Pre-Lecture



Outdoor Emergency Care, Fourth Edition

CHAPTER 13: COMMON MEDICAL EMERGENCIES

Lesson Guide

Kathleen A. Olsen, Pebble Creek Patrol, Inkom, ID

Note: This lesson guide is provided in an electronic format in the OEC Instructor’s Tool Kit so you can modify and customize it to fit your course.

INSTRUCTOR TOOLS

• OEC Instructor’s Manual, 4th edition (lesson guides, activities, skill guides)

• OEC Instructors’ Tool Kit CD (lesson guides, PowerPoint presentations, activities, image bank)

• OEC Test Bank CD (questions, scenarios—generate quizzes, chapter tests, midterms, finals)

• Mechanism of Injury is more fully described in Chapter 18

• , instructor,

• Activities section of this manual

• Skill Guides

o Vital Signs Determination (chapter 5)

o Use of Oxygen and Airway Adjuncts (chapter 6)

o Patient Assessment (chapter 7)

o Bleeding Control/Shock Management (chapters 8 and 9)

STUDENT TOOLS

• Outdoor Emergency Care, 4th edition

• Student Workbook, 4th edition

• ,

• Skill Drill 13-1—Administering Glucose

• Skill Drill 13-2—Using an Auto-Injector

• BSI devices; e.g. rubber (latex) gloves, mask, goggles

• Emergency care supplies

CORE OBJECTIVES for initial patrol training

Note: The objectives listed below are specific for first-time patroller training. All other objectives identified in the textbook should be used when customizing your course for other audiences and for continuing education purposes.

Cognitive (Information)

• Identify the signs and symptoms of the acute abdomen and the necessity for immediate transport of patients with these symptoms.

• Identify the patient taking diabetic medications with altered mental status and the implications of a history of diabetes.

• State the steps in the emergency care of the patient taking diabetic medicine with an altered mental status and a history of diabetes.

• Recognize the patient experiencing an allergic reaction.

• Describe the emergency care of the patient with an allergic reaction.

• Describe the mechanisms of allergic response and the implications for airway management.

• List signs and symptoms associated with poisoning.

• Describe the steps in the emergency care for the patient with suspected poisoning.

Affective (Comprehension)

None

Psychomotor (Application)

• Perform a rapid gentle assessment of the abdomen.

• Demonstrate the steps in the emergency care for the patient taking diabetic medicine with an altered mental status and a history of diabetes.

• Demonstrate the emergency care of the patient experiencing an allergic reaction.

• Demonstrate the steps in the emergency care for the patient with suspected poisoning.

CHAPTER SET

You are the rescuer

Use this activity to encourage discussion regarding the types and complexity of abdominal pain and diabetic emergencies. It provides a starting point for the presentation of the critical and time-sensitive nature of treating allergic reactions and the significance and concerns associated with understanding and treating problems resulting from substance abuse. This activity will allow students an opportunity to explore the significance and concerns associated with assessing and treating rapidly a patient with any one of these emergency problems.

Scenario

A brief stop for coffee in the lodge cafeteria turns into work when a 25-year-old woman just in front of you in the line collapses. You help the woman to the floor. She is complaining of “terrible stomach pain.”

1. Why would a patient with a serious abdominal problem complain of pain elsewhere, such as the shoulder?

• Abdominal pain is often referred to other areas of the body.

2. How is it possible to go into shock from an “acute abdomen?”

• Loss of body fluid into the abdominal cavity due to peritonitis (hypovolemic shock).

• Vomiting with loss of fluids and electrolytes

• Dehydration from metabolic abnormalities.

WORKBOOK ACTIVITY - Chapter 13

These exercises will allow students an opportunity to refresh their knowledge of the acute abdomen, allergic reactions, diabetes, poisoning, drug abuse, and other common emergencies that occur in the outdoor environment as well as facilitate a review of this lesson’s major topics.

ESSENTIAL CONTENT – COMMON MEDICAL EMERGENCIES

I. The Acute Abdomen

A. Abdominal pain

1. Common complaint

2. Cause is often difficult to identify, so not necessary to determine the exact cause

3. Need to be able to recognize life-threatening problems and act swiftly.

B. Physiology of the acute abdomen

1. Sudden onset of abdominal pain

2. Indicates peritoneal irritation

3. Caused by infection, penetrating wound, blunt injury, and many diseases

4. Major symptom is severe pain.

5. Clinical signs are abdominal tenderness and distention.

C. Peritoneum is the thin membrane that lines the entire abdominal cavity.

1. Consists of two membranes and two types of nerves supply these areas.

a. Parietal peritoneum lines the walls of the abdominal cavity.

i. Supplied by the same nerves that supply the skin

ii. Can perceive pain, touch, pressure, heat, and cold

iii. The nerves cannot localize a point of irritation.

b. Visceral peritoneum covers the surface of each of the organs in the abdominal cavity.

i. Supplied by the autonomic nervous system, so the patient is less able to localize sensation.

ii. Stimulated only when distension or forceful contraction of the hollow abdominal organs activates stretch receptors

iii. Sensation is usually interpreted as colic, a severe, intermittent

cramping pain.

D. Referred pain

1. Perceived pain at a distant point of the body caused by irritation of the visceral peritoneum

2. Result of connections between the body’s two separate nervous systems

a. Spinal cord supplies sensory nerves to skin and muscles.

b. Autonomic nervous system controls abdominal organs and the blood vessels.

c. Nerves connecting these two systems cause the stimulation of the autonomic nerves to be perceived as stimulation of the spinal sensory nerves. Example: Acute cholecystitis may cause pain in the right shoulder, because the autonomic nerves serving the gallbladder lie near the spinal cord at the same anatomic level as the spinal sensory nerves that supply the skin of the shoulder.

E. Peritonitis

1. Irritation of the peritoneum caused by illness or injury

2. Typically causes ileus, or paralysis of the muscular contractions in the intestine, which causes abdominal distention.

3. Nothing that is eaten can pass normally out of the stomach or through the bowel.

4. The only means by which the stomach can empty itself is through vomiting.

5. Almost always associated with nausea and vomiting

6. These signs and symptoms can accompany almost every type of gastrointestinal disease or injury.

F. Signs and symptoms of acute abdomen

1. Nausea and vomiting (ileus)

2. Vomit (emesis), Anorexia

a. Loss of hunger or appetite

b. An almost universal complaint in gastrointestinal and abdominal disease or injury

3. Loss of body fluid into the abdominal cavity

a. Usually results from abnormal shifts of fluid from the bloodstream into body tissues.

b. Decreases the volume of circulating blood

c. May eventually cause shock

4. May have normal vital signs or tachycardia and hypotension

5. Fever may or may not be present.

6. Abdominal pain and tenderness

a. May be localized or diffuse and will vary in severity

b. Localized pain provides a clue to the problem.

c. Tenderness may be minimal or great.

7. Tenseness of the abdominal muscles over the irritated area

a. Board-like muscle spasm called guarding, which accompanies major problems

b. Patients comfortable only when lying in one particular position, which relaxes muscles and lessens the pain.

c. Patients with distention caused by peritonitis usually have abdominal pain, even when lying quietly.

d. Patients may take rapid, shallow breaths because of pain.

e. Tenderness on palpation of the abdomen or when patient moves

f. Degree of pain and tenderness is usually related to the severity of peritoneal inflammation.

8. Common signs and symptoms of acute abdomen

a. Local or diffuse pain and/or tenderness

b. A quiet patient who is guarding the abdomen (in shock)

c. Rapid and shallow breathing

d. Referred (distant) pain

e. Anorexia, nausea, vomiting

f. Tense, often distended, abdomen

g. Sudden constipation or bloody diarrhea

h. Tachycardia

i. Hypotension

j. Fever

k. Rebound tenderness (less pain when direct pressure is applied, but very painful when pressure is released)

9. Examining the abdomen

a. Explain to the patient what you are about to do.

b. Position patient supine with the legs drawn up and flexed at the knees.

c. Evaluate and inspect for restlessness or quietness; whether motion causes pain; any characteristic position; distention; or obvious abnormalities.

d. Palpate the four quadrants of the abdomen gently to determine whether it is tense (guarded) or soft.

e. Determine whether the patient can relax the abdominal wall on command.

f. Determine whether the abdomen is tender when palpated.

