DOT National Standard EMT-Intermediate/85 Refresher

1. Welcome! DOT National Standard EMT-Intermediate/85 Refresher

2. MEDICAL EMERGENCIES • Allergic reaction • Possible overdose • Near-drowning • ALOC • Diabetes • Seizures • Heat & cold emergencies • Behavioral emergencies • Suspected communicable disease

3. Possibleoverdose Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment MEDICAL EMERGENCIES

4. General Support ABCs Poison control (1-800-222-1222) Empty the stomach Gastric lavage Syrup of ipecac Activated Charcoal (adsorbent) Specific Toxidromes (common toxic syndromes) Anticholinergic Sympathomimetic Opioid/sedative/ ethanol Cholinergic OD/Poisoning

5. Acetaminophen Anticholinergics Arsenic, lead & mercury Benzodiazepines Black widow spider bite Beta-blockers Calcium channel blockers Cyanide Digitalis Ethylene glycol Tricyclic antidepressants Hydrofluric acid Iron Lead Methanol Methemoglobin-forming agents Opioids Organophosphates & carbamates Rattlesnake bite Serotonin syndrome Sulfonureas Valproic acid OD/Poisoning- Specific Antidotes

6. Poisoning/OD • Nerve Agent/Organophosphate Exposure • Beta-blocker toxicity • Narcotic opioid OD • Ethanol OD

7. Perspective • Ethanol has been used by humans since prehistory as the intoxicating ingredient of alcoholic beverages • Dried residue on 9,000-yr-old pottery found in China imply that Neolithic people consumed alcoholic beverages

8. Perspective • Ethanol (CH3CH2OH, molecular weight 46.07) is a colorless, volatile liquid and is the most frequently used & abused drug in the world

9. Perspective • Most morbidity from acute ethanol intoxication is related to secondary injuries rather than direct toxic effects • Toxicity most commonly results from ingestion, but ethanol may also be absorbed via inhalation or percutaneous exposure

10. Perspective • Ethanol is readily available in many different forms. • Standard alcoholic beverages • 12oz of beer = 2-6% ethanol by volume • 5oz of wine = 10-20% ethanol by vol. • 1.5oz of 80-proof spirits = 40% ethanol by vol.

11. perspective • In the 18th century & until Jan 1980, the UK defined alcohol content in terms of “proof spirit” • Defined as the most dilute spirit that would sustain combustion of gunpowder

12. perspective • The term originated in the 18th century, when payments to British sailors included rations of rum

13. perspective • To ensure that the rum had not been watered down, it was “proved” by dousing gunpowder in it

14. perspective • Then tested to see if the gunpowder would ignite • If it did not, then the rum contained too much water and was considered to be “under proof”

15. perspective • It was found that gunpowder would not burn in rum that contained less than 57.15% alcohol by volume (abv) • Therefore, rum that contained this percentage of alcohol was defined to have “100 degrees proof”

16. perspective • An alcohol content of 57.15% abv is very close to a 4:7 ratio of alcohol to the total volume of the liquid • Thus, the definition amounted to declaring that (4 divided by 7) x 175 = 100 degrees proof spirit.

17. perspective • Rum that contains 50% abv had (3.5 divided by 7) x 175 = 87.5 degrees proof spirit • Alcohol proof in the US is defined as twice the percentage of alcohol by volume • Consequently 100-proof whiskey contains 50% alcohol by volume

18. pathophysiology • Ethanol is rapidly absorbed after oral administration & blood levels peak about 30-60 minutes after ingestion • The presence of food in the stomach prolongs absorption and delays the peak blood level

19. pathophysiology • High concentrations of ethanol in the stomach may cause pylorospasm & delays gastric emptying • Theoretically, one standard drink will elevate the blood ethanol level by 35mg/dl, assuming instantaneous & complete absorption & no distribution or metabolism

20. pathophysiology • Only a small proportion of ethanol is excreted unchanged in the urine • >90% is eliminated via enzymatic oxidation by 3 pathways in the liver: • Alcohol dehydrogenase pathway - principle • Catalase - minor • Microsomal ethanol-oxidizing system - minor

21. pathophysiology • Alcohol dehydrogenase pathway (ADH) • Starts in stomach • More pronounced in men than women • More pronounced in tolerant individuals

22. pathophysiology • Conversion process process • Metabolism of ethanol to acetaldehyde (catalyzed by a 2nd class of ADH in liver) • Acetaldehyde >> acetate by aldehyde dehydrogenase (ALDH) • Acetate >> CO2 + H2O • Mutation in mitochondrial ALDH have a decreased ability to metabolize acetaldehyde

23. pathophysiology • Acetaldehyde accumulation • 30% of Caucasians • 40% of Asians • 80% of Native Americans • flushing

24. pathophysiology • A 70kg adult male metabolizes 7 to 10 g of alcohol per hour, corresponding to an hourly decrease of the blood ethanol level by approximately 15 to 20 mg/dL/hr • The tolerant individual may increase this clearance of ethanol to 30mg/dL/hr

25. pathophysiology • The exact mechanism of inebriation is still unclear, but current theories postulate that ethanol acts upon a variety of neurotransmitters • GABAA • Blocks NMDA • CNS stimulant & CNS depressant!

26. pathophysiology

27. Differential Diagnosis Considerations • Acute alcohol intoxication is a dx of exclusion • Hypoglycemia • Hypoxia • Carbon dioxide narcosis • Mixed alcohol-drug OD • Ethylene glycol poisoning • Methanol poisoning • Hepatic encephalopathy • Psychosis • Severe vertigo • seizures

28. Review Protocol • Go to ALOC-Adult

29. Pathophysiology • Epidemiology • Physical Exam Findings • Diagnostic Findings • Signs and Symptoms • Differential considerations • Treatment

30. 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.