ROUNDS JUNE 2016 The Last Roundup

This presentation may be found at AndrewGeller@weebly.com

TOXICOLOGY

• Designer opiates… Fentanyl is 50 times more powerful than morphine. This newest drug is 10,000 times as potent! W 18 is a Mu receptor opioid agonist . It was synthesized in 1981 in a lab in an attempt to develop non addictive analgesics.The W series has 32 compounds. We are not certain if they can be reversed by Narcan. It may require much more than we carry.

TOXICOLOGY CONTD

• In Alberta they confiscated pills last August that were labelled as Oxycontin , but were in fact W18. These designer opioids are being synthesized in China and smuggled into the US. In March a man was arrested with Fentanyl and 2.5 pounds of W18 .

• If a patient has a narcotic toxidrome and cannot be reversed with Narcan we can suspect one of these designer narcotics.

More Toxicology

• Kratom is an herb that is sold over the counter and may be found on the internet. It has a number of active ingredients , alkaloids. Both have a high affinity for the opioid Mu receptors and are more potent than morphine!

• Traditionally local residents in Southeast Asia chew the leaves to relieve fatigue, muscle aches and to increase sociability. This is similar to coca leaves in South America and khat in Africa.

Still More Toxicology

• The effects of Kratom are dichotomous. At low doses it is a stimulant, at higher doses it is opioid like and at very high doses it will result in stupor and death. Treatment is supportive.

• OTC…Scary...

OPIOID INDUCED HYPERALGESIA

• This phenomenon is seen in patients who take chronic narcotics and require massive doses of narcotics to control their pain.

• “This is a state of increased baseline pain that is caused by exposure to opioids”, according to James Roberts in Emergency Medicine News in March.

More Opioid Induced Hyperalgesia

• This is not the same as tolerance , but it is hard to separate from it. Increasing the dose of a narcotic with tolerance will result in relief, but increasing the dose in a patient with opioid induced hyperalgesia will increase the pain. Decreasing the dose or eliminating it will decrease or relieve the pain.

More on Opioid Induced Hyperalgesia

• The basis for this syndrome is that the narcotics paradoxically render the patients more sensitive to their pain. They render opioids useless as analgesics. OIH can occur in as little as 4 weeks of exposure. It is usually seen in patients on long term narcotics.

Toxicology, Narcotic Deaths• 1379 people died of narcotic overdoses in

2015 in Massachusetts, and EMS treated 11,884 overdoses in 2015. Men were 1048/1379 and over half were 25-44.

• Over half of the deaths had fentanyl in their bloodstream according to the DPH in Massachusetts in 2015.

Benzodiazepines

• Benzodiazepine overdoses have soared as well with fatal overdoses more than quadrupling over the last 20 years

• Xanax ,Valium , Ativan, Versed, Klonopin , Serax , Restoril and Librium [alprazolam ,diazepam , lorazepam , midazolam , clonazepam ,oxazepam , temazepam , and chlordiazepoxide

Benzos cont’d

• The biggest problem with their use is falls in the elderly.

• Isolated overdoses of benzodiazepines are rarely fatal. When combined with ETOH or other drugs, fatalities are more frequently seen.

Language Barriers and EMS

• In an article in May from the Annals of Emergency medicine Tata et al discuss this issue. They look at New Mexico. What they found was that 20 % of households in the US report a home language other than English and they suggest that the unmeasured burden of language barriers in prehospital care is substantial.

Language Barriers cont’d

• They studied dispatchers and field providers and found that 88 % of dispatchers used telephonic interpreter services, many used the interpreter services daily . Delays were frequently mentioned as issues .

Needle Decompressions

• Remember that the “best anatomical location for a tension pneumothorax is the 5th ICS in the anterior axillary line” , not the 2nd ICS in the MCL. The failure rate is 42.5 % vs 16.7 %. We have to get this taught.

Oxygen and STEMIs

• AVOID Trial For every 100 liters of O2 exposure there is a 1.2- 1.4 % increase in the size of the MI!

• Remember with chest pain and an O2 sat > 94 % [unless the patient is clearly having trouble breathing ] do not give the patient O2

Boston and CVA’s

• The city is starting a study to see if they can pick out which patients should go to centers that offer neurosurgical care for patients that can benefit from it. These would include subarachnoid hemorrhages, subdural hematomas, large vessel ischemic CVAs within 6 hours.

• The Dispatch will be refined and the medics on scene will use CSTAT

More On CVAs

• Determine last known well• Use the Massachusetts CVA Scale to determine if

the patient needs possible embolectomy or neurosurgical procedure

• Facial droop 0/1• Arm drift 0/1 • and speech garbled 0/1• If the Stroke scale is >0 then a CSTAT needs to be

performed

CVAs Cont’d

• CSTAT • Gaze 0/2• Weakness arm or leg0/1• Follow Commands 0/1• If the CSTAT score is >2 the patient will be triaged

to a hospital that offers acute neurosurgical intervention, including embolectomy, if the Comprehensive Stroke Center is less than 30 minutes farther than the primary Stroke Center

CVAs Cont’d

• This is not yet a finished product and the definition of a comprehensive stroke center is not yet fixed. Will BLS be able to triage or only Advanced EMT’s? Should some patients be brought to primary stroke centers and get IV TPA and then sent out?