G. Causes of abdominal pain

1. Gastrointestinal and urinary tract

a. Nearly every kind of abdominal problem can cause an acute abdomen.

b. Any condition that allows pus, blood, feces, urine, gastric juice, intestinal contents, bile, pancreatic juice, amniotic fluid, or other foreign material to lie within or adjacent to the abdominal cavity can cause an acute abdomen.

c. Technically, organs such as kidneys, ovaries, and other genitourinary structures are retroperitoneal but because they lie next to the peritoneum, problems in these organs can lead to an acute abdomen.

d. Common abdominal conditions

i. Acute appendicitis

ii. Perforated gastric ulcer

iii. Cholecystitis

iv. Diverticulitis

2. Indigestion

a. A sign that the upper gastrointestinal tract is not functioning normally.

b. Symptoms include pain, nausea and vomiting (a sign).

c. Frequently associated with excess acid production.

d. Can be brought on by: stress, infection, alcohol, and spicy meals.

e. Can be an early sign of ulcer or cancer

f. Pain is described as burning, dull, cramping or pressure

g. Felt in the epigastric area

h. Heartburn is a burning in the epigastric, throat and substernal regions

i. A sign or acid in the esophagus

ii. Can mimic cardiac pain

i. Nausea is a sense of an impending urge to vomit

j. Vomiting is the process of ejecting the stomach contents through the mouth.

k. Stomach will empty due to stimuli which include:

i. Infection

ii. Food poisoning

iii. Drugs

iv. Alcohol

v. Trauma,

vi. Tumors, Ulcers

vii. High altitude

viii. Headache,

ix. Motion sickness

x. Various types of stress

l. Nausea and vomiting can be mild, severe, acute or chronic. It can lead to serious side effects such as:

i. Loss of fluids and electrolytes

ii. Aspiration of vomit leading to obstruction and infection

iii. Tears and bleeding in the stomach and esophagus

m. If vomiting doesn’t subside transport to medical care

n. Vomiting blood is almost always serious

o. Usually associated with disease or injury to the stomach or esophagus which include:

i. Ulcers

ii. Tears due to vomiting

iii. Esophageal varices

p. Vomited blood can be bright red or when digested like coffee grounds

q. Evacuated these patients to a hospital

3. Diarrhea

a. Passage of soft or liquid stools frequently

b. Prolonged bouts lead to dehydration, starvation, and shock

c. Accompanied by nausea and vomiting at time.

d. Usually caused by contaminated food and water. Varies geographically.

e. Caused frequently by infection by:

i. Campylobacter, Salmonella, Shigella bacteria

ii. Staphlococcus, which grows readily in some food.

iii. Giardia lamblia protozoa

iv. Cryptosporidium protozoa

v. Escherichea coli (E-coli) colon bacillus

f. Traveler’s diarrhea can be prevented through scrupulous attention to personal cleanliness and food preparation.

g. Hospitalization can be necessary when nausea and vomiting accompany diarrhea.

4. Blood in the stools

a. Bright red blood in the stools is bleeding form the rectum or lower colon

b. Can be from higher in the track with rapid passage to the bowel

c. Usually hemorrhoids or anal fissure

d. Darker blood (tarry stools) indicates bleeding in the upper tract.

e. Causes include:

i. Stomach ulcers

ii. Polyps

iii. Cancer

f. Pepto-Bismol and vitamins can turn the stool dark

g. Beets can turn the stool and urine red

h. Inflammatory bowel disease can cause blood in the stools

i. Tarry stools signify a condition that needs medical attention

j. Bright red blood and pain in the anal region is usually from a bleeding hemorrhoid, fissure or abrasion.

5. Colic

a. Intermittent, severe pain caused by obstruction to hollow organs such as:

i. Gall bladder

ii. Bowel

iii. Ureter

b. Muscle contraction causes pain as contents pass obstruction.

c. Common causes include:

i. Gall stones

ii. Kidney stones

iii. Intestinal obstructions

iv. Tumors

d. Gall stones can be felt in the RUQ and below the right scapula

e. Urethral colic (kidney stones) pain can be felt in the corresponding flank

f. Intestinal colic pain can be felt peri-umbilical

g. Can be symptom of serious disease

6. Constipation

a. The passage of hard dry stools at less than normal intervals

b. Caused by:

i. Limited activity

ii. Dehydration

iii. Anxiety

iv. Lack of bulk (fiber)

c. Not simply infrequent stools.

d. The elderly are susceptible.

e. Persistent constipation can be a sign of bowel cancer

f. Fecal impaction may have to be digitally cleared.

7. Difficulty swallowing

a. Disphagia can be caused by abnormal function or the esophageal muscles, tumor, scar tissue or a foreign body

b. It can be acute, chronic, or intermittent

c. Usually a temporary muscle spasm

d. Cancer is the most serious and all patients should get medical care.

8. Jaundice

a. A yellowing of the skin, mucous and sclera caused by accumulation of bilirubin in the blood.

b. Can be seen also as brown urine or pale stools.

c. Bilirubin is a normal by product of the metabolism of old red blood cells.

d. If it exceeds normal levels jaundice occurs

e. Common causes include:

i. Liver dysfunction (hepatitis)

ii. Gall stones

iii. Tumor

f. Patients need medical care promptly

H. Uterus and ovaries

1. Problems with ovaries, fallopian tubes, and uterus are common causes of acute abdominal pain in women.

2. Always consider the possibility that a woman with lower abdominal pain and tenderness may have a gynecological problem.

3. Pain may also be related to normal menstrual cycle.

4. Common cause of an acute abdomen in women is pelvic inflammatory disease (PID), an infection of the fallopian tubes and tissues of the pelvis.

5. Ectopic pregnancy

a. Fertilized egg is implanted outside the uterus, usually in a fallopian tube.

b. Fallopian tube is not large enough to support the growth for more than about 6 to 8 weeks.

c. When the tube ruptures, it produces massive internal hemorrhage and abrupt abdominal pain.

d. Patient needs immediate transport to the hospital.

6. Other organ systems

a. Aneurysm

i. Wall of the aorta sometimes develops weak areas that swell to form an aneurysm.

ii. Ruptured aneurysms can cause massive hemorrhage.

iii. May also cause severe back pain

iv. The bleeding usually leads to profound shock.

v. Patient needs immediate transport.

vi. Avoid unnecessary or vigorous palpation of the abdomen.

vii. Handle gently.

b. Pneumonia, especially in the lower parts of the lungs, may cause ileus and abdominal pain.

c. Hernia: Protrusion of an organ or tissue through a hole in the body wall.

i. Causes

• Congenital defect

• Surgical wound that has failed to heal properly

• Natural weakness in an area such as in the groin

ii. Produces a mass or lump that will be noticeable to the patient.

iii. Incarcerated hernia

• Mass that cannot be pushed back within the body

• Contents of incarcerated hernias may become compressed by surrounding tissue.

• Eventually compromises the blood supply

• This is strangulation, a serious medical emergency.

• Patient may experience pain, tenderness, red or blue skin discoloration over the hernia.

• Prompt transport needed.

I. Emergency care

1. Do not delay transport.

2. Carry out the following steps as quickly as possible before transport:

a. Do not attempt to diagnose the cause of the acute abdomen.

b. Clear and maintain the airway.

c. Anticipate vomiting.

d. Administer oxygen.

e. Do not give the patient anything by mouth.

f. Document all pertinent information.

g. Anticipate the development of hypovolemic shock.

h. Make the patient as comfortable as possible.

i. Monitor vital signs.

3. Geriatric patients

a. May have decreased pain perception

b. May not have fever with infection

c. May delay seeking care because pain is minimal

d. Assess carefully.

II. Diabetes

A. Definition and scope of diabetes

1. Full name is diabetes mellitus.

2. Metabolic disorder in which the body cannot metabolize simple carbohydrates (blood glucose), usually due to a lack of insulin.

a. Glucose, or dextrose, is one of the basic sugars in the body.

b. Glucose and oxygen are the primary fuels for cellular metabolism.

c. The central problem with diabetes is the lack or ineffective action of insulin, a hormone produced by the pancreas that enables glucose to enter the cells.

i. Hormone: A chemical produced by a gland that has special regulatory effects on other body organs and tissues

ii. Without insulin, cells begin to “starve” because insulin acts like a key to let glucose into the cells.

d. If left untreated, diabetes leads to a wasting of body tissues and death.

e. Considered to be an autoimmune problem in which the body becomes allergic to its own tissues and literally destroys them.

3. Affects about 6% of population.

a. Most patients can live a normal life.

b. Must be willing to adjust eating habits and activities

c. Even with medical care, some patients die relatively young from complications.

A. Types of diabetes

1. Type I diabetes, or insulin-dependent diabetes

a. Patients do not produce insulin at all.

b. Need daily injections of supplemental, synthetic insulin

c. Often affects children

d. Patients more likely to have metabolic problems and organ damage.

2. Type II diabetes, or non–insulin-dependent diabetes

a. Usually appears later in life

b. Patients produce inadequate amounts of insulin.

c. Some patients may require some supplemental insulin.

d. Most patients can be treated with diet and non-insulin-type oral medications (hypoglycemic agents).

i. Chlorpropamide (Diabinase)

ii. Tolbutamide (Orinase)

iii. Glyburide (Micronase)

e. These stimulate the pancreas to produce more insulin and thus lower blood glucose.

f. In some cases, these drugs can lead to hypoglycemia, particularly when patient activity and exercise levels are too vigorous or excessive.

3. The two types are equally serious and require lifelong medical management although type II diabetes is easier to regulate.

B. The role of glucose and insulin

1. Glucose

a. Major source of energy for the body

b. All cells need it.

c. Constant supply of glucose to the brain is as important as oxygen.

d. Without glucose, or with very low levels, brain cells rapidly suffer permanent damage.

2. Insulin

a. With the exception of the brain, insulin is needed to allow glucose to enter

body cells.

b. Insulin is said to be a “cellular key.”

3. Hyperglycemia

a. Without insulin, glucose from food remains in the blood and gradually rises to extremely high levels.

b. Once the blood glucose levels reach twice the usual amount, the kidney excretes excess glucose.

c. This process requires a large amount of water.

d. The loss of water in such large amounts causes the classic symptoms of uncontrolled diabetes, the “3 Ps”.

i. Polyuria: Frequent and plentiful urination

ii. Polydipsia: Frequent drinking of liquid to satisfy continuous thirst

iii. Polyphagia: Excessive eating; seen only occasionally

4. Acidosis

a. Without glucose, the body turns to other fuel sources.

i. The most abundant fuel source is fat.

ii. When the body uses fat as an immediate energy source, it forms chemicals called ketones and fatty acids, which are hard for the body to excrete.

b. Ketones can produce a dangerous condition called acidosis; in uncontrolled diabetes it is called diabetic ketoacidosis.

c. Signs and symptoms

i. Vomiting

ii. Abdominal pain

iii. Deep, rapid breathing called Kussmaul respirations

iv. When acid levels are too high, individual cells cease to function.

v. Without fluid and insulin, ketoacidosis will progress to unconsciousness, diabetic coma, and eventually death.

C. Available treatments

1. Diabetes mellitus is treatable.

2. Treatment must be tailored for the individual patient.

a. Patient’s need for glucose with the available supply of insulin needs to be constantly balanced by testing either the blood or the urine.

b. In the past, most patients tested their urine daily.

c. Many patients now measure the level of glucose in the blood using a blood glucose self-monitoring unit that is simpler and more accurate.

i. A drop of blood from the fingertip is placed on a thin strip of chemically treated paper.

ii. The paper turns color and is compared to a color chart, which matches colors with approximate blood glucose readings.

iii. The readings are measured in milligrams per deciliter of blood (mg/dL).

iv. Normal blood glucose level is between 80 and 120 mg/dL.

d. Patients can also buy a device called a glucometer.

i. Patient pricks a finger tip.

ii. Device gives a digital print out of blood glucose level.

D. Diabetic emergencies

1. Two conditions can lead to diabetic emergencies.

a. Diabetic coma (high blood glucose or extreme hyperglycemia)

b. Insulin shock (low blood glucose or hypoglycemia)

c. Signs and symptoms of both can be quite similar.

2. Diabetic coma

a. State of unconsciousness resulting from several problems

i. Ketoacidosis which usually develops over a period of time (from hours to days)

ii. Dehydration because of excessive urination

iii. Hyperglycemia

b. Patients at risk

i. Those not under medical treatment

ii. Patients taking insufficient insulin

iii. Patients markedly overeating

iv. Patients undergoing some sort of stress

• Infection

• Illness

• Overexertion

• Fatigue

• Drinking alcohol

c. Signs of diabetic coma

i. Kussmaul respirations

ii. Dehydration, as indicated by dry, warm skin and sunken eyes

iii. A sweet or fruity (acetone) breath odor, caused by the usual waste products in the blood (ketones)

iv. A rapid, weak (“thready”) pulse

v. A normal or slightly low blood pressure

vi. Varying degrees of unresponsiveness

3. Insulin shock

a. Caused by insufficient glucose in blood (hypoglycemia)

i. When insulin levels are high, glucose is taken out of the blood to fuel the cells.

ii. If blood glucose levels get too low, there may be an insufficient amount to supply the brain.

iii. If blood glucose levels remain low, unconsciousness and permanent brain damage can quickly follow.

b. Patients at risk of insulin shock

i. Patients who have taken too much insulin

ii. Patients who have taken a regular dose of insulin but have not eaten

enough food

iii. Patients who have had an unusual amount of activity and have used all available glucose

iv. May occur with no identifiable predisposing factor

v. Children who have diabetes may pose a particular management problem.

• High levels of activity cause circulating glucose to be used more quickly than in adults.

• Children do not always eat correctly or on schedule.

• Insulin shock can develop more often and more severely in children than in adult patients.

c. Insulin shock develops much more quickly than diabetic coma, sometimes in a matter of minutes.

d. Signs and symptoms of insulin shock

i. Normal or rapid respirations

ii. Pale, moist (clammy) skin

iii. Diaphoresis (sweating)

iv. Dizziness, headache

v. Rapid pulse

vi. Normal to low blood pressure

vii. Altered mental status, aggressive, confused, lethargic, or unusual behavior

viii. Anxious or combative behavior

ix. Hunger

x. Fainting, seizure, or coma

xi. Weakness on one side of the body (may mimic stroke)

4. Diabetic coma and insulin shock require different treatments.

a. Diabetic coma is a complex metabolic condition that usually develops over time and involves all the tissues of the body for which correction takes many hours in the hospital.

b. Insulin shock is an acute condition that can develop rapidly and can just as quickly be reversed by giving the patient glucose.

c. Patients with diabetes also may have “silent,” or painless, heart attacks.

5. Diabetes and alcohol abuse (This information does not appear in the text, but could be included in course content.)

a. Occasionally, patients in insulin shock or a diabetic coma are thought to be intoxicated.

b. Always suspect hypoglycemia in any patient with altered mental status.

c. Be alert to the similarity in symptoms of acute alcohol intoxication and diabetic emergencies.

E. Emergency care (Skill Drill 13-1)

Note: Be familiar with local protocols for glucose administration. If ALS providers in your area perform blood glucose tests, make sure to present this to your students as ALS information.

1. Assessment

a. Questions to ask patients known to have diabetes

i. Do you take insulin or any pills that lower your blood sugar?

ii. Have you taken your usual dose of insulin (or pills) today?

iii. Have you eaten normally today?

iv. Have you had any illness, unusual amount of activity, or stress today?

b. Patients who have eaten but not taken insulin are more likely to have developed diabetic ketoacidosis.

c. Patients who have taken insulin but have not eaten are more likely to be in insulin shock.

d. The patient will often know what is wrong.

e. Patient assessment

i. Perform an initial assessment to verify that the airway is open, using BLS maneuvers if necessary.

ii. Perform the focused assessment and detailed physical exam while your partner obtains the baseline vital signs and SAMPLE history.

iii. Check to see whether the patient has an emergency medical identification symbol.

iv. Always do a full, careful assessment, paying attention to ABCs; the problem may not be diabetic in origin.

v. Ask the patient or family about the patient’s last meal and insulin dose.

vi. Do not attempt to give anything by mouth to an unconscious patient.

2. Giving oral glucose

a. Gel that dissolves in the mouth

i. Glutose

ii. Insta-Glucose

b. One tube of gel equals one dose.

c. Glucose gel should be given to any patient with a decreased level of consciousness who has diabetes that is controlled by medication.

d. Confirm that the patient is conscious and able to swallow; contraindications are an inability to swallow or unconsciousness.

e. A conscious patient (even if confused) who does not really need glucose will not be harmed by it.

f. Administration

i. Wear gloves before placing anything into a patient’s mouth.

ii. Examine the tube to ensure that it is not open or broken. Check the expiration date.

iii. Squeeze the entire tube onto the bottom third of a bite stick or tongue depressor.

iv. Open the patient’s mouth.

v. Place the tongue depressor on the mucous membranes between the cheek and gum, with the gel side next to the cheek. Once the gel is dissolved, or if the patient loses consciousness or has a seizure, remove the tongue depressor.

g. Reassess regularly after giving glucose.

3. Treatment of insulin shock and diabetic coma

a. Patients in insulin shock (rapid onset of coma, hypoglycemia)

i. Need sugar immediately

b. Patients in diabetic coma (ketoacidosis, dehydration, and hyperglycemia)

i. Need insulin, complex IV fluid treatment, and probably other medications

ii. Need prompt transport to the hospital.

iii. Most protocols err on the side of giving glucose.

iv. Amount of sugar typically given to such a patient is very unlikely to make a patient in diabetic ketoacidosis significantly worse.

c. When in doubt, consult medical control.

4. Complications of diabetes affect all tissues

a. Heart disease

b. Visual disturbances

c. Renal failure

d. Stroke

e. Ulcers

f. Infections of the feet or toes

g. Seizures

h. Altered mental status

5. Complications of diabetes – seizures

a. Seizures are rarely life threatening but should be considered very serious.

b. In the patient with diabetes, consider hypoglycemia as the cause.

c. Use appropriate BLS measures for airway management.

d. Provide prompt transport.

6. Complications of diabetes – altered mental status

a. Altered mental status is often caused by complications of diabetes or a variety of other conditions.

b. Ensure that the airway is clear.

c. Be prepared to ventilate and suction.

d. Provide prompt transport.

7. Relationship to airway management

a. Patients with altered mental status are at risk for losing gag reflex.

b. Treatment

i. Carefully monitor the airway in patients with hypoglycemia, diabetic coma, or a diabetic complication such as stroke or seizure.

ii. Place patient in a lateral recumbent position.

iii. Make sure suction is available.

