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Medical Emergencies

Diabetes

The bodies inability to use sugar properly

Hypoglycemia Too much insulin or not enough sugar

Hyperglycemia Too much sugar or not enough insulin

Diabetes

Signs and Symptoms

Progresses quickly Increased heart rate Pale, cool and clammy skin Dilated pupils Lethargic Slurred speech, confusion Seizures, agitated Combative, may appear intoxicated

Hypoglycemia (Insulin Shock)

Signs and Symptoms Progresses slowly Excessive thirst, hunger Frequent urination Vomiting, ABD Pain Musty odor (acetone) on breath Fast, deep respirations (Kussmal’s) Altered LOC Dehydration

Hyperglycemia (Diabetic Coma)

Allergies and Anaphylaxis

Anaphylaxis

An immediate, systemic, life-threatening allergic reaction associated with major changes in the cardiovascular, respiratory, and cutaneous systems Prompt recognition and appropriate drug

therapy are important to patient survival

Antigens

A substance that induces the formation of antibodies Antigens can enter the body by injection,

ingestion, inhalation, or absorption Examples:

Drugs (penicillin, aspirin) Envenomation (wasp stings) Foods (seafood, nuts) Pollens

Antibodies

Protective protein substances developed by the body in response to antigens Bind to the antigen that produced them Facilitate antigen neutralization and removal

from the body This normal antigen-antibody reaction

protects the body from disease by activating the immune response

Immune Response

Immune responses are normally protective They can become oversensitive or be

directed toward harmless antigens to which we are often exposed This response is termed “allergic” The antigen or substance causing the allergic

response is called an “allergen” Common allergens include drugs, insects,

foods, and animals

Immune Response

The healthy body responds by a defense system known as immunity that may be: Natural

present at birth Acquired

resulting from exposure to a specific antigenic agent or pathogen

Artificially induced inoculation

Allergic Reaction

Marked by an increased physiological response to an antigen after a previous exposure (sensitization) to the same antigen Initiated when a circulating antibody (IgG or

IgM) combines with a specific foreign antigen, resulting in hypersensitivity reactions

Or to antibodies bound to mast cells or basophils (IgE)

Hypersensitivity Reactions

Agents that may cause hypersensitivity reactions (including anaphylaxis) Drugs and biological agents Insect bites and stings Foods

Localized Allergic Reaction

Localized allergic reactions (type IV) do not manifest multi-system involvement

Common signs and symptoms of localized allergic reaction include: Conjunctivitis Rhinitis Angioedema Urticaria Contact dermatitis

Anaphylaxis

comes from Greek and means “against or opposite of protection”

It is the most extreme form of an allergic reaction

Rapid recognition and aggressive therapy are essential

Anaphylaxis

Almost any substance can cause anaphylaxis

Most common: Penicillin (by ingestion or injection) Envenomation by stinging insects

Risk increases with the frequency of exposure

Histamines

Promote vascular permeability Cause dilation of capillaries and venules Cause contraction of nonvascular smooth

muscle, especially in the GI tract and bronchial tree

Increased capillary permeability allows plasma to leak into the interstitial space The profound vasodilation that results further

decreases cardiac preload, compromising stroke volume and cardiac output

Histamines

These physiological effects lead to: Cutaneous flushing Urticaria Angioedema Hypotension

Onset of action is very rapid Effects are short lived because they are

quickly broken down by plasma enzymes

Other Chemical Mediators

The remaining chemical mediators (heparin…) exert varying effects that may include: Fever, Chills, Bronchospasm Pulmonary vasoconstriction

These chemical processes can rapidly lead to: Upper airway obstruction and bronchospasm Dysrhythmias and cardiac ischemia Circulatory collapse and shock

Assessment Findings

Respiratory effects Cardiovascular effects Gastrointestinal effects Nervous system effects Cutaneous effects

Assessment Findings

Palpitations Parasthesia Pruritis (itching) Erythema or urticaria Throbbing in the ears Coughing , wheezing and difficulty breathing Difficulty swallowing because of swelling of the

tongue and throat In a severe reaction, patient may go into shock,

become incontinent, convulse, become unconscious and die

Initial Assessment Airway and breathing

Airway assessment is critical Evaluate the conscious patient for voice changes,

stridor, or a barking cough Complaints of tightness in the neck and dyspnea

suggest impending airway obstruction The airway of unconscious patient should be

evaluated and secured

Initial Assessment

If airflow is impeded, endotracheal intubation should be performed

If there is severe laryngeal and epiglottic edema, surgical or needle cricothyrotomy may be indicated to provide airway access

Monitor the patient closely for signs of respiratory distress

Circulation Assess pulse quality, rate, and location

frequently

History

May be difficult to obtain but is critical to rule out other medical emergencies that may mimic anaphylaxis Question the patient regarding the chief

complaint and the rapidity of onset of symptoms Signs and symptoms of anaphylaxis usually

appear within 1 to 30 minutes of introduction of the antigen

Significant Past Medical History

Previous exposure and response to the suspected antigen Not always reliable

Method of introduction of the antigen Chronic or current illness and medication

use Preexisting cardiac disease or bronchial

asthma Prescribed Epi-Pen

Physical Examination

Assess and frequently reassess vital signs Inspect the patient's face and neck for

angioedema, hives, tearing, and rhinorrhea, and note the presence of erythema or urticaria on other body regions

Assess lung sounds frequently to evaluate the clinical progress of the patient and to monitor the effectiveness of interventions

Monitor ECG

Drug Therapy

Ventilatory support Epinephrine

are the most specific interventions in the management of anaphylaxis

Fluid resuscitation in the presence of hypovolemia

Additional pharmacological therapy: Benadryl, Ventolin, Corticosteroids Antidysrhythmics Vasopressors to manage protracted hypotension

Pathophysiology of anaphylactic shock.

Urticaria as a result of an allergic reaction.

Urticaria

Toxicology

Poisonings

Poison Any substance that produces harmful

physiological or psychological effects

Routes of Absorption

Poisons may enter the body through: Ingestion Inhalation Injection Absorption

Types of Toxicological Emergencies

Accidental poisoning Dosage errors Idiosyncratic reactions Childhood poisoning Environmental exposure Occupational exposure

Drug/alcohol abuse Intentional poisoning/overdose

Chemical warfare Assault/homicide Suicide attempts

Types of Toxicological Emergencies

Statistics from the grand ole USA 80% of suicidal gestures are from OD

28,000 suicidal deaths/yr from OD

Peak age for accidental OD is 2 years old

Chance of reoccurrence post poisoning is 25% in within one year

General Guidelines

Most poisoned patients require only supportive therapy to recover

Airway: monitor and clear if req’d Breathing: support as req’d Circulation: support as req’d Oxygen (100%), IV, Monitor and Blood glucose Consider other causes in the Unconscious or

seizing patient Obtain a thorough history and perform a focused

physical examination

General Guidelines

If overdose is suspected, obtain an overdose history from the patient, family, or friends

Consult with OLMC/poison control center for specific treatment to prevent further absorption of the toxin (or antidote therapy)

Frequently reassess the patient; monitor vital signs and ECG

Safely obtain any substance or substance container of a suspected poison and transport it with the patient

Transport the patient for physician evaluation

Assessment

Consider ICP Watch for seizures Watch for changes in condition (ABC’s) Expose the patient History………………………….

General Management Principles

Vitals Evaluate skin for perfusion status

Monitor Head to Toe (rule out old trauma) Neuro

Pupils LOC (GCS, AVPU) Symmetry of motion, ataxia

Poisoning by Ingestion

About 80% of all accidental ingestions of poisons occur in children 1 to 3 years of age Most result from household products

Poisoning in adults is usually intentional, although accidental poisoning from exposure to chemical in the workplace also occurs.

Toxic effects of ingested poisons may be immediate or delayed, depending on the substance ingested

Poisoning by Ingestion

Early management focuses on: Removing the toxin from the stomach

or Binding the toxin to prevent absorption

before the poison enters the intestines

Assessment and Management

The primary goal of physical assessment of poisoned patients is to identify the poison’s effects on the three vital organ systems most likely to produce immediate morbidity and mortality: Respiratory system Cardiovascular system Central nervous system

Assessment and Management

Five signs of major toxicity Coma Cardiac dysrhythmias GI disturbances Respiratory depression Hypotension or hypertension

History

What was ingested? When was the substance ingested? How much of the substance was ingested? Was an attempt made to induce vomiting? Has an antidote or activated charcoal been

administered? Does the patient have a psychiatric history

pertinent to suicide attempts or recent episodes of depression?

Poisoning by Inhalation

Accidental or intentional inhalation of poisons can lead to a life—threatening emergency The type and location of injury caused by toxic

inhalation depend on the specific actions and behaviors of the chemical involved

Toxic gases can be classified in three categories: simple asphyxiants, chemical asphyxiants, and irritants/corrosives

General Management—Inhaled Poisons Scene safety Personal protective measures Rapidly remove the patient from the poison environment Surface decontamination Adequate airway, ventilatory, and circulatory support Initial assessment and physical examination Irrigation of the eyes (as needed) IV line with a saline solution Regular monitoring of vital signs and ECG Rapid transport to an appropriate medical facility

Carbon Monoxide Poisoning

A colorless, odorless, tasteless gas produced by incomplete combustion of carbon-containing fuels Does not physically harm lung tissue

Its affinity for hemoglobin is 250 times that for oxygen Small concentrations of carbon monoxide can result in

severe physiological impairments Physical effects of carbon monoxide poisoning are

related to the level of COHb in the blood Treatment

Poisoning by Injection

Human poisonings from injection may result from: Drug abuse Arthropod bites and stings Reptile bites Hazardous aquatic life

Injected poisons are often mixtures of many different substances, which may produce several different toxic reactions Be prepared to manage reactions in many organ systems

simultaneously

Arthropod Bites and Stings

Hymenoptera (bees, wasps, and ants) and Arachnida (spiders, scorpions, and ticks) cause the highest incidence of need for emergency care

Reactions to venoms are classified as local, toxic, systemic, and delayed

Poisoning by Absorption

Many poisonings by absorption result from exposure to organophosates and carbamates that are available for commercial and public use as flea collars and home and commercial insecticides Organophosphates and carbamates are among the most

toxic chemicals currently used in pesticides They are well absorbed by ingestion, inhalation, and

dermal routes

Toxidromes

A collection of clinical clues to a particular poison

5 Major: Sympathomimetic Anticholinergic Cholinergic (muscarinic) Cholinergic (nicotinic) Narcotic (and withdrawal)

Toxidromes

For each toxidrome identify: Signs and symptoms Typical toxins Treatment

Sympathomimetic

S/S: agitation, psychosis, seizures,

tachycardia, hypertension, hyperthermia, diaphoresis, ECG changes

Toxins: Epi, Norepi, amphetamines, cocaine,

ephedrine, pseudoephedrine, PCP, LSD, caffeine

Anticholinergic“DRY” patient

S/S: Red as a beet, Dry as a bone, Mad as a

hatter, Hot as a stone, Blind as a bat, Bladder and Bowel lose their tone while the heart runs alone

Toxins: Atropine, TCA’s, antihistamines,

mushrooms

Cholinergic – Muscarinic“WET” patient

S/S: “SLUDGE”

Salivation, lacrimation, urination, deification, GI upset, emesis

bradycardia, wheezing, bronchoconstriction, miosis, confusion, coma, convulsion, diaphoresis, seizures

Toxins: Organophosphates, insecticides, nerve gas,

carbamates

Cholinergic - Nicotinic

S/S: Biphasic response excitation followed by depression,

tachycardia/bradycardia, hyper/hypotension, fasciculations/paralysis, coma seizures

Toxins: tabacco, nicotinic insecticides, nicotine

patches and gum

Narcotic

S/S: CNS depression, miosis, hypothermia,

hypoventilation, hypotension, pinpoint pupils

Toxins: opiates, opiodes

Withdrawal

S/S: Tachycardia, hypertension, N/V, DT,

seizures, hallucinations, insomnia, diarrhea, piloerection, cramps, mydriasis

Toxins: withdrawal from ETOH, barbs, benzos,

narcotics

Common Toxins and Management

Acetaminophen mucomist Salicylate charcoal Methanol ETOH Digoxin Charcoal Lithium Dialysis Organophosphate Atropine Phenytoin Charcoal CO hyperbaric chamber

Common Toxins and Management

Anticholinergic physostigmine Beta blockers glucagon Ca Channel blocker Calcium Cyanide Nitrate Dystonias Benadryl Opiates Naloxone

Methods to decrease absorption

#1 RULE: DO NOT POISON YOURSELF Eyes:Remove contacts, flush for 20 min Skin: Remove clothes and wash GI: Don’t empty corrosives

GI

Optimal time: < 10 min After 1 hour charcoal has less effect Stay away from ipecac Lavage: Best for adult Charcoal:

Large surface area, absorbs most toxins effectively

Doesn’t work with etoh, petroleum, metals

Wrapping it Up

Know common poisons in your area Remember anything is a potential poison

Manage ABC’s as before HISTORY!!!! Identify toxidrome Remember patient may be mixing

toxidromes

Poison Control Centers

Poison control centers exist across the Canada to help manage poisoning emergencies Most are based in major medical centers

or teaching hospitals IWK houses Nova Scotia’s

1-800-565-8161