the last roundup

1. ROUNDS JUNE 2016
The Last Roundup
This presentation may be found at
AndrewGeller@weebly.com

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

3. TOXICOLOGY CONTD
• In Alberta they confiscated pills last August
that were labelled as Oxycontin , but were in
fact W18. These designer opioids are being
synthesized in China and smuggled into the
US. In March a man was arrested with
Fentanyl and 2.5 pounds of W18 .
• If a patient has a narcotic toxidrome and
cannot be reversed with Narcan we can
suspect one of these designer narcotics.

4. More Toxicology
• Kratom is an herb that is sold over the counter
and may be found on the internet. It has a
number of active ingredients , alkaloids. Both
have a high affinity for the opioid Mu receptors
and are more potent than morphine!
• Traditionally local residents in Southeast Asia
chew the leaves to relieve fatigue, muscle aches
and to increase sociability. This is similar to coca
leaves in South America and khat in Africa.

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

6. OPIOID INDUCED HYPERALGESIA
• This phenomenon is seen in patients who take
chronic narcotics and require massive doses of
narcotics to control their pain.
• “This is a state of increased baseline pain that
is caused by exposure to opioids”, according to
James Roberts in Emergency Medicine News
in March.

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

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

9. Toxicology, Narcotic Deaths
• 1379 people died of narcotic overdoses in
2015 in Massachusetts, and EMS treated
11,884 overdoses in 2015. Men were
1048/1379 and over half were 25-44.
• Over half of the deaths had fentanyl in their
bloodstream according to the DPH in
Massachusetts in 2015.

10. Benzodiazepines
• Benzodiazepine overdoses have soared as well
with fatal overdoses more than quadrupling
over the last 20 years
• Xanax ,Valium , Ativan, Versed, Klonopin ,
Serax , Restoril and Librium [alprazolam
,diazepam , lorazepam , midazolam ,
clonazepam ,oxazepam , temazepam , and
chlordiazepoxide

11. Benzos cont’d
• The biggest problem with their use is falls in
the elderly.
• Isolated overdoses of benzodiazepines are
rarely fatal. When combined with ETOH or
other drugs, fatalities are more frequently
seen.

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

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

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

15. Oxygen and STEMIs
• AVOID Trial For every 100 liters of O2
exposure there is a 1.2- 1.4 % increase in the
size of the MI!
• Remember with chest pain and an O2 sat >
94 % [unless the patient is clearly having
trouble breathing ] do not give the patient O2

16. Boston and CVA’s
• The city is starting a study to see if they can
pick out which patients should go to centers
that offer neurosurgical care for patients that
can benefit from it. These would include
subarachnoid hemorrhages, subdural
hematomas, large vessel ischemic CVAs within
6 hours.
• The Dispatch will be refined and the medics
on scene will use CSTAT

17. More On CVAs
• Determine last known well
• Use the Massachusetts CVA Scale to determine if
the patient needs possible embolectomy or
neurosurgical procedure
• Facial droop 0/1
• Arm drift 0/1
• and speech garbled 0/1
• If the Stroke scale is >0 then a CSTAT needs to be
performed

18. CVAs Cont’d
• CSTAT
• Gaze 0/2
• Weakness arm or leg0/1
• Follow Commands 0/1
• If the CSTAT score is >2 the patient will be triaged
to a hospital that offers acute neurosurgical
intervention, including embolectomy, if the
Comprehensive Stroke Center is less than 30
minutes farther than the primary Stroke Center

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

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

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

22. Ketamine
• We will be adding Ketamine to the STP in
January.
• Ketamine is a drug that is a derivative of PCP,
phencyclidine! It is rapidly broken down and
metabolized in the liver . It stimulates the
cardiovascular system and raises BP and heart
rate.

23. More on Ketamine
• In many ways it is an ideal drug for prehospital
care. It does not lower BP and does not cause
a patient to lose their airway reflexes. They
don’t get so drowsy that they stop breathing
and die.
• It is on the WHO list of essential medications.
It is also used extensively by the military in the
battlefield. It is reasonably safe.

24. Still more
• It acts on the NDMA receptors, but also acts on
the opiate receptors to relieve pain , without the
side effects we all fear. [decreased BP and severe
sedation]. It is a great pain reliever.
• It can be given IM, IV , IN and PO. Onset is within
1 minute when given IV.
• It has a great safety profile and even when an
overdose is administered there is little likelihood
of adverse outcomes.

25. What is the downside ?
• It may raise intraocular pressure and may be an issue
for glaucoma patients [and maybe not]. It may raise
intracranial pressure , but again it may not. So there is
a warning about head injuries. It may be a problem
with severe hypertension, but if the BP elevation is due
to pain the BP will likely fall with the relief of pain.
• The major issue is the possibility of an “emergence
reaction” Nightmares, hallucinations and
psychotomimetic effects.
• It is an addictive drug. It is a schedule III drug. To add it
we will have to get approval from the narcotics division
at the state. It has already been added in Worcester.

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

27. Ketamine for Excited Delirium
• Rapid Onset 1-3 minutes IM.
• 10 % get a postadministration emergence
phenomenon, often mild and “easily treated with low
dose midazolam” [Roberts, James 12/15 Emergency
Medicine News]. Following the use of the drug the
patient cannot be evaluated by psychiatry for 8 hours,
use it selectively.
• Short duration, it wears off in 30-40 minutes.
• Ketamine “appears to be an ideal drug for the patient
who presents in an uncontrollable and violent
state…Quelling undiffentiated excited delirium in a
patient without a history or even vital signs is a huge
plus”

28. Are Narcotics Created Equal?
• The key is histamine release. Histamine release
results in urticaria , itching , wheezing, cough ,
sloing gastric emptying and resultant nausea and
vomiting , vasodilation and hypotension .
• The release is different for different narcotics.
Morphine releases a bunch hence its former use
for pulmonary edema [with venodilation]
Mortality is increased with CHF and MI with
morphine , hence we no longer use it.

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

30. IOM and Cardiac Arrest
• Three Interventions to improve survival
• 1. Measurement : we cannot improve what
we do not measure . Join CARES
• 2. Encourage Bystander CPR , get the 911
centers to track data on arrests and get them
our prehospital follow up data.
• 3.Foster High Performance CPR . Measure
the CPR quality : rate, pauses, depth of
compressions

31. CASES
• 1. 71 y/o cardiac arrest
lessons… short down time, need for police
intervention, get the patient on the floor, PEA
protocol 2015
2.ESRD and SOB, CONTEXT IS ALL
3. and 4. 23 y/o with chest pain and BP 116/61,
55 y/o chest pain and a 50 mm drop in BP after
NTG

32. MORE CASES
• 5. 76 y/o woman with Sob and a low Sat, no
EKG
• 6. 94 y/o chest pain, N, and Vomiting. O2 sat
78-86 % , also repeat VS after NTG
• 7. 65 y/o cardiac arrest no CCR

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