I Allergic Reactions

A. An allergic reaction is an exaggerated immune response to any substance.

B. Reaction by the body’s immune system, which releases chemicals to combat the stimulus

1. Histamines

2. Leukotrienes

C. May be mild and local, involving hives, itching, or tenderness

D. May be severe and systemic, resulting in shock and respiratory failure

E. Anaphylaxis: An extreme allergic reaction that typically involves multiple organ systems

1. Can rapidly result in death in severe cases

2. Two of the most common signs are:

a. Wheezing

b. Widespread urticaria, or hives

3. Can be triggered by almost any substance, resulting in an allergic reaction

4. Five general categories of allergens

a. Insect bites and stings

i. When an insect bites and injects the bite with its venom, it is called envenomation.

ii. Most common envenomations are honeybee, wasp, ant, yellow jacket, and hornet.

b. Medications

i. May not generate an allergic reaction on the first dose

ii. May trigger an allergic reaction later

c. Plants

i. Inhaling dust, pollens, or other plant materials may cause a rapid and severe reaction in allergic individuals.

ii. Can also be triggered by eating or by touching certain plants

d. Food

i. Allergies to certain foods can result in a slower onset, but can cause quite a severe reaction.

e. Chemicals

i. Various chemicals, soaps, and makeup can cause severe reactions.

5. Insect stings

a. Deaths from anaphylactic reactions to stinging insects far outnumber deaths from snakebites.

b. The stinging organ of most bees, wasps, yellow jackets, and hornets is a small hollow spine projecting from the abdomen.

i. Wasps and hornets can sting repeatedly.

ii. The stinger of the honeybee is barbed, so the bee cannot withdraw it. The honeybee leaves a part of its abdomen embedded with the stinger and dies shortly after flying away.

iii. Some ants, especially the fire ant (Formicoidea), also strike repeatedly.

c. Signs and symptoms of insect bites include:

i. Sudden pain, swelling, localized heat, and redness in light-skinned individuals, usually at the site of injury

ii. Itching and sometimes a wheal, which is a raised, swollen area on the skin.

d. Steps in treating insect bites include:

i. Applying ice to reduce irritation

ii. Removing the stinger of a honeybee

iii. Watching carefully to ensure anaphylaxis doesn’t develop

e. Because the stinger of the honeybee remains in the wound, it can continue to inject venom for up to 20 minutes.

i. Gently attempt to remove the stinger and attached muscle by scraping the skin with the edge of a sharp, stiff object such as a credit card.

ii. Do not use tweezers or forceps, because squeezing may cause the stinger to inject more venom into the bite wound.

iii. Gently wash the wound with soap and water or a mild antiseptic.

iv. Remove jewelry before swelling begins.

v. Position the injection site slightly below the level of the heart and apply ice or cold packs to the area, but not directly on the skin.

vi. Be alert for vomiting or any signs of shock or allergic reaction.

vii. Do not give the patient anything by mouth.

viii. Place the patient in the shock position and give oxygen if needed.

ix. Monitor vital signs and be prepared to provide further support.

f. Anaphylactic reactions to stings

i. Approximately 5% of all people are allergic to the venom of the bee, hornet, yellow jacket, or wasp.

ii. This type of allergy accounts for approximately 200 deaths a year.

iii. More than two thirds of patients who die of anaphylaxis do so within the first half hour.

iv. Signs and symptoms include:

• Itching and burning

• Widespread urticaria

• Wheals

• Swelling of the lips and tongue

• Bronchospasm and wheezing

• Chest tightness and coughing

• Dyspnea

• Anxiety

• Abdominal cramps

• Hypotension

v. Occasionally, respiratory failure occurs.

6. Patient assessment

a. Allergic symptoms are almost as varied as allergens themselves.

b. Assessment should include evaluating the respiratory system, the circulatory system, the patient’s mental status, and the skin.

c. Wheezing occurs because excessive fluid and mucus are secreted into the bronchial passages.

i. Muscles around these passages tighten in reaction to the allergen.

ii. Fluid in the air passages and the constricted bronchi together produce the wheezing sound.

iii. Breathing rapidly becomes more difficult.

iv. Prolonged respiratory difficulty can cause a rapid heartbeat (tachycardia), shock, and even death.

d. Stridor occurs when swelling in the upper airway closes off the airway; this can eventually lead to total obstruction.

e. Hypoperfusion (shock) or respiratory distress indicates that the patient is having a severe allergic reaction that can lead to death.

7. Emergency care (Skill Drill 13-2)

Note: Be sure to replace the generic epinephrine administration guideline provided with your local protocol, if appropriate. Be sure your students clearly understand their local scope of practice. If SC or IM injections of epinephrine are allowed locally, an additional training program is usually required.

a. Give oxygen.

b. Perform a focused history and physical examination.

i. Find out whether the patient has a history of allergies, what the patient was exposed to, and how the patient was exposed.

ii. Determine the effects of the exposure and how they have progressed.

iii. Find out what interventions were completed.

c. Obtain baseline vital signs and a SAMPLE history.

d. Inform medical control.

e. Find out whether the patient has any prescribed, preloaded medications for allergic reactions.

f. Be prepared to use standard airway procedures.

g. If the patient appears to be having a severe allergic (or anaphylactic) reaction, administer BLS at once.

i. Request ALS backup.

ii. In addition to providing oxygen, be prepared to maintain an airway or give CPR.

iii. Placing ice over the injury site may slow absorption of the toxin and diminish swelling, but placing ice packs directly on the skin may freeze it and cause more damage.

iv. In some areas, you may be allowed to assist the patient with administration of epinephrine.

• Epinephrine works rapidly to raise the pulse rate and blood pressure by constricting the blood vessels.

• It inhibits the allergic reaction and dilates the bronchioles.

• Your EMS service may or may not allow you to help patients self-administer epinephrine.

• If the patient is known to be allergic, he or she may be carrying a kit that contains epinephrine.

• The adult system delivers 0.3 mg of epinephrine via an automatic needle and syringe system; the infant/child system delivers 0.15 mg.

• To use or help with the auto-injector, take the following steps:

• Follow local protocols.

• Follow BSI precautions.

• Make sure the medication has been prescribed specifically for that

person.

• Make sure the medication is not discolored or expired.

v. Give the medication, using the following steps:

• Remove the safety cap and, if possible, wipe the patient’s thigh with alcohol or some other antiseptic; do not delay administration.

• Place the tip of the auto-injector against the lateral part of the patient’s thigh, midway between the waist and the knee.

• Help the patient push the injector firmly against the thigh until the injector activates.

a. This will help prevent the kick that the spring-loaded syringe can

cause.

b. Hold in place until the medication is injected (10 seconds).

• Remove from thigh and dispose of properly in a biohazard container.

• Record the time and dose of injection on your run sheet.

• Reassess and record vital signs 2 minutes after administration.

vi. Epinephrine constricts blood vessels and may cause blood pressure to rise significantly.

• Other side effects include:

• Tachycardia

• Pallor

• Dizziness

• Chest pain

• Headache

• Nausea

• Vomiting

• All of these effects may cause the patient to feel anxious or excited.

• Patients who are not wheezing or who have no signs of respiratory compromise or hypotension should not be given epinephrine.

• Always provide prompt transport for any patient who may be having an allergic reaction or has experienced a poisonous envenomation or bite.

• Reassess vital signs en route; signs and symptoms can change rapidly.

I Specific Bites and Envenomations

Note: If your local area has specific destination protocols for snakebites, be sure to provide this information to your students.

A. Spider bites

1. Spiders are numerous and widespread in the United States.

a. Many species of spiders bite.

b. Only two, the female black widow spider and the brown recluse spider, deliver serious, even life-threatening bites.

c. Your safety is of paramount importance.

2. Black widow spider

a. The female black widow spider is fairly large, measuring approximately 2' long with its legs extended.

b. It is usually black with a distinctive, bright red-orange marking in the shape of an hourglass on its abdomen.

c. The female is larger and more toxic than the male.

d. It is found in every state except Alaska.

e. They prefer dry, dim places around buildings, in woodpiles, and among debris.

f. The bite is sometimes overlooked.

g. If the site becomes numb right away, the patient may not even recall being bit.

h. However, most black widow spider bites cause localized pain and symptoms, including agonizing muscle spasms.

i. In some cases, a bite on the abdomen causes muscle spasms so severe that they resemble an acute abdomen.

j. The main danger is the venom, which is poisonous to nerve tissues.

k. Other systemic symptoms include dizziness, sweating, nausea, vomiting, and rashes.

l. Tightness in the chest, difficulty breathing, severe cramps, and a board-like rigidity of the abdominal muscles develop within 24 hours.

m. Generally, these signs and symptoms subside over 48 hours.

n. Emergency treatment for a black widow spider bite consists of BLS for the patient in respiratory distress.

o. Transport as soon as possible.

p. If possible, bring the spider.

3. Brown recluse spider

a. Brown recluse spider (Loxosceles) is dull brown in color and, at 1˝ long, somewhat smaller than the black widow.

b. The shorthaired body has a violin-shaped mark, brown to yellow in color, on its back.

c. It lives mostly in the southern and central parts of the country, but may be found throughout the continental United States.

d. It tends to live in dark areas, such as in the corners of old, unused buildings, under rocks, and in woodpiles.

e. In cooler areas, it moves indoors to closets, drawers, cellars, and old piles of clothing.

f. The venom of the brown recluse spider is not neurotoxic but cytotoxic; and causes severe local tissue damage.

g. Typically, the bite is not painful at first but becomes so within hours.

h. The area becomes swollen and tender, developing a pale, mottled, cyanotic center and possibly a small blister.

i. A scab of dead skin, fat, and debris will form and dig down into the skin, producing a large ulcer that may not heal unless treated promptly.

j. Transport patients with such symptoms as soon as possible.

k. Brown recluse spider bites rarely cause systemic symptoms and signs.