I/O

• More fluids can be administered faster by the humeral approach [ 5L/hour vs 1 L/hr] and the time to the heart for rx is faster [ 2.6 secs vs 7.2 secs ] . I am not sure how important each of these is .

Pediatric Dosing

• Broselow versus Handtevy• The Handtevy Length Based Tape system is better at

estimating doses than the Broselow system. It is also faster to determine doses. The Handtevy guide provides the recommended weight based dose along with the volume of medication that should be administered. 91 % of the medics said they preferred the Handtevy system to the Broselow. They said it was easier to use and more accurate.

Ketamine

• We will be adding Ketamine to the STP in January.

• Ketamine is a drug that is a derivative of PCP, phencyclidine! It is rapidly broken down and metabolized in the liver . It stimulates the cardiovascular system and raises BP and heart rate.

More on Ketamine

• In many ways it is an ideal drug for prehospital care. It does not lower BP and does not cause a patient to lose their airway reflexes. They don’t get so drowsy that they stop breathing and die.

• It is on the WHO list of essential medications. It is also used extensively by the military in the battlefield. It is reasonably safe.

Still more

• It acts on the NDMA receptors, but also acts on the opiate receptors to relieve pain , without the side effects we all fear. [decreased BP and severe sedation]. It is a great pain reliever.

• It can be given IM, IV , IN and PO. Onset is within 1 minute when given IV.

• It has a great safety profile and even when an overdose is administered there is little likelihood of adverse outcomes.

What is the downside ?• It may raise intraocular pressure and may be an issue for

glaucoma patients [and maybe not]. It may raise intracranial pressure , but again it may not. So there is a warning about head injuries. It may be a problem with severe hypertension, but if the BP elevation is due to pain the BP will likely fall with the relief of pain.

• The major issue is the possibility of an “emergence reaction” Nightmares, hallucinations and psychotomimetic effects.

• It is an addictive drug. It is a schedule III drug. To add it we will have to get approval from the narcotics division at the state. It has already been added in Worcester.

Where it May be Used Prehospitally

• Excited delirium. It has ONLY been approved for excited delirium. It will only be given IM , not IV in a dose of 400 mg.

Ketamine for Excited Delirium• Rapid Onset 1-3 minutes IM. • 10 % get a postadministration emergence phenomenon,

often mild and “easily treated with low dose midazolam” [Roberts, James 12/15 Emergency Medicine News]. Following the use of the drug the patient cannot be evaluated by psychiatry for 8 hours, use it selectively.

• Short duration, it wears off in 30-40 minutes.• Ketamine “appears to be an ideal drug for the patient

who presents in an uncontrollable and violent state…Quelling undiffentiated excited delirium in a patient without a history or even vital signs is a huge plus”

Are Narcotics Created Equal?

• The key is histamine release. Histamine release results in urticaria , itching , wheezing, cough , sloing gastric emptying and resultant nausea and vomiting , vasodilation and hypotension .

• The release is different for different narcotics. Morphine releases a bunch hence its former use for pulmonary edema [with venodilation] Mortality is increased with CHF and MI with morphine , hence we no longer use it.

Narcs Cont’d

• Fentanyl has little to no effect on mast cells and thus there is no histamine release. Thus nausea and vomiting are unusual, and urticaria is rare .

IOM and Cardiac Arrest

• Three Interventions to improve survival• 1. Measurement : we cannot improve what we

do not measure . Join CARES• 2. Encourage Bystander CPR , get the 911

centers to track data on arrests and get them our prehospital follow up data.

• 3.Foster High Performance CPR . Measure the CPR quality : rate, pauses, depth of compressions

CASES

• 1. 71 y/o cardiac arrest lessons… short down time, need for police intervention, get the patient on the floor, PEA protocol 20152.ESRD and SOB, CONTEXT IS ALL3. and 4. 23 y/o with chest pain and BP 116/61,55 y/o chest pain and a 50 mm drop in BP after NTG

MORE CASES• 5. 76 y/o woman with Sob and a low Sat, no

EKG• 6. 94 y/o chest pain, N, and Vomiting. O2 sat

78-86 % , also repeat VS after NTG • 7. 65 y/o cardiac arrest no CCR

MORE CASES• 8. 83 y/o fall struck head, no C spines• 9. 87 y/o GI bleed , VS not repeated• 10. 91 y/o confusion , no ETCO2• 11. 87 y/o fall facial injury, no C spines