This presentation discusses various topics including: 1. Treatment of hypoglycemia is more effectively done with D10 rather than D50 due to D10 being less hypertonic and less likely to cause complications. 2. Synthetic cannabinoids are dangerous drugs that are increasingly causing emergency department visits. They are full agonists with high affinity for cannabinoid receptors. 3. Oxygen should only be given to patients with acute MI, stroke or ACS if the oxygen saturation is below 94% according to ACLS guidelines, as supplemental oxygen can be harmful above this level.

1. Rounds November 2015
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2. Cases

3. Cases
• O2 and a Sat of 98 %
• Anaphylaxis and benadryl use
• Heroin Overdose and a cardiac arrest

4. Hypoglycemia
• Why do we use D50 ?
• An ampoule of D50 has 25 gms of glucose .
We normally have only 5 gms of glucose in our
bloodstream. We are giving 5 x that dose. At a
normal glucose level we cannot transport any
more glucose to the brain. This results in
hyperglycemia.

5. Hypoglycemia cont’d
• Furthermore D50 is very hypertonic. The
osmolality of D50 is 2,525 milliosms and normal
is 295. It is almost 10 fold higher. This results in
skin necrosis if the D50 leaks. It also may sclerose
the vein .
• D10 has 10 gms of glucose and is twice the
normal amount in the bloodstream. It is not very
hypertonic [twice normal] and is unlikely to cause
skin necrosis if it leaks or cause a vein to sclerose.

6. Hypoglycemia
• In a recent study of 164 hypoglycemic adult
patients only 18 % of patients required a second
dose of 10 gms and only 1 patient needed a third
dose. There were no reported adverse events.
• We should only use D10 [assuming we have it] .
It is less likely to wreak havoc on the veins, and it
is far less likely to cause rebound hyperglycemia .
No down side and plenty of upside.

7. Videolaryngoscopy
• In a recent EMS study from Texas and
Mississippi they showed a marked difference
in the rate of intubation with the use of a
video laryngoscope versus direct
laryngoscopy. First pass success was 74 % vs
44 %. Overall success was 92 % with the video
laryngoscope vs 65 % for direct laryngoscopy.

8. Synthetic Cannabinoids
• Marijuana…active ingredient is THC. There are
now many synthetic cannabinoids [SC]
available . They first appeared in 2008 and
they have proliferated. Sold as liquid for e
cigarettes , dissolved in energy drinks , sold as
“legal alternatives to marijuana” , they are
dangerous. Over 26 synthetic cannabinoids
are considered schedule 1 drugs [highly illegal]
.

9. Toxicology of the Month
K2, Spice, and Synthetic Cannabinoids
• 1. What are they? They are full agonists of the
cannabinoid receptor with an affinity 100 x
greater than THC!
• Usually bought from China, sprayed on inert plant
material.
• Earlier this year NYC reported 2,300 ED visits in 2
months ! Marijuana is the most frequently used
substance, synthetic cannabinoids are 2nd , with
up to 10 % of high school students reporting use
in one survey !

10. More K2
• These are sold in gas stations, smoke shops,
and widely available online. They are cheap to
buy [$5 per gram in some cases] .
• They are smoked as joints or in pipes in 50 %,
or in a water bong in half %. They are
occasionally ingested in cookies or cakes.

11. ER Presentations
• In a recent case series over half had
hyperglycemia, and over half had a
tachycardia . A low k was seen in 41 v%, and
nausea and vomiting were seen in 1/3.
Confusion was seen in 1/3, aggressive
behavior [like PCP or bath salts] in 1/3 or
lethargy in 1/3. One fourth needed an ICU and
required intubation. This can be a big deal.

12. RX
• 1. Toxic screens are negative for these drugs.
More advanced labs can identify the drugs .
• 2 . Treatment is supportive…. Benzos and
haldol prn. The effects of these drugs are
usually shortlived [thank goodness] .

