Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Lecture presentation amls_lesson10_toxicology
Similar to Lecture presentation amls_lesson10_toxicology (20)
Recently uploaded
Recently uploaded (20)
Lecture presentation amls_lesson10_toxicology
- 1. Chapter 10 Toxicology, Hazardous Materials, and WMD
- 2. Objectives ⢠Review basic pathophysiology associated with toxidromes. ⢠Discuss early recognition and management of hazardous environments. ⢠Describe how to rapidly recognize, diagnose, and manage common toxicologic emergencies using the AMLS Assessment Pathway. ⢠Review case studies and identify toxidromes.
- 3. Toxic Terms ⢠Toxicology ⢠The study of the adverse effects of chemicals on living organisms, especially the poisoning of people ⢠Toxidrome ⢠Collection of signs and symptoms resulting from a given poison ⢠A syndrome caused by a dangerous level of toxins in the body, often the consequence of a drug overdose, whether intentional or unintentional
- 4. Major Toxidromes ⢠Simulant/sympathomimetic ⢠Narcotic (Opioid) ⢠Sedative/hypnotics ⢠Cholinergic ⢠Anticholinergic
- 5. Toxidromes ⢠Physical exam ⢠Vitals signs ⢠Skin color/temperature/moisture ⢠Eye exam ⢠Neurologic exam
- 6. Autonomic Nervous System ⢠Sympathetic (SNS) ⢠âFight or flightâ nervous system ⢠Adrenergicâadrenalin ⢠Alpha/beta receptors ⢠Parasympathetic (PSNS) ⢠âRest and digestâ nervous system ⢠Cholinergicâacetylcholine ⢠Muscarinic/nicotinic receptors
- 7. Initial Approach for a Hazardous Scene ⢠Scene and crew safety? ⢠Is this a hazardous incident? WMD? ⢠Number of patients? ⢠Do we have enough and the right resources? ⢠Any need for special PPE? ⢠Is the patient sick or not sick? ⢠Your general impression Š Dave Navarro Jr/Shutterstock.
- 8. Weapons of Mass Destruction ⢠WMD exposures can present as toxidromes. ⢠Consider the number of patients. ⢠Consider the nature and location of the incident. ⢠May require access to large cache of antidote for peer and self-rescue.
- 9. Case 1 ⢠Dispatch ⢠You are dispatched to a local hotel for a male who has barricaded himself in his room and destroying everything in there. ⢠Screaming and wailing as well as lot of commotion are coming from within the room. ⢠Law enforcement is on scene and attempts to communicate with the male through the door are unsuccessful. ⢠It is unknown if he is alone. What are your concerns as you respond to this call?
- 11. Initial Observations ⢠Scene safety considerations ď§ Is the scene safe?
- 12. Initial Observations ⢠Law enforcement is let into the room by management and a scuffle ensues with all involved ending up in a pile on the floor. ⢠A very anxious male is screaming and wailing incoherently. ⢠Patient is eventually restrained but continues to struggle
- 13. Initial Observations ⢠Cardinal presentation ⢠Excited delirium ⢠Chief complaint ⢠Unable to verbalize except through screaming Š Barcroft Media/Getty.
- 14. Initial Observations ⢠Primary Survey ⢠Level of Consciousness (LOC)â Awake, eyes glazed over, and disoriented. ⢠Airwayâ Patent. ⢠BreathingâRapid, labored, unable to obtain breath sounds during restraint. ⢠Circulation/PerfusionâSkin is flushed, hot, and moist; once restrained pulse is rapid and bounding.
- 15. First Impression ⢠Do you identify any life threats? ⢠Is the patient sick/not sick?