B. Snake bites

1. Snake bites are a worldwide problem of some significance.

a. More than 300,00 injuries from snake bites occur worldwide.

b. Each year 30,000 to 40,000 people die of snakebites worldwide.

2. Snake bites in the United States occur less often.

a. Approximately 40,000 to 50,000 are reported yearly.

b. Snake bite fatalities in the United States are extremely rare—about 15 a year for the entire country.

3. Of the approximately 115 different species of snakes in the United States, only 19 are venomous.

a. These include the rattlesnake (Crotalus), the copperhead, the cottonmouth or water moccasin (Agkistrodon pisci-vorus), and the coral snakes (Micrurus and Micruroides).

b. At least one of the poisonous species is found in every state except Alaska, Hawaii, and Maine.

4. Snakes usually do not bite unless provoked, angered, or accidentally injured, as when they are stepped on.

5. There are a few exceptions.

a. Cottonmouths are often aggressive.

b. Coral snakes are very shy and usually bite only when they are being handled.

6. Most snake bites occur between April and October and tend to involve young men who have been drinking alcohol.

7. Almost any time you are caring for a patient with a snake bite, another snake could come along and create a second victim—you.

8. Use extreme caution on these calls and wear the proper protective equipment for the area.

9. Only one third of snake bites results in significant local or systemic injuries.

10. Often, envenomation does not occur because the snake recently struck another animal and exhausted its supply of venom.

11. With the exception of the coral snake, poisonous snakes native to the United States have hollow fangs in the roof of the mouth that inject the poison from two sacs at the back of the head.

12. The classic appearance of the poisonous snake bite is two small puncture wounds, usually about ½” apart, with discoloration, swelling, and pain.

13. Nonpoisonous snakes can also bite, usually leaving a horseshoe of tooth marks.

14. Fang marks are a clear indication of a poisonous snake bite.

C. Pit vipers

1. Rattlesnakes, copperheads, and cottonmouths are all pit vipers, with triangular-shaped, flat heads.

2. They have small pits that contain poison located just behind each nostril and in front of each eye.

3. The pit is a heat-sensing organ that allows the snake to strike accurately at any warm target.

4. The fangs are special hollow teeth that act much like hypodermic needles connected to a sac containing a reservoir of venom.

5. The most common form of pit viper is the rattlesnake.

a. Rattlesnakes have many patterns of color, often with a diamond pattern.

b. They can grow to 6´ or more in length.

6. Copperheads are smaller than rattlesnakes.

a. They have a reddish coppery color crossed with brown or red bands.

b. Copperheads typically inhabit woodpiles and abandoned dwellings.

c. They account for most of the venomous snake bites in the eastern United States.

d. The bites are almost never fatal, but the venom can destroy extremities.

7. Cottonmouths grow to about 4" in length.

a. Also called water moccasins, they are olive or brown, with black cross-bands and a yellow undersurface.

b. They are water snakes, with an aggressive pattern of behavior.

c. Although fatalities from these snake bites are rare, tissue destruction from the venom may be severe.

8. Signs of envenomation by a pit viper are severe burning pain at the site of injury, followed by swelling and a bluish discoloration (ecchymosis).

9. Signs are evident within 5 to 10 minutes and spread over the next 36 hours.

10. In addition to destroying tissues locally, the venom of the pit viper can also interfere with the body’s clotting mechanism and cause bleeding at various distant sites.

11. Other signs which may or may not occur include weakness, sweating, fainting, and shock.

12. If the patient has no local signs an hour after being bitten, it is safe to assume that envenomation did not take place.

13. If swelling has occurred, mark its edges on the skin.

14. Do not confuse a fainting spell with shock.

15. If shock occurs, it will happen much later.

16. When treating a bite from a pit viper, take the following steps:

a. Calm the patient.

b. Have the patient lie flat, face up, and explain that staying quiet will slow the spread of any venom through the system.

c. Locate the bite area and clean it gently with soap and water.

d. Do not apply ice.

e. If the bite occurred on an arm or leg, splint the extremity to decrease movement.

f. Be alert for vomiting, which may be a sign of anxiety rather than the toxin itself.

g. Do not give anything by mouth.

h. If the patient was bitten on the trunk, keep him or her supine and quiet and transport as quickly as possible.

i. Monitor vital signs and mark the skin with a pen over the area that is swollen.

j. If there are any signs of shock, treat for it.

k. If the snake has been killed, bring it with you.

l. Notify the hospital; if possible, describe the snake.

m. Transport promptly.

17. If the patient shows no signs of envenomation, provide BLS as needed, place a sterile dressing over the suspected bite area, and immobilize the injury site.

18. All patients with a suspected snake bite should be taken to the emergency department.

19. Treat the wound as you would any deep puncture wound to prevent infection.

20. Know the local medical protocol for handling snake bites.

D. Coral snakes

1. A coral snake is a small reptile with a series of bright red, yellow, and black bands completely encircling the body.

2. “Red on yellow will kill a fellow; red on black, venom will lack.”

3. It is a relative of the cobra snake that lives primarily in Florida and in the Southwest desert.

4. It injects the venom with its teeth and tiny fangs by a chewing motion, leaving puncture wounds.

5. Because of its small mouth and teeth and limited jaw expansion, the coral snake usually bites its victims on a small part of the body, such as a finger or toe.

6. Coral snake venom is a powerful toxin that causes paralysis of the nervous system.

7. Within a few hours of being bitten, a patient will exhibit bizarre behavior, followed by progressive paralysis of eye movements and respiration.

8. Successful treatment depends on positive identification of the snake and support of respiration.

9. Antivenin is available, but most hospitals do not stock it.

10. Emergency care

a. Immediately quiet and reassure the patient.

b. Flush the area of the bite with 1 to 2 quarts of warm, soapy water to wash away any poison.

c. Do not apply ice.

d. Splint the extremity.

e. Check and monitor the patient’s baseline vital signs.

f. Keep the patient warm and elevate the lower extremities to help prevent shock.

g. Give oxygen if needed.

h. Transport promptly, giving hospital personnel notice that the patient has been bitten by a coral snake.

i. Give the patient nothing by mouth.

E. Scorpion stings

1. Scorpions are eight-legged arachnids with a venom gland and a stinger at the end of their tail.

2. They are rare and live primarily in the deserts of the southwestern United States.

3. With one exception, a scorpion’s sting is usually very painful but not dangerous.

a. The exception is the Centruroides sculpturatus.

b. The venom of this species may produce a severe systemic reaction that brings about circulatory collapse, severe muscle contractions, excessive salivation, hypertension, convulsions, and cardiac failure.

c. If you are called to care for a patient with a suspected sting from Centruroides sculpturatus, notify medical control as soon as possible.

d. Administer all the elements of BLS and transport the patient as rapidly as possible.

F. Tick bites

1. Ticks are tiny insects that usually attach themselves directly to the skin.

2. They are found most often on brush, shrubs, trees, sand dunes, or other animals.

3. They can easily be mistaken for freckles.

4. The bite is not painful.

5. The danger with a tick bite is from infecting organisms.

6. Ticks commonly carry Rocky Mountain spotted fever and Lyme disease.

a. Both are spread through the tick’s saliva.

b. Rocky Mountain spotted fever occurs within 7 to 10 days after the bite.

i. Symptoms include nausea, vomiting, headache, weakness, paralysis, and possibly cardiorespiratory collapse.

c. Lyme disease has received extensive publicity.

i. After AIDS, it is the second most rapidly growing infectious disease in the United States.

ii. Lyme disease has now been reported in 35 states.

iii. The first symptom, a rash that may spread to several parts of the body, begins about 3 days after the bite of an infected tick.

iv. In one third of patients, the rash eventually resembles a target bull’s-eye pattern.

v. After a few more days or weeks, painful swelling of the joints, particularly the knees, occurs.

vi. Lyme disease may be confused with rheumatoid arthritis and may result in permanent disability.

vii. If it is recognized and treated promptly with antibiotics, the patient may recover completely.

7. Tick bites occur most commonly during the summer months.

a. Transmission of the infection from tick to person takes at least 12 hours, so if you are called on to remove a tick, you should proceed carefully and slowly.

b. Do not attempt to suffocate or burn the tick.

c. Using fine tweezers, grasp the tick by the body and pull it straight out of the skin.

d. This will usually remove the whole tick.

e. Once the tick is removed, paint the area with disinfectant and save the tick in a glass jar for identification.

f. Do not handle the tick with your fingers.

g. Provide any necessary supportive care and transport the patient to the hospital.

G. Dog bites and rabies

1. Dog bites can be very serious.

2. A dog’s mouth is heavily contaminated with bacteria.

3. Consider all dog bites as contaminated and potentially infected wounds that may require antibiotics, tetanus prophylaxis, and suturing.

4. A physician should treat all dog bites.

5. Place a dry, sterile dressing over the wound and promptly transport.

6. If an arm or leg was injured, splint the extremity.

7. A major concern with animal bites is the spread of rabies, an acute, fatal viral infection of the central nervous system.

8. Rabies is extremely rare today, but it still exists.

9. Virus is in the saliva of a rabid (infected), animal and is transmitted through biting or licking an open wound.

10. Infection can be prevented in a person who has been bitten only by a series of special vaccine injections, a painful procedure.

11. A person’s only chance to avoid the vaccine is to find the animal and turn it over to the health department for observation and/or testing.

12. Children may be seriously injured or even killed by dogs.

13. Sometimes, the child unknowingly provokes the animal.

14. You must assume that it may turn and attack you as well.

15. You generally should not enter the scene until either the police or an animal control officer has secured the animal.

H. Human bites

1. The human mouth contains an exceptionally wide range of bacteria and viruses.

2. Regard any human bite that has penetrated the skin as a very serious injury.

3. If you have occasion to treat someone who has been punched in the mouth, remember that the person who delivered that punch may also need treatment.

4. Emergency treatment steps for a human bite

a. Promptly immobilize with a splint or bandage.

b. Apply a dry, sterile dressing.

c. Provide transport.

I. Injuries from marine animals

1. Coelenterates such as fire coral, Portuguese man-of-war, sea wasp, sea nettles, true jellyfish, sea anemones, true coral, and soft coral are responsible for more envenomations than any other marine animals.

2. The stinging cells are called nematocysts.

3. Envenomation causes very painful, reddish lesions in light-skinned individuals; the lesions extend in a line from the site of the sting.

4. Systemic symptoms include headache, dizziness, muscle cramps, and fainting.

5. To treat a sting from jellyfish, a Portuguese man-of-war, various anemones, corals, or hydras, remove the patient from the water and pour any type of alcohol on the affected area.

6. Alcohol will inactivate the nematocysts.

7. Do not try to manipulate the remaining tentacles; this will only cause further discharge.

8. Remove the tentacles by scraping them off with the edge of a sharp, stiff object such as a credit card.

9. Persistent pain may respond to immersion of the area in hot water (110° to 115°F) for 30 minutes.

10. On rare occasions, a patient may have a systemic allergic reaction.

a. Treat such a patient for anaphylactic shock.

b. Give BLS, and provide immediate transport to the hospital.

11. Toxins from the spines of urchins, stingrays, and certain spiny fish such as the lionfish, scorpion fish, or stonefish are heat sensitive.

12. The best treatment is to immobilize the affected area and soak it in hot water for 30 minutes.

13. Patient still needs to be transported.

14. If you work near the ocean, you should be familiar with the marine life in your area.

15. Emergency treatment of common coelenterate envenomations

a. Limit further discharge of nematocysts by avoiding fresh water, wet sand, showers, or careless manipulation of the tentacles.

b. Keep the patient calm and reduce motion of the affected extremity.

c. Inactivate the nematocysts by applying alcohol (any kind available; isopropyl or rubbing alcohol, cologne or high-proof liquor).

d. Remove the remaining tentacles by scraping them off with the edge of a sharp, stiff object.

e. Persistent pain may respond to immersion in hot water.

f. Provide transport.

V Substance Abuse and Poisoning

A. Acute poisoning affects some 5 million children and adults each year.

B. Poisoning death rates for children have decreased steadily since the 1960s, when safety caps were introduced.

C. Poisoning deaths in adults have been rising, primarily as a result of drug abuse.

D. Identifying the patient and the poison

Note: Verify local protocols for direct contact to poison control center or alternate destination sites.

1. Definition of poisoning and substance abuse

a. A poison is any substance whose chemical action can damage body structures or impair body function.

i. Poisons act by changing the normal metabolism of cells or by actually destroying them.

ii. Poisons may act acutely, as in an overdose of heroin.

iii. Poisons may act chronically, as in years of alcohol or other substance abuse.

b. Substance abuse is the knowing misuse of any substance to produce a desired effect.

1. Signs and symptoms of poisoning vary according to the specific agent.

a. Pulse might speed up or slow down.

b. Pupils might dilate or constrict.

c. In patients with difficult respiration, cyanosis might occur.

d. Skin or mucous membranes might be irritated, burned, or blistered.

i. This type of injury at the mouth indicates ingestion of poison, such as lye.

ii. Ask the following questions in these cases:

• What substances did you take?

• When did you take it (or become exposed to it)?

• How much did you ingest?

• What actions have been taken?

• How much do you weigh?

2. Determining the nature of the poison

a. Objects at the scene can help physicians determine how much poison has been ingested and what specific treatment may be required.

b. Place any suspicious material in a plastic bag and take to the hospital.

c. Take any containers you find to potentially provide critical information.

i. Name and concentration of the drug

ii. Specific ingredients

iii. Number of pills originally in bottle

iv. Name of the manufacturer

v. The dose that was prescribed

vi. For certain food poisonings, a food container that lists the name and location of the maker or the vendor, which may save life of patient and possibly other people.

d. Collect any vomitus and take to hospital.

3. Poison control centers

a. Staff have information on most substances.

b. Center has information available about emergency treatment and antidotes.

c. Consult a regional poison control center or a specialty treatment center for certain cases.

4. How poisons get into the body

a. Ingested poisons

i. Approximately 80% of all poisonings are by mouth.

ii. Examples of ingested poisons include:

• Liquids

• Household cleaners

• Contaminated food

• Plants

• Drugs

iii. Ingested poisoning is usually accidental in children and, except for contaminated food, deliberate in adults.

iv. Treatment goal is to remove as much of the poison as possible from the gastrointestinal tract.

• Activated charcoal comes as a suspension.

• It binds to the poison in the stomach and carries it out of the system.

• Always assess the ABCs of every patient who has been poisoned.

• Be prepared to provide ventilatory support and CPR to a patient who has ingested an opiate, sedative, or barbiturate.

• Each of these can cause depression of the central nervous system.

5. Inhaled poisons

a. Effects of inhaled poisons

i. Some inhaled poisons, such as carbon monoxide, are odorless and produce severe hypoxia without damaging or even irritating the lungs.

ii. Other inhaled poisons, such as chlorine, are very irritating and cause airway obstruction and pulmonary edema.

iii. Some inhaled agents cause progressive lung damage.

b. Patients may report the following signs and symptoms:

i. Burning eyes

ii. Sore throat

iii. Cough

iv. Chest pain

v. Hoarseness

vi. Wheezing

vii. Respiratory distress

viii. Dizziness

ix. Confusion

x. Headache

xi. Stridor in severe cases

xii. Possible seizure or an altered mental status

c. Treatment for patients who have inhaled poisons

i. Move patients into fresh air immediately.

ii. Make certain that only trained rescuers remove the patient from the poisonous environment.

iii. Provide supplemental oxygen and basic life support, if necessary.

iv. All patients who have inhaled poison require immediate transport.

v. Make sure a suctioning unit is available in case the patient vomits.

vi. Bring containers, bottles, and labels when you transport the patient to the hospital.

6. Injected poisons

a. Almost always the result of a deliberate drug overdose

b. Signs and symptoms of poisoning by injection can have a multitude of presentations, including:

i. Weakness

ii. Dizziness

iii. Fever

iv. Chills

v. Easy excitability

vi. Unresponsiveness

c. Injected poisons are impossible to dilute or remove.

d. Usually absorbed quickly into the body or cause intense local tissue destruction

e. Treatment for patients who have injected poisons

i. Monitor the patient’s airway.

ii. Provide high-flow oxygen.

iii. Be alert for nausea and vomiting.

iv. Remove rings, watches, and bracelets from areas around the injection site if swelling occurs.

v. Provide prompt transport.

7. Absorbed (surface contact) poisons

a. Many corrosive substances will damage the skin, mucous membranes, or eyes, causing chemical burns, telltale rashes, or lesions.

b. Acids, alkalis, and some petroleum (hydrocarbon) products are very destructive.

c. Signs and symptoms of absorbed poisoning

i. History of exposure

ii. Liquid or powder on a patient’s skin

iii. Burns

iv. Itching

v. Irritation

vi. Redness of the skin in light-skinned individuals

vii. Typical odors of the substance

d. Emergency care

i. Avoid contaminating yourself or others.

ii. Remove the irritating or corrosive substance from the patient as rapidly as possible.

iii. Remove all clothing that has been contaminated.

iv. Dust off any dry chemicals.

v. Flush skin with running water.

vi. Wash with soap and water.

vii. When a large amount of material has been spilled, flood the affected part for at least 20 minutes.

viii. If the patient has a chemical agent in the eyes

• Irrigate them quickly and thoroughly

• At least 5 to 10 minutes for acid substance

• 15 to 20 minutes for alkalis

• Make sure that the fluid runs from the bridge of the nose outward.

ix. Many chemical burns occur in industrial settings

• Showers and specific protocols are available.

• Wash the substance off immediately with lots of water.

x. The only time you should not irrigate the contact area with water is when the poison reacts violently with water.

