EMS Medical Control Rounds Nov 8, 2012

1. EMS Medical Control RoundsNov 8, 2012 Domenic Martinello, MD EMS Medical Director, Asst. Med Dir Emergency Dept Anna-Jaques Hospital, Newburyport, MA

2. Tonight’s Outline • New Business • Old Business • Objectives • Scary Patient Problem • Trauma Lecture • Medical Case • Q&A Session

3. Old Business • Transition from AMR to Atlantic/Cataldo • We will miss you AMR… • Great Skills Night • If you missed it please let us know so we can ensure some additional skills time for you all • Other OLD business?

4. New Business • Last Lecture for 2012! • If the world ends in December, be advised there will be no lectures in 2013 • If you’ve been living under a rock for the past decade, the Myan calendar ends Dec 21, 2012 • Fire and brimstone coming down from the skies! Rivers and seas boiling! Forty years of darkness! Earthquakes, volcanoes... The dead rising from the grave! Human sacrifice, dogs and cats living together... mass hysteria! • Otherwise, we will get you dates soon • Anyone have opinions on good times? • Any other new business?

5. Academic Objectives: • Three Cases tonight! • First: Short case on bad report • Second: Nasty Trauma Case • Third: Odd Medical Complaint with life threatening consequences

6. Short Case of Bad Report Or: Why We Need The FULL Story!

7. Primer • This case was a recent case from our local area • Providers names will not be mentioned despite the fact they did nothing wrong • The case will be very short because the point is not in the care or outcome

8. Case • Local BLS transport called for non-emergency transfer of adolescent patient to hospital for “Psych Eval” • Transport was from Amesbury Psychological • No info given to dispatch other than that the patient needs “an eval”

9. Crew Arrives • Crew arrives to Ames Psych and are walked down to the patient care area • After 15 minutes the patient is woken up and staff walks her to gurney • Patient sleepy but well, staff seem unconcerned • EMS Crew asks for report and staff member informs them that shift changed and she does not know the incident but its “all in the packet” • The only information was that the patient was “suicidal”

10. Transport • Is uneventful • Patient is flatly affected, does not talk to staff or EMS crew, no history gained. • Able to take VS and there are no issues • Patient looks well • Short transport so EMS crew never had time to sort through the horribly disorganized chart to find out more specifics • Assumed this is non emergent in light of the fact a transport unit called, not 911 • Arrives to ER without issue

11. Seems silly we review this? • Of course it does! • No bad outcome, no clinical problems • Crew followed standard protocols • Arrived safely

12. So… why are we talking about it? • What if I told you that several hours before the EMS service arrived the patient hung herself with a blanket • What if I told you the patient was cut down, unresponsive, cyanotic, and only started breathing once laid down on the floor again? • Would this change your feelings? • This is what actually happened!

13. It is ever so important… • To get the whole story on every patient • If the staff will not give you the story easily you MUST insist on it • Verbal AND written report are part of the care transfer • If you ever have a problem, CALL MEDICAL CONTROL • In cases of life threatening emergency, however, report may be abbreviated.

14. As an aside • We have addressed this issue with the facility and have resolved any future issues • But these things will always crop up, so always be on your toes!

15. Our Nasty Trauma Case Names changed to protect the innocent

16. Primer • This is a VERY recent case! • Information regarding some specifics may be inaccurate since the charts are still in the aether someplace • The filled-in details were to help illustrate treatment strategies. They may not be identical • If anyone would like to discuss the ACTUAL scene please let me know at the end! • Bear with me 

17. How it begins • 49 Year old male professional truck driver was heading south on I-495 in the Methuen area • Swerved to miss a tyre in the road and lost control of his truck • Truck impacted object and rolled onto side, patient belted but was pinned partially in and partially out of the truck (A-Pillar pinning)

18. This is the scene:

19. Also:

20. Tell Me About… Your scene concerns…

21. Initial Scene Issues • Trucks carry several hundred gallons of fuel • It is usually diesel. Less reactive than standard gasoline but still a dangerous chemical • Tends to spill right in the area you need to work! • Night • Working in dark confines • Lots of sharp metal and electrical wiring you can not see well • Difficult to assess patient • On major highway • Traffic concerns • It may be shocking to hear, but some people drive drunk! • Moral of the story: Scene Safety First! Protect YOURSELF!

22. Patient • Trapped with torso under A-pillar • Right leg trapped by dash • Partial Ejection • Awake and talking • Blood…. EVERYWHERE! • Scalp Injury vs Open Skull Fracture

23. Treatment Priorities • Airway? • C-Spine? • Bleeding Control? • Head Injury? • Extrication?

24. Care Priorities • Immobilize the C-Spine while managing the airway • Put on a collar, keep the patient talking • If Airway is patent you may continue on to “B” • What would you do if the patient had an unstable airway? • What if your first management option does not work? • What if your second does not work?

25. Care Priorities (cont) • Once airway is managed (determined safe, or made safe) you need to address life threatening traumatic processes. In this case the “B” is breathing • Can the patient ventilate and oxygenate with your current management? • Does the patient need decompression of the chest? • How do you determine this? (exam findings) • Note: In this case the patient did need lifesaving chest decompression! • Question: What is the only downside of a needle decompression?