- 16. First Impression ⢠What are your initial differential diagnoses? ⢠Which do you think are most likely? More Likely Less Likely
- 17. First Impression Anxiety Behavioral emergency Pulmonary embolus Seizure Mass effect Pseudotumor CVA - Stroke Hypoglycemia Toxins/drugs Excited delirium
- 18. Detailed Assessment ⢠History Taking ⢠OPQRST ⢠OâCame on suddenly and reported by guests in adjoining rooms. ⢠Pâ Establishing contact seems to make it worse. ⢠QâN/A ⢠Râ N/A ⢠Sâ N/A ⢠Tâ 30 minutes ago
- 19. Detailed Assessment ⢠History Taking, continued ⢠SAMPLER ⢠SâExtremely anxious male, awake, tachypnea, increased work of breathing, screaming, and out of control. ⢠AâUnknown. ⢠M â Unknown but a variety of brightly colored pills and a crystalline substance resembling sea salt found on the desk in the room. ⢠PâUnknown. ⢠Lâ Unknown; empty candy wrappers and sweet energy drinks on floor. ⢠Eâ Neighboring guests heard an outburst of screaming and items crashing against the wall; the manager was called, who then called law enforcement, who determined only one person was in the room ⢠RâHistory of drug abuse and psychiatric problems known to law enforcement.
- 20. 160 99 % N/A 28 210/114 Secondary Survey ⢠Vital Signs 103.9° F (39.9°C) ECGfrom:Introductionto12-LeadECG:TheArtofInterpretation, SecondEdition,courtesyofTomasB.Garcia,MD. Detailed Assessment
- 21. Detailed Assessment Pupils dilated and slow to respond Rapid heart rate; lungs are clear Abdomen soft, nontender Warm, flushed, sweaty; no pedal edema noted; moves well No pedal edema noted; moves well Responds to name; unable to assess for stroke; circulation intact
- 22. Detailed Assessmentâ Diagnostics BLS ALS Critical Care Blood glucose level ⢠72 mg/dL (4 mmol/L) Cardiac monitoring ⢠Sinus tachycardia 150s ⢠12-lead ECG â tachycardia with no acute changes Urinalysis Rapid troponin Lactate level Toxicology drug screen Angiogram
- 24. Refine the Differential Diagnosis Anxiety Behavioral emergency Pulmonary embolus Seizure Mass effect Pseudotumor CVA - Stroke Hypoglycemia Toxins/drugs Excited delirium
- 25. Treatment ⢠BLS ⢠Position of comfort. ⢠Physical restraints. ⢠Cool the patient. ⢠ALS ⢠IV fluids. ⢠Chemical restraint â benzodiazepines. ⢠Critical Care ⢠Further medications to deter the delirium.
- 26. Ongoing Management ⢠Reassess the patient ⢠Further refine the possible diagnoses ⢠Modify treatment as necessary
- 27. Case Wrap-up ⢠Diagnosis: ⢠Sympathomimetic toxidrome ⢠Based on substances found in the room possibly Ecstasy and Flakka CourtesyofDEA. CourtesyofDEA.
- 28. Sympathomimetic Toxidrome ⢠Mimics the effects of the Sympathetic Nervous System (SNS) ⢠âFlight-or-fightâ response ⢠Adrenalin release ⢠AlphaâBeta adrenergic receptor stimulation
- 29. Sympathomimetic Toxidrome ⢠Tachycardia ⢠Arrhythmias ⢠Hypertension ⢠CNS excitement ⢠Tremors, hyper-reflexia ⢠Hyperthermia ⢠Mydriasis (dilated pupils) ⢠Diaphoresis
- 30. Sympathomimetics ⢠Cocaine ⢠MDMA (Ecstasy, Molly) ⢠Amphetamines, methamphetamine ⢠Cathinones (Bath Salts / Flakka) ⢠Phencyclidine (PCPâangel dust) ⢠Theophylline ⢠Decongestants (ephedrine, pseudoephedrine, phenylpropanolamineâPPA) ⢠Nicotine/caffeine
- 31. Case Closure ⢠Patient is transferred to the ED for further care and counseling on the dangers of sympathomimetic drug use. ⢠He is admitted for detox and drug rehabilitation.
- 32. Further Discussion ⢠Using the AMLS assessment pathway should enable you to quickly identify life threats that should be managed when found. ⢠Obtaining a thorough history and conducting a physical exam will identify differential diagnoses that will drive your treatment based on your scope of practice. ⢠Failure to recognize the sympathomimetic toxidrome in this case would be detrimental
- 33. Case 2 ⢠A female patient presents to the ED holding her abdomen and complains of feeling ill. She states she thinks she has food poisoning and tells you she is pregnant.
- 35. Initial Observations ⢠Scene safety considerations ď§ Is the scene safe?
- 36. Initial Observations ⢠A pregnant female feeling ill. ⢠She wretches at times but brings nothing up. ⢠Looks pale and diaphoretic. What are your initial concerns for this patient? ŠWestend61/Shutterstock.
- 37. Initial Observations ⢠Cardinal presentation ⢠Pregnant female wretching. ⢠Chief complaint ⢠Wretching and abdominal cramping. ⢠Patient thinks she has food poisoning.
- 38. Initial Observations ⢠Primary Survey ⢠LOCâ Awake but confused to time. ⢠Airwayâ Patent. ⢠BreathingâRapid and lungs are clear. ⢠Circulation/Perfusion ⢠Distal pulses are rapid and weak. ⢠Skin is pale, warm, and moist to touch.
- 39. First Impression ⢠Do you identify any life threats? ⢠Is the patient sick/not sick?
- 40. First Impression ⢠What are your initial differential diagnoses? ⢠Which do you think are most likely? More Likely Less Likely
- 41. First Impression Influenza Food poisoning Labor UTI PID Cholecystitis Endometritis Drug ingestion Toxic inhalation Cardiomyopathy Diabetes PE Eclampsia/pre- eclampsia HELLP Abruptio placenta Head injury Brain tumor
- 42. Detailed Assessment ⢠History Taking ⢠OâWhile doing her laundry at the laundromat. ⢠Pâ Seems a little better since coming to hospital. ⢠QâSudden flu-like feeling; mild abdominal cramping. ⢠Râ N/A. ⢠Sâ Pain is rated as 4 to 5 on a scale of 1 to 10; not as sick as she was in her first trimester with morning sickness. ⢠Tâ About 1 ½ hours now.
- 43. Detailed Assessment ⢠History Taking, continued ⢠SâSudden flu-like symptoms, headache, blurred vision, confusion, wretching, abdominal cramping. ⢠AâNKDA. ⢠M â Prenatal vitamins and fluoxetine (Prozac); denies recreational drug use. ⢠PâPara 1, gravida 2 at 32 weeks of gestation. ⢠LâVending machine sandwich about an hour ago. ⢠Eâ At the laundromat the last few hours doing laundry. ⢠RâPregnancy â eclampsia, HEELP, PE. ⢠C/O her head pounding, blurred vision, shortness of breath, and cramping in her abdomen.
- 44. Detailed Assessment 138 99% N/A 24 108/62 ECG: Figure 8-4, Introduction to 12-Lead ECG: The Art of Interpretation, 2nd ed Secondary Survey ⢠Vital Signs 98.6°F (32°C) ECGfrom:12-LeadECG:TheArtofInterpretation,SecondEdition, courtesyofTomasB.Garcia,MD.
- 45. Heart sounds normal; lungs are clear Abdomen distended, rigid, nontender, FHTs in 160s; quiet bowel sounds Warm, pale, sweaty; 1+ pedal edema; moves extremities well Warm, pale, sweaty; 1+ pedal edema; moves extremities well PEARL; excessive throat tissue CMS intact
- 46. Detailed Assessmentâ Diagnostics BLS ALS Critical Care Blood glucose level ⢠92 mg/dL (5.1 mmol/L) Cardiac monitoring ⢠Sinus Tachycardia 110s ⢠12-lead ECG â Normal ⢠CO-oximetry reading â 26% Abdominal ultrasound or fetal monitoring The SpO2 was 99% - what was the significance of the reading?
- 48. Refine the Differential Diagnoses Influenza Food poisoning Labor UTI PID Cholecystitis Endometritis Drug ingestion Toxic inhalation Cardiomyopathy Diabetes PE Eclampsia/pre- eclampsia HELLP Abruptio placenta Head injury Brain tumor
- 49. Treatment ⢠BLS ⢠Position of comfort. ⢠Oxygen. ⢠ALS ⢠IV/monitor/12-lead ECG. ⢠Critical care
- 50. Ongoing Management ⢠Reassess the patient ⢠Further refine the possible diagnoses ⢠Modify treatment as necessary
- 51. Characteristics of CO ⢠Limits oxygen transport ⢠Greater affinity (>210 x) for hemoglobin than oxygen. ⢠Inhibits oxygen transfer ⢠Interferes with normal unloading to tissues. ⢠Binds with myoglobin (muscle) ⢠Interferes with heart and skeletal muscle function.
- 52. Half-life of CO Bound to Hemoglobin ⢠Breathing room air ⢠4 to 6 hours. ⢠Breathing 100% oxygen ⢠40 to 90 minutes. ⢠100% oxygen in a hyperbaric chamber ⢠22 minutes. ⢠Indications for hyperbaric chamber ⢠CO >25%. ⢠Pregnancy with COHb >15%. ⢠Loss of consciousness, ECG changes, chest pain. ⢠pH <7.1.
- 53. Case Wrap-Up ⢠Diagnosis: ⢠Carbon monoxide (CO) poisoning from a leaky gas dryer in the laundromat.
- 54. Case Wrap-Up ⢠Patient was placed on high-flow O2 and her carboxyhemoglobin levels were monitored. ⢠The COHb levels quickly resolved to less than 5% with quick diagnosis and treatment. ⢠No evidence of fetal stress was determined. ⢠No need for hyberbaric oxygen chamber.
- 55. Further Discussion ⢠Using the AMLS assessment pathway should enable you to quickly identify life threats that should be managed when found. ⢠Obtaining a thorough history and conducting a physical exam will identify differential diagnoses that will drive your treatment based on your scope of practice. ⢠Failure to recognize the carbon monoxide poisoning in this case would have been detrimental. ⢠Fetal hemoglobin has a stronger affinity to CO than maternal and low levels in the mother could still be high in the fetus
Editor's Notes
- Discuss each learning objective and the importance of thoroughly understanding each one.
- With the knowledge of toxidromes you will be able to shorten the list of suspected drugs or chemicals that the patient may have taken. Describe how to rapidly recognize, diagnose, and manage common toxicologic emergencies, as well as alert you to possible complications and treatment options. It is important for students to memorize which drugs or chemicals are in each toxidrome. In addition, students need to know what signs and symptoms are consistent with a given toxidrome group.
- Instructor note: Remind the students that unfortunately more often than not they will be dealing with more than one toxin, especially in the case of an intentional exposure. Refer students to Table 10-6 in their textbooks for a listing of the signs and symptoms and drugs examples for each toxidrome.