• Phosphorus or elemental sodium ignite when they come into contact with water.

• Brush the chemical off.

• Remove contaminated clothing.

• Apply a dry dressing.

• Wear gloves and the proper protective clothing.

• Provide prompt transport.

8. Emergency care Note: Identify local protocols for administration of activated charcoal.

a. External decontamination is important.

b. Treatment focuses on support: assessing and maintaining the ABCs.

A. Specific Poisons

1. Developing a tolerance or an addiction to a substance

a. Tolerance: When, over time, a person who routinely misuses a substance needs increasing amounts of it to achieve the same result

b. Addiction: Someone with an addiction has an overwhelming desire or need to continue using the agent.

i. Increasing tolerance can lead to addiction.

ii. In addition to classic drugs of abuse, such as cocaine, almost any substance can be abused.

• Laxatives

• Nasal decongestants

• Vitamins

• Food

c. Known drug abusers have a fairly high incidence of serious and undiagnosed infections, including AIDS and hepatitis.

d. Always be sure to wear appropriate protective equipment.

2. Alcohol

a. It is the most commonly abused drug in the United States.

i. Affects people from all walks of life

ii. Kills more than 200,000 each year

iii. More than 50% of all traffic fatalities or injuries, 67% of murders, and 33% of suicides are related to alcohol.

b. Characteristics and effects of alcoholism

i. Alcohol is a powerful CNS depressant.

• It is a sedative, a substance that decreases activity and excitement

• It is also a hypnotic, which induces sleep.

ii. A person who appears intoxicated may have other medical problems, as well.

• Look for signs of head trauma, toxic reactions, or uncontrolled diabetes.

• Severe acute alcohol ingestion may cause hypoglycemia.

c. Actions

i. Assume that all intoxicated patients are experiencing a drug overdose and require examination by a physician.

ii. Provide respiratory support for patients who exhibit signs of serious CNS depression.

• Depression of the respiratory system can cause emesis, or vomiting.

• May be very forceful or even bloody (hematemesis), since large amounts of alcohol irritate the stomach.

d. A patient in alcohol withdrawal may experience frightening hallucinations or delirium tremens (DTs).

i. Characteristics of the DT syndrome

• Agitation and restlessness

• Fever

• Sweating

• Confusion and/or disorientation

• Delusions and/or hallucinations

• Seizures

ii. DTs may develop 1 to 7 days after a person stops drinking or when consumption levels are decreased suddenly.

iii. A person who is experiencing hallucinations or DTs is extremely ill.

• Provide prompt transport.

• Should seizures develop, treat them as you would any other seizure.

• Give oxygen.

• Watch for vomiting.

iv. These patients may not respond appropriately to suggestions or conversation.

v. Your approach should be calm and relaxed.

3. Opioids

a. The pain relievers called opioid analgesics are named for the opium in poppy seeds, the origin of heroin, codeine, and morphine.

b. Most of these drugs have legitimate medical uses.

i. Codeine

ii. Morphine

iii. Synthetic opioids

• Meperidine (Demerol)

• Hydromorphone (Dilaudid)

• Propoxypyhene (Darvon)

• Oxycodone (Percocet, Oxycontin)

• Hydrocodone (Vicodin)

• Methadone

iv. Exception is heroin, which is illegal

c. Many addicts may have started using opioids with an appropriate medical prescription.

d. These agents are CNS depressants and can cause severe respiratory depression.

e. Administered intravenously, they produce a characteristic “high” or “kick.”

f. Tolerance to these drugs develops rapidly.

g. Emergency medical problems are caused by respiratory depression.

h. Patients typically appear sedated, cyanotic, and have pinpoint pupils.

i. Treatment

i. Support the airway and breathing.

ii. You may try to arouse patients by talking loudly or shaking them gently.

iii. Always give supplemental oxygen.

iv. Be prepared for vomiting.

v. Only effective antidotes are certain narcotic antagonists such as naloxone (Narcan), which is usually administered by paramedics or in the emergency department.

4. Sedative-hypnotic drugs

a. Barbiturates and benzodiazepines have been a part of legitimate medicine for a long time.

i. These drugs are CNS depressants and alter level of consciousness.

ii. Effects similar to those of alcohol

iii. The patient may appear drowsy, peaceful, or intoxicated.

b. Possible situations

i. Less likely to treat an acute overdose in someone who chronically abuses these drugs

ii. More likely to be called to a scene of an attempted suicide in which the patient has taken large quantities of these drugs

iii. These patients will have marked respiratory depression and may even be in a coma.

iv. Sedative-hypnotic drugs may also be given to people unknowingly as a “knock-out” drink, or “Mickey Finn.”

v. Drugs such as Rohypnol have been abused as a “date rape drug.”

c. Emergency care

i. General treatment is to provide airway clearance, ventilatory assistance, and prompt transport.

ii. As multi-drug use becomes more common, you may find it increasingly difficult to determine what agents the patients have taken.

• Treat any obvious injuries or illnesses.

• Keep in mind that drug use may complicate the picture and make full life support necessary.

• Focus on the following:

• ABCs, especially the possibility of airway problems

• Dealing with vomiting

• Handling respiratory depression

• Being prepared for cardiac arrest

5. Abused inhalants

a. Many abused inhalants produce several of the same CNS effects as other sedative-hypnotics.

b. Some common agents found in glues, cleaning compounds, paint thinners, and lacquers

i. Acetone

ii. Toluene

iii. Xylene

iv. Hexane

c. Gasoline and various halogenated hydrocarbons, such as Freon, used as propellants in aerosol sprays

d. None of these inhalants is a medication.

e. Teenagers seeking an alcohol-like high commonly abuse them.

f. Effects

i. Effects range from mild drowsiness to coma

ii. May often cause seizures

iii. Halogenated hydrocarbon solvents can make the heart supersensitive to the patient’s own adrenaline.

iv. Patient is at high risk for sudden cardiac death.

v. Even the action of walking may release enough adrenaline to cause a fatal ventricular arrhythmia.

g. Emergency care

i. Use special care in dealing with patients who may have used inhalants.

ii. Try to keep such patients from struggling or exerting themselves.

iii. Give supplemental oxygen, and use a stretcher to move patients.

iv. Prompt transport is essential.

v. Monitor vital signs en route.

6. Sympathomimetics

a. CNS stimulants (“uppers”)

i. Agents that produce an excited state

ii. Frequently cause hypertension, tachycardia, and dilated pupils

b. Effects

i. Users of these agents may display disorganized behavior, restlessness, and sometimes anxiety or great fear.

ii. Paranoia and delusions are common with sympathomimetic abuse.

c. Amphetamine and methamphetamine (“ice”)

i. Commonly taken by mouth

ii. Also injected in many cases

iii. Typically taken to make the user “feel good,” improve task performance, suppress appetite, or prevent sleepiness

d. Cocaine

i. Classically inhaled into the nose and absorbed through the nasal mucosa

ii. Damages tissues, causes nosebleeds, and ultimately destroys the nasal septum

iii. Also injected intravenously or subcutaneously (skin-popping)

iv. Another method of abusing cocaine is by smoking it.

• Crack is pure cocaine and is easily smoked.

• Smoked crack produces the most potent effect.

v. One of the most addicting substances known

vi. Acute cocaine overdose is a genuine emergency.

vii. Patients are at high risk for seizures and cardiac arrhythmias.

e. Care for patients who have been poisoned with any sympathomimetic

i. Be aware that severe agitation can lead to tachycardia and hypertension.

ii. Patients may also be paranoid, putting you and other health care providers in danger.

iii. Law enforcement officers should be at the scene to restrain the patient, if necessary.

iv. Do not leave the patient unattended and unmonitored during transport.

v. All of these patients need to get to the emergency department promptly.

vi. Give supplemental oxygen and be ready to provide suctioning.

7. Marijuana

a. An estimated 20 million people use marijuana daily in the United States.

b. Effects

i. Inhaling produces euphoria, relaxation, and drowsiness.

ii. Impairs short-term memory and the capacity to do complex thinking and work

iii. In some people, euphoria progresses to depression and confusion.

iv. Altered perception of time is common.

v. Anxiety and panic can occur.

vi. With very high doses, patients experience hallucinations.

c. A person who has been using marijuana rarely needs transport.

d. Exceptions may include someone who is hallucinating, very anxious, or paranoid.

e. Marijuana is often used as a vehicle to get other drugs into the body, (ie, it can be covered with PCP or crack).

8. Hallucinogens

a. Hallucinogens alter an individual’s sense of perception.

b. Classic hallucinogen is lysergic acid diethylamide (LSD).

c. PCP (“angel dust”) is a dissociative anesthetic that is dangerous, causing severe behavioral changes.

d. Effects

i. Visual hallucinations

ii. Intensified vision and hearing

iii. Users feel separated from reality.

iv. Altered sensory state is not always pleasurable, can be terrifying or a “bad trip.”

v. Patient will usually be hypertensive, tachycardic, anxious, and probably paranoid.

e. Emergency medical care

i. Use same care as for a patient on a sympathomimetic.

ii. Use a calm, professional manner.

iii. Provide emotional support.

iv. Do not use restraints unless you or the patient is in danger of injury and then always within the guidelines.

v. Watch the patient carefully during transport.

vi. Never leave a patient unattended and unmonitored.