26. Care Priorities (cont) • Airway and Breathing assessed, now we need to address circulatory status • In this case, the patient had several sources of bleeding. • Multiple abrasions • Scalp laceration vs open skull fracture • Right leg entrapped under dash • Amputation? Crush? Arterial wound? We don’t know yet! • BP 70/p, Heart Rate elevated • How would you manage bleeding in this patient?

27. Care Priorities (cont) • The “D” is your quick neuro examination • This patient was GCS 14-15 • How do we manage head injuries (open or closed)? • What is the SINGLE most important thing we can do to prevent further injury?

28. Problem • We mentioned the leg under the dash. How would we manage: • Crush Injury • What kind of bad things can happen? • Amputation • You think it may bleed?

29. Transport Priorities • What do the current state prehospital trauma criteria say we should do? • What are our local trauma centers? • What is the highest level of trauma

30. Case Discussion • Any other Thoughts on this case?

31. Case 2: Ketoacidosis in the non-diabetic patinet Also known as “Another Reason Ethanol is Bad”

32. The case • 42 year old female with history of alcohol abuse and opiate dependency arrives intoxicated • Patient states she is here for generalized pain for one month • Is currently intoxicated • Appears generally unwell • States is hungry and has not eaten in days, possibly weeks

33. Eval • Initial evaluation shows a tachycardic (133BPM) and hypertensive patient (162/82) who is awake and alert requesting medication for one month of pain • Occasional vomiting noted

34. ER workup • Patient arrived with similar complaints • Had been given NS by EMS as well as ondansetron (Zofran) by EMS with some resultant improvement • EKG by EMS was normal, as is the ER EKG

35. The problem • Routine labs return: • Na 134 • K: 3.4 • Cl: 90 • Bicarb: 11 (critical low) • BUN: 22 • Cr: 1.0 • Anion Gap: 33 (normal 12) • Anion Gap = Na – (Cl + Bicarb)

36. The anion gap • A little tool we use to determine if there is acidosis • Normally if you calculate sodium, chloride, and bicarbonate you should get a number 10-14 which means that you have a normal amount of anions. The “gap” is because the major cations are proteins that we do not usually measure (mostly albumin) and are major buffering components. The other major cations are chloride and bicarb • Anion Gap >14 is ACIDOSIS

37. More labs • Patient had typical life function abnormalities of elevated AST, ALT, GGT, but normal lipase. • GLUCOSE: 50 (low) • Venous pH: 7.12 (severe acidosis)

38. Those labs are bad • Patient is suffering from rather severe acidosis, but the question remains “why” • Patient glucose is actually LOW • Patient is not diabetic • No meds • No ingestions • So what we have is…

39. Alcoholic Ketoacidosos • First described in the 1940’s as a mixture of low glucose, high anion gap, acidemia, elevated ketones, and in the setting of acute alcohol consumption and no food intake with or without vomiting • 3 Pathologic processes • Volume depletion • Glycogen depletion (no liver stores of glucose) • Elevated NADH to NAD+ ratio • Part of the glycolysis/Kreb’s Cycle pathway necessary for making ATP

40. Physiology • Progression of disease leads to decreased insulin production (conserve glucose for the brain), increased counter-regulatory hormones which increase lipolysis (fat breakdown) which will provide energy but also generates ketosis. Depletion of liver glycogen stores by elevated glycogen levels • Ketosis leads to vomiting and further depletion of volume • Alcohol reduces NAD+ to NADH • Impairs lactate  pyruvate pathway leading to lactic acidosis • Inhibition of gluconeogenesis • Shift in acetoacetate to beta-hydroxybutyrate

41. Presentation • Patients usually present exactly like patients in overt DKA but with LOW blood glucose and recent alcohol binge • May have classic “fruity breath” • Often hard to tell with alcohol on board • May present in frank shock, pulmonary edema, seizures and arrhythmias are possible (usually electrolyte related)

42. Workup • Basic labs (Chemistry, ABG or VBG, CBC, Alcohol Level) • Observe for other possible causes • Methanol or ethylene-glycol ingestions • Aspirin overdose • DKA • Ketone and beta-hydroxybutyrate levels • High clinical suspicion!

43. Treatment • Believe it or not, treatment is shockingly easy • Replace volume (NS, LR, etc) • NS, LR • Replace glucose and replete glycogen deficiency; increase stores of NAD+ by forcing NADH  NAD+ conversion • D5 or D10 solutions, D50 if needed • Reverse thiamine deficiency • Give IV or IM Thiamine, 100mg • Manage electrolyte issues • Potassium, Magnesium, and Phosphate are most common • Manage comorbid conditions • Alcohol w/d, pancreatitis, alcoholic hepatitis and cirrhosis • CONSIDER Bicarb is pH <7.1

44. That’s really it! • AKA is one of those life-threatening problems that is REMARKABLY easy to treat. • It rarely carries a high mortality, and 1 and 5 year mortality is directly related to patient ability to maintain sobriety after treatment!

45. Questions? • This was a short little series since we only so recently were together • Please be safe this winter • Rounds schedule will be determined soon and posted ASAP • My email is always on: dmartinello@ajh.org • Happy Holidays!