- The physical exam will guide you in identifying a particular toxidrome. Vital signs are important because most toxins initially affect a patientâs vital signs. A baseline set of vitals may clue you into the type of toxidrome you are dealing with, and trending them will indicate patient improvement or deterioration. A complete set of vitals includes the skinâcolor/temperature/moisture, as well as pupil size and response to light and level of consciousness. Sympathomimetic/stimulant everything is up â vital signs include dilated pupils. Opioid/Sedative everything is depressed â vital signs include pinpoint pupils â a classic triad to look for in this toxidrome is depressed level of conscious, depressed respirations and pinpoint pupils. Cholinergic â everything is wet. Anticholinergic â everything is dry â classic presentation would be dry as a bone. Instructor note: Have students list examples of toxins that would elevate vital signs (sympathomimetics) or toxins that would decrease vital signs (opioids), toxins that would dry skin (anticholinergics) or toxins that would make skin very wet (cholinergics), or toxins that would cause pupils to be pinpoint (opioids or cholinergics) or toxins that would dilate pupils (sympathomimetic or anticholinergics). Other considerations: Timing of the ingestion or exposure Suspected dose or chemical The patient's access to the drug or chemical Situational information, such as the patient's position and location and the presence or absence of nearby drug paraphernalia Multiple patients with the same signs and symptoms
- Review the branches of the autonomic nervous system. A branch of the peripheral nervous system the autonomic nervous system includes the SNS and the PSNS. Adrenalin is the neurotransmitter for the sympathetic nervous system and when released stimulates alpha and beta receptors causing vasoconstriction/ vasodilation, pupil dilation, bronchial dilation, increase in rate and strength of heart beat, increased sweating Acetylcholine is the neurotransmitter for the parasympathetic nervous system and when released stimulates the muscarinic and nicotinic receptors causing âSLUDGEBBMâ or âDUMBBELLSâ and muscle fasciculations and paralysis. Note to instructor: Refer students to the Rapid Recall box on Mnemonics for Signs and Symptoms of Organophosphate and Carbamate Poisoning in the textbook on page 396.
- Initial Approach for Hazardous Scene Discuss the importance of each bullet beginning with scene safety. What is the scene telling you about the toxin or chemical? Are there multiple people with the same signs and symptoms, the presence of dead animals and birds, etc. This could be a hazardous scene requiring the decontamination of patients prior to treatment or transport. Are you trained to do decontamination? Do you have the necessary equipment?
- Initial approach for WMDs: The toxidrome most likely to be observed is the cholinergic toxidrome. Hundreds or thousands of people may have been exposed. Symptoms will vary depending on the nature of exposure or dose of agent. Many patients may present as worried but well. Even with large caches, antidote may be in short supply due to the large doses required.
- Note to instructor: Is the scene safe? What is the plan to gain access to the room and restrain your patient?
- Review the steps of the AMLS assessment pathway. Assessment is a dynamic process that occurs simultaneously. The key is to slow the provider down and move through each of these steps so as not to miss an important piece of information needed to develop a differential diagnosis.
- Initial impression begins when the dispatch information is received. When you arrive on scene, assess for safety threats and situational clues. Youâll be able to determine how well your initial impression agrees with your initial observations. Follow standard precautions. Use personal protective equipment to shield yourself from exposure to body fluids. At the scene, providers must ask themselves the following: Are the scene and crew safe? How many patients are involved? Do you have enough resources? Do you have the right resources? Is there any need for special personal protective equipment (PPE)? What is your general impression?
- Your patient is a very anxious male who is out of control.
- Instructor note: Differentiating cardinal presentation from chief complaint is important. The cardinal presentation is the patientâs medical problem â excited delirium. The chief complaint is what the patient complains of â patient is unable to verbalize except through screaming. For some patients, the cardinal presentation and chief complaint might be the same.
- Instructor note: Be certain to review the primary survey information with your students. Altered mental status is a concern because he is awake with disorientation. Pulse and respirations are rapid and respirations are labored, which may reflect an underlying medical problem or be the result of the struggle.
- There are no immediate life threats as his airway is patent, he is breathing although it is labored, and he does have a rapid pulse with no obvious bleeding you can see. The patient is sick. His altered mental status and erratic behavior as well as his increased rate work of breathing may lead to a life threat.