9. Anticholinergic agents

a. The classic picture of too much anticholinergic medication is “hot as a hare, blind as a bat, dry as a bone, red as a beet, and mad as a hatter.”

b. These drugs block the parasympathetic nerves.

c. Common medications

i. Atropine

ii. Diphenhydramine (Benadryl)

iii. Jimsonweed

iv. Certain tricyclic antidepressants

d. Overdoses

i. With the exception of jimsonweed, these medications usually are not abused drugs but may be taken as an intentional overdose.

ii. Often difficult to distinguish between an anticholinergic overdose and a sympathomimetic overdose.

iii. In both, patients may be agitated and tachycardic and have dilated pupils.

10. Cholinergic agents

a. Examples

i. “Nerve gases” designed for chemical warfare

ii. Organophosphate insecticides

iii. Certain wild mushrooms

b. Effects

i. Overstimulate normal body functions that are controlled by parasympathetic nerves

• Salivation

• Mucous secretion

• Urination

• Crying

• Heart rate

c. Signs and symptoms of cholinergic drug poisoning are easy to remember by two mnemonic devices.

i. DUMBELS

• Defecation

• Urination

• Miosis (contraction of the pupils)

• Bronchorrhea (discharge of mucus from the lungs)

• Emesis

• Lacrimation (tearing)

• Salivation

ii. Alternatively, use SLUDGE

• Salivation

• Lacrimation

• Urination

• Defecation

• GI irritation

• Eye constriction

iii. In addition, patients may have either bradycardia or tachycardia.

d. Emergency medical care

i. Most important consideration is to avoid exposure yourself.

ii. Field decontamination may take priority over immediate transport.

iii. Priority after decontamination is to decrease the secretions in the mouth and trachea.

iv. Provide airway support.

v. Depending on local protocol, this can be treated as a HazMat situation.

11. Miscellaneous drugs

a. Aspirin

i. Aspirin poisoning remains a potentially lethal condition.

ii. Effects

• Nausea

• Vomiting

• Hyperventilation

• Ringing in the ears

• Patients are frequently anxious, confused, tachypneic, and in danger of having seizures.

• Patients should be transported quickly.

b. Acetaminophen

i. Acetaminophen is generally not very toxic.

ii. Overdosing with acetaminophen is very common.

• Symptoms of an overdose generally do not appear until it is too late.

• Liver failure may not be apparent for a full week.

iii. Patients may not provide the information necessary for a correct diagnosis.

iv. Gathering information at the scene is very important.

c. Methyl alcohol and ethylene glycol

i. Some alcohols, including methyl alcohol and ethylene glycol, are even more toxic than ethyl alcohol (drinking alcohol).

• Methyl alcohol is found in dry gas products and Sterno.

• Ethylene glycol is found in some antifreeze products.

ii. People at risk

• Chronic alcoholics who are unable to obtain drinking alcohol

• More often taken by someone attempting suicide

• Even ethyl alcohol—typical drinking alcohol—can stop a patient’s breathing if taken in too high a dose or too fast, particularly in children.

iii. Effects

• Both cause a “drunken” feeling.

• If left untreated, both can cause:

• Severe tachypnea

• Blindness (methyl alcohol)

• Renal failure (ethylene glycol)

• Eventually death

• Immediate transport is essential.

B. Food Poisoning

1. Almost always caused by eating food that is contaminated by bacteria, even though food may appear perfectly good, with little or no decay or odor to suggest danger.

2. Two main types of food poisoning

a. An organism, itself, causes disease.

i. Salmonella bacterium is one organism that produces direct effects.

ii. Symptoms of salmonellosis

• Severe gastrointestinal symptoms within 72 hours of ingestion

• Nausea

• Vomiting

• Abdominal pain

• Diarrhea

iii. Some people are carriers of certain bacteria.

• May transmit diseases, particularly if they work in food services.

• Prevention

• Usually, proper cooking kills bacteria.

• Proper cleanliness in the kitchen prevents the contamination of uncooked foods.

3. More common cause of food poisoning is the ingestion of powerful toxins produced by bacteria, often in leftovers, that cause disease.

a. Toxin: Poison or harmful substance produced by bacteria, animals, or plants.

b. The bacterium Staphylococcus is quick to grow and produce toxins in foods that have been kept too long.

c. Foods prepared with mayonnaise, when left unrefrigerated, are a common vehicle.

d. Staphylococcal food poisoning typically results in sudden gastrointestinal symptoms

i. Nausea

ii. Vomiting

iii. Diarrhea

e. Symptoms may start within 2 to 3 hours after ingestion or as long as 8 to 12 hours after ingestion.

f. The most severe form of toxin ingestion is botulism.

i. Often-fatal disease usually results from eating improperly canned food.

ii. The spores of Clostridium bacteria grow and produce a toxin.

iii. Symptoms may develop as long as 4 days after ingestion or as early as the first 24 hours.

g. Emergency medical care

i. In general, do not try to determine the specific cause of acute gastrointestinal problems.

ii. Gather as much history as possible.

iii. Transport promptly.

iv. If two or more persons have the same illness, bring some of the suspected food if possible.

C. Plant poisoning

1. Several thousand cases of poisoning from plants occur each year, some severe.

2. Many household plants are poisonous if ingested.

3. Effects

a. Local irritation of the skin

b. Effects on circulatory system, gastrointestinal tract, and the central nervous system

4. Emergency care

a. Assess the patient’s airway and vital signs.

b. Notify the regional poison center.

c. Take the plant to the emergency department.

d. Provide prompt transport.

5. Problem with diffenbachia, which resembles “elephant ears”

a. Irritates skin and/or mucous membranes

b. Chewing a single leaf may irritate the lining of the upper airway enough to cause difficulty in swallowing, breathing, and speaking.

c. In rare circumstances, the airway may be completely obstructed.

d. Emergency care

i. Maintain an open airway.

ii. Give oxygen.

iii. Transport the patient as promptly as possible.

iv. Continue to assess for airway difficulties throughout transport.

CHAPTER SWEEP

Assessment in Action

This activity is designed to assist the student in gaining a further understanding of issues surrounding the patient with acute abdominal pain, diabetes, allergic reactions and envenomations, and substance abuse and poisoning. The activity incorporates both critical thinking and application of basic OEC knowledge.

Scenario

Two college students have driven to your local ski are for Christmas break and are staying in an RV in the parking lot. John went in early for lunch, and Bob kept skiing, returning to the RV about an hour later. When he entered the RV, he found John lying on the bed, unconscious and unresponsive. He immediately ran to the patrol office for help. When you arrive you find a 20-year-old male dressed in ski gear. The patient appears very pale, and is unresponsive to ant stimuli. He is breathing quickly with no apparent airway problems.

Answers to Multiple-Choice Questions

1. D

2. C

3. B

4. B

5. A

Challenging Questions Answers

6. Stroke, intoxication, head injury, dementia.

7. There may be an insufficient amount of glucose to supply the brain resulting in unconsciousness and permanent brain damage. Also, insulin shock develops much more quickly than diabetic coma.

Points to Ponder

This activity will allow you to help your students probe the more difficult situations that they face. Use this as an opportunity to allow them to express differences of opinion and approach, while directing them to be thorough and decisive in their answers. Encourage challenges.

Scenario

You are enjoying a day off by going for a hike. You are about two hours away from where you started when you come across a woman who asks you if you can help her. You find out that her friend is a short distance off of a trail and is having trouble breathing. She tells you that he is “allergic to bee stings” And has been stung. When you find the friend, he is unresponsive, barey breathing and is showing signs of anaphylactic shock. You quickly check his pockets and find his “Epi kit.” Would you administer the EpiPen? If you are off-duty, are you functioning as a rescuer? Could the woman give you permission to give the injection? Is administration of epinephrine covered under Good Samaritan laws?

Issues

• Provision of care

• Consent

• Local/State regulations

• Good Samaritan Laws

• Invasive procedures

1. Would you administer the EpiPen?

• If the local protocol of the area provides for the administration of an EpiPen, you could administer the EpiPen.

• Otherwise, you could call medical control, give them your training background, and follow their instructions.

• It becomes a personal risk decision in which one must weigh the legal implications and possible risks versus the life-threatening nature of the anaphylactic shock.

2. If you are off-duty, are you functioning as a rescuer?

• If you offer assistance, you assume the role of a rescuer and may have a duty to act until the patient is transferred to other similarly trained EMS providers.

3. Could the woman give you permission to give the injection?

• Unless the woman is the legal guardian, she cannot authorize a consent to treat.

4. Is administration of epinephrine covered under Good Samaritan laws?

• You would need to research and know the Good Samaritan laws of the area where you are providing rescue services.

Online Outlook

This activity requires students to have access to the Internet. This may be accomplished through personal access, employer access, or through a local educational institution. Some community colleges, universities, or adult education centers may have classrooms with Internet capability that will allow for this activity to be completed in class. Check out local access points and encourage students to complete this activity as part of their ongoing reinforcement of basic OEC knowledge and skills.

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