13. More
• Three side effects of cannabis will be noted.
Cannabis use increases the likelihood of
psychosis by 1.5-2 fold. You are one and one
half to twice as likely to become psychotic if
you smoke marijuana.
• Marijuana use decreases testosterone levels
and lowers sperm counts . It will decrease
fertility in men.

14. Dietary Supplements
• Between 2004 and 2014 the CDC estimates that
there are 23,000 ER visits per year from adverse
effects from dietary supplements. Weight loss
and energy products caused ¾ of these events.
Unsupervised kids had overdoses accounting for
1/5 of the ER visits. These include weight loss
products, vitamin pills, energy products, iron
supplements. In men, body building and sexual
enhancement products were implicated in 1/7 of
the ER visits.

15. Treatment of Hypoglycemia
• Why do we use D50 ?
• An ampoule of D50 has 25 gms of glucose .
We normally have only 5 gms of glucose in our
bloodstream. We are giving 5 x that dose. At a
normal glucose level we cannot transport any
more glucose to the brain. This results in
hyperglycemia.

16. Hypoglycemia cont’d
• Furthermore D50 is very hypertonic. The
osmolality of D50 is 2,525 milliosms and normal
is 295. It is almost 10 fold higher. This results in
skin necrosis if the D50 leaks. It also may sclerose
the vein .
• D10 has 10 gms of glucose and is twice the
normal amount in the bloodstream. It is not very
hypertonic [twice normal] and is unlikely to cause
skin necrosis if it leaks or cause a vein to sclerose.

17. Hypoglycemia
• In a recent study of 164 hypoglycemic adult
patients only 18 % of patients required a second
dose of 10 gms and only 1 patient needed a third
dose. There were no reported adverse events.
• We should only use D10 [assuming we have it] .
It is less likely to wreak havoc on the veins, and it
is far less likely to cause rebound hyperglycemia .
No down side and plenty of upside.

18. Oxygen ?
High flow, low flow or no flow? What
evidence do we have that it is
harmful?

19. Cochrane Database and O2
• The Cochrane database review in 2010 and in
2013 reported that there are 4 trials of AMI
and O2 that looked at 430 patients. You are
more than 3 times more likely to die if O2 is
given when you are having an acute MI if the
O2 saturation is >than 94 % [you don’t need it
] .

20. Oxygen and Acute MI, CVA and ACS
• The 2010 ACLS guidelines suggest that EMS
care include oxygen only if the O2 saturation is
< 94 % for all patients with acute MI, CVA and
ACS patients.
• The use of oxygen is also suggested for
patients with dyspnea, obvious heart failure,
or if the oxygen saturation is unknown.

21. More on O2
• Hyperoxia will decrease cerebral blood flow,
shown in a 1988 study.
• These studies make it clear that O2 is a
vasoactive drug and that it should be given
only to patients who need it…. Per the AHA
2010 guidelines

22. Oxygen and Acute MI, CVA and ACS
• The 2010 ACLS guidelines suggest that EMS
care include oxygen only if the O2 saturation is
< 94 % for all patients with acute MI, CVA and
ACS patients.
• The use of oxygen is also suggested for
patients with dyspnea, obvious heart failure,
or if the oxygen saturation is unknown.

23. Harm
• “ There is no single threshold of FiO2 defining
a safe upper limit for prevention of oxygen
toxicity .” [UPTODATE 2011] How long the
patient is exposed to a high FiO2 , and the
concentration of the oxygen determines how
likely the patient is to suffer harm.

24. Harm From Intubation
• The ROC investigators showed a 6.8 x increase
in the risk of aspiration pneumonia after
prehospital intubation

25. Anaphylaxis
• Definition: remember skin plus either upper
or lower respiratory involvement with
shortness of breath , hypoxemia, wheezes , or
stridor .
• OR
• Skin or mucosa, plus decreased BP, or
respiratory symptