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DOT National Standard EMT-Intermediate/85 Refresher

Welcome!. DOT National Standard EMT-Intermediate/85 Refresher. Introduction. Mary Koskovich EMT 1988 - 23 yrs Paramedic 1991- 20 yrs Educator 1997 - 14 yrs. Course content. An approved 36-hour DOT National Standard EMT-Intermediate/85 Refresher

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DOT National Standard EMT-Intermediate/85 Refresher

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

  2. Introduction • Mary Koskovich • EMT 1988 - 23 yrs • Paramedic 1991- 20 yrs • Educator 1997 - 14 yrs

  3. Course content • 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

  4. Go to mandatory core content

  5. Go to: • Intermediate Refresher Feb 21 22 Monday Tuesday Schedule

  6. 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.

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

  8. 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 MEDICAL EMERGENCIES

  9. Allergic Reaction • 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)

  10. Allergic Reaction • 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

  11. 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 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 receptors- up to (105) Allergic Reaction

  12. 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

  13. Allergic Reaction • 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

  14. 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

  15. Allergic Reaction • They coined the term anaphylaxis from Greek • (ana, against; phylax, guard or protect), meaning “againstprotection”

  16. Allergic Reaction • Richet was awarded the Nobel Prize in Medicine and Physiology in 1913 • Today, anaphylaxis refers to a life-threatening allergic syndrome characterized by multiorgan involvement and rapid onset

  17. Allergic Reaction • 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

  18. Allergic Reaction • Fixation of this allergen-specific IgE to surface receptors on mast cells completes the process known as sensitization

  19. In plain English: • The immune system creates disease-fighting antibodies (called IgE) toward a substance that is normally harmless, such as food.

  20. In plain English: • When the body is 1st exposed to the substance- the body does not react [but it does produce the antibodies] = sensitization

  21. In plain English: • Then when the body is exposed to the substance again, the antibodies spring into action believing that the substance is a dangerous foreign invader

  22. Allergic reaction • 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)

  23. Allergic Reaction • 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

  24. Allergic Reaction

  25. Allergic Reaction The chemical mediators released from mast cells exert their effect on target organs to produce the clinical symptoms of allergic reaction

  26. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S

  27. 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

  28. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S • Urticaria (aka- hives) = itchy skin eruption characterized by weals with pale interiors & well-defined red margins

  29. 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

  30. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S • 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

  31. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S • Vasodilation can lead to: • Flushing • HA • Reduced peripheral vascular resistance • Hypotension • Syncope

  32. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S • Contraction of smooth muscles can cause: • Bronchospasms • Abdominal cramping • Diarrhea • Pulmonary vessel vasoconstriction can lead to pulmonary HTN, pulmonary edema & decreased cardiac filling pressures

  33. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S • Coronary vasoconstriction can lead to: • Myocardial ischemia • Decreased myocardial contractile force (negative inotropy) • Cardiac dysrhythmias

  34. Allergic Reaction: Physical Exam Findings, Diagnostic Findings, S/S • 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”)

  35. Pathologic features identified at autopsy • 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

  36. Pathologic features identified at autopsy • Pts who die of vascular collapse show varying degrees of • Myocardial damage • Visceral congestion • & other findings suggestive of a loss of intravascular blood volume

  37. Pathologic features identified at autopsy • Other autopsy findings: • Urticarial eruptions • Angioedema • Visceral congestion • Submucosal edema • Hemorrhagic gastritis • Notably- autopsy findings may also be normal after an anaphylactic death

  38. Review

  39. Epidemiology • 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.

  40. 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

  41. Other causes • Iodinated contrast media • Foods • Peanuts, tree nuts, shellfish, milk, eggs, wheat • NSAID • Exercise-induced anaphylaxis • (usu. associated with prior food or drug ingestion)

  42. Onset • Symptoms of anaphylaxis usu. begin <30 mins post exposure & are often immediate • Oral antigens - may have a 2 hr delay

  43. Onset • 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

  44. Onset • About 6% of pts with anaphylaxis experience a biphasic course with recurrent anaphylaxis within 8 hrs (despite earlier resolution!)

  45. Differential Considerations • 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

  46. Scenario • 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

  47. 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.

  48. Scenario • 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

  49. Scenario

  50. Question? • What initial management is indicated for this patient?

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