint allows
caregiver to reassess
the patient
In-Custody
Death Factors
Death Factors
Struggle prior to
arrest
Prone restraint
Stimulant or
hallucinogenic usage
Death Factors
Drug or alcohol
intoxication
Obesity
Other medical issues
Death Factors
Excited delirium
Summary
Not without risk (but
less risk for officers
and for public)
Summary
Be hypervigilant in
recognizing
symptoms
Summary
Educate law
enforcement if not
already
Thank You
EMS
80411
Prehospital Setting:
Sedation/Positional Asphyxia
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EMS
80411
Release Date:
12/01/2011
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EMS
80411
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