- Instructor note: Ask the students to generate a list of possible problems. Discuss from the list of differentials for screaming and out of control behavior and how you would categorize the different causes from more likely to less likely. Students may have lists that do match and/or lists that are shorter. Here are diagnoses to consider. Ask students to provide a rationale for each diagnosis that is shared. Discuss from the list of differentials for how you would categorize the different causes from more likely to less likely. Pulmonary embolus (hypoxia-induced altered mental status) Pseudotumor, mass effect, CVA, seizure, behavioral emergency, or brain bleed can initially cause anxiety and erratic behavior Low blood glucose can cause anxiety and erratic behavior Excited delirium Toxin and/or drug inhalation, ingestion, injection, absorption
- Instructor note: Students may debate how the conditions are categorized. Categories are not absolute and depend on the severity of the patient, which is not presented here. Keep an open mind with a broad differential at this initial stage. Take this opportunity to list all of the potential causes of the chief complaint/cardinal presentation. Later in the case you can narrow it down to a smaller number of causes that should still be of concern either due to their seriousness or their likelihood. Possible diagnoses include: Pulmonary embolus Pseudotumor Mass effect CVA Seizure Behavioral emergency, or brain bleed can initially cause anxiety and erratic behavior Low blood glucose levels can cause anxiety and irritability Excited delirium Toxin and/or drug inhalation, ingestion, injection, absorption
- Review history taking using the OPQRST mnemonic and what help if any help it has been in narrowing the list of differentials.
- Review the SAMPLER history taking and discuss if this new information has helped narrow down the list of differentials.
- Instructor note: Ask the students what the vital signs tell about the patient. Respirationsâ28 breaths/min Pulseâ160 beats/min Blood pressureâ210/114 mm Hg Pulse oximetryâ99% CO2âN/A Temperatureâ103.9°F (39.9°C) The patient is hypoxic and hypercapneic. The patient is in respiratory distress. Reassess the patient after treatment. Use standard languageâŚ. Note that all vital signs are elevated. The patient is tachycardic with bounding pulses, tachypneic with labored breathing, hypertensive, and febrile. Any idea of the toxidrome?
- HEENT: Head Unremarkable Eyes Pupils are dilated and slow to respond Ears Unremarkable Nose Unremarkable Throat Unremarkable Heart and Lungs: Heart sounds difficult to obtain with the rapid rate, lungs are clear to auscultation bilaterally Neuro: Unable to conduct a stroke assessment â patient noncompliant but moves all extremities well and very difficult to overcome to restrain. Responds to name in hotel register. Abdomen and Pelvis: Soft, nontender Upper and Lower Extremities: Warm, flushed, sweaty. No pedal edema, moves all extremities well.
- Instructor note: Discuss how these diagnostics support the differentials.
- 12-Lead ECG showing sinus tachycardia.
- Instructor Note: Discuss where participants would place him now. Use the âpenâ in PowerPoint to make comments or circle the potential differential. CVA-Stroke: likely, would need a head computed tomographic (CT) scan to rule out. Unable to obtain a stroke score. Hypoglycemia: unlikely, ruled out with bedside glucose reading of 72 mg/dL. Toxins/drugs: very likely; consistent with erratic behavior vital signs, drug paraphernalia, and past medical history indicating stimulant use. Excited delirium: very likely; consistent with erratic behavior, vital signs, drug paraphernalia, and past medical history indicating stimulant use. Pulmonary emboli: unlikely; inconsistent with pulse oximetry reading of 99% and absence of risk factors. Seizure: unlikely; nonconvulsive status epilepticus is possible; however, absence of postictal signs and incontinence or tongue biting. Mass effect/pseudotumor: unlikely, but requires CT for confirmation. Anxiety: unlikely as the only cause due to the severity of the symptoms. Behavioral emergency: very likely due to past medical history of drug abuse.
- The patient should be treated for excited delirium caused by a sympathomimetic toxidrome. Treatment possibilities: Position of comfort IV/monitor/12-lead ECG Reduce temperature Attempt to calm him down Benzodiazepines Antipsychotic medication (haldoperidol, geodon, ketamine)
- Instructor note: Group discussion can include how scopes of practice differ, which would require providers to think about their care based on their scope of practice.
- Instructor note: Sympathomimetic toxidrome is the most likely differential because all the patientâs vital signs are enhanced and he has risk factors for drug abuse. Ecstacy and Flakka are both powerful stimulants known as cathanones. A large dose may cause excited delirium, which can lead to death from a variety of reasons including metabolic acidosis, rhabdomyolysis, and acute coronary syndrome.
- Sympathomimetic Beta stimulation would account for the patientâs elevated heart rate and blood pressure, which are both dangerously high and could be causing some type of acute coronary syndrome.
- Instructor note: Review the classic signs and symptoms of sympathomimetic toxidrome Life threats could be arrhythmias, hyperthermia, and an acute coronary syndrome.
- Discuss and possibly research some of the more common street drugs in your area, including bath salts, flakka, and K2 (or spice).
- Patients required continued care for drug addiction.
- Review the points listed above.
- Case 2 involves a pregnant woman with flu-like symptoms. Instructor note: Although this is in a controlled setting (the ED) discuss with students the importance of screening for safety, which would include contagious diseases, hazardous substances, and weapons.
- Review the steps of the AMLS Assessment pathway. Assessment is a dynamic process that occurs simultaneously. The key is to slow the provider down and move through each of these steps so as not to miss an important piece of information needed to develop a differential diagnosis.
- Instructor note: Although this is in a controlled setting (the ED) discuss with students the importance of screening for safety, which would include contagious diseases, hazardous substances, and weapons.
- Instructor note: Discuss the following questions with students: What are your initial concerns about the patient being pale and diaphoretic? Is the patientâs wretching and nausea of concern?
- Instructor note: Differentiating cardinal presentation from chief complaint is important. The cardinal presentation is the patientâs medical problem â wretching. The chief complaint is what the patient complains of â wretching, abdominal cramping, and possible food poisoning. For some, the cardinal presentation and chief complaint might be the same.
- Instructor note: Students should be asked to differentiate between normal physiological changes of pregnancy (tachycardia and tachypnea) and potential medical problems such hypoxia or shock. The confusion is clearly abnormal and potential causes need to be explored. AirwayâHer airway is patent. BreathingâNote her breathing is rapid but her lungs sound clear. Circulation/PerfusionâHer skin is warm because of the heat generated from the increased work of breathing.
- There are no immediate life threats. Her airway is patent. But she has slight tachypnea and tachycardia and is mildly confused. Therefore she should be considered sick. Her altered mental status and erratic behavior as well as her increased rate work of breathing may lead to a life threat.
- Discuss from the list of differentials for shortness of breath how you would categorize the different causes. Instructor note: Students may have lists that do match and/or lists that are shorter. The patient could have the following problems. Influenza Food poisoning Labor Pre-eclampsia / eclampsia/HELLP Abruptio placenta Urinary tract infection Cholecystitis Endometritis/pelvic inflammatory disease Head injury Tumor Cardiomyopathy Pulmonary emboli Gestational diabetes Toxic inhalation Drug ingestion
- Instructor note: Students may debate how the conditions are categorized. Categories are not absolute and depend on the severity of the patient, which is not presented here. Keep an open mind with a broad differential at this initial stage. Take this opportunity to list all of the potential causes of the chief complaint/cardinal presentation. Later in the case you can narrow it down to a smaller number of causes that should still be of concern either due to their seriousness or their likelihood. Keep students focused on how this patient is presenting. Possible diagnoses include: Influenza Food poisoning Labor Pre-eclampsia/eclampsia/HELLP (Hemolysis Elevated Liver Enzymes Low Platelets) Abruptio placenta Urinary tract infection (UTI) Cholecystitis Endometritis/pelvic inflammatory disease (PID) Head injury Tumor Cardiomyopathy Pulmonary emboli (PE) Gestational diabetes Toxic inhalation Drug ingestion
- Review history taking using the OPQRST mnemonic and discuss if this new information has helped narrow down the list of differentials.
- Review history taking using SAMPLER and discuss if this new information has helped narrow down the list of differentials. Instructor note: Prozac is contraindicated in the third trimester of pregnancy and may create side effects.
- Instructor note: Ask the students what the vital signs tell about the patient and how are they affected during the 3rd trimester of pregnancy. Respirationsâ24 breaths/min Pulseâ138 beats/min Blood pressureâ108/62 mm Hg Pulse oximetryâ99% CO2âN/A Temperatureâ98.6°F (32°C) A rapid pulse with relatively low blood pressure would indicate inadequate perfusion. The pulse oximeter reading is 100% but discuss what a pulse oximeter displays â the amount of hemoglobin saturated with a gas. It does not tell you the patientâs hemoglobin concentration or the gas being sampled. Would there be a benefit to obtain ETCO2 in this patient? If a CO-oximeter is available, what would the benefit be of obtaining a carboxyhemoglobin reading? If students ask, the reading is 26%.
- HEENT: Head Unremarkable Eyes PEARL Ears Unremarkable Nose Unremarkable Throat Excessive soft tissue Heart and Lungs: Heart sounds normal, lungs are clear to auscultation bilaterally Neuro: CMS intact Abdomen and Pelvis: Distended, rigid, nontender, with fetal heart tones in the 160s; quiet bowel sounds Upper and Lower Extremities: Warm, pale, sweaty. 1+ pedal edema, moves all extremities well
- Instructor note: Discuss how these diagnostics support the differential and what if anything would they tell you about the patient.
- Normal 12-lead ECG.
- Instructor note: Discuss where students would place her now. Use the âpenâ in PowerPoint to make comments or circle the potential differential. CO poisoning can be critical if the level gets high enough (> 45%). She is out of the environment so she is no longer breathing in CO. Keep in mind that fetal hemoglobin has a stronger bond with CO than maternal hemoglobin so the fetal CO level could be much higher. Discuss each differential and either rule it in or out. Influenza: Food poisoning: Labor: Pre-eclampsia/eclampsia/HELLP (Hemolysis Elevated Liver Enzymes Low Platelets): Abruptio placenta: Urinary tract infection (UTI): Cholecystitis: Endometritis/pelvic inflammatory disease (PID): Head injury: Tumor: Cardiomyopathy: Pulmonary emboli (PE): Gestational diabetes: Toxic inhalation: Drug ingestion:
- The patient should be treated for carbon monoxide poisoning. High-flow oxygen at 100% should be administered until near-normal carboxyhemoglobin levels are obtained. Why does the patient need a 12-lead ECG? Acute coronary syndrome can be precipitated by CO poisoning. Discuss the effects of CO on the patientâs pregnancy. CO crosses the placental barrier and CO levels of the fetus will be much higher than the motherâs. The baby could have life-threatening CO levels. Discuss the role of CPAP in this patientâs treatment. Prehospital CPAP can maximally saturate hemoglobin and increase oxygen solubility -strongly suggested for moderate to severe poisonings. Discuss the scenario that involves a fire rather than a laundromat. Cyanide poisoning as well as CO poisoning would have to be considered.
- Instructor note: Discuss with students the treatment options based on scope of practice and local protocols.
- CO not only binds to hemoglobin but to all iron-containing molecules and can prevent proper function of heart and brain tissue leading to an acute myocardial infarction.
- Instructor note: Discuss the half-life of CO in the body and the role of the provider in reducing it â 100% oxygen.
- CO Poisoning In the United States, carbon monoxide is a leading cause of morbidity and mortality from poisoning. Carbon monoxide is a colorless, odorless gas produced by incomplete combustion of organic fuels. Sources include household furnaces, space heaters, generators, gas stoves, motor vehicles, and smoke from house fires. CO quickly and easily displaces oxygen off the hemoglobin molecule because of its strong affinity. You may suspect CO poisoning because of a fuel source you smell. But in this case of the patient was likely smelling fabric softener. Clues to the patientâs exposure: Sudden onset of flu-like symptoms while around gas dryers that improved with fresh air. Instructor note: Normal CO levels â 3 â 7% Her levels were moderate and would explain her symptoms.
- Review the points above.
- Review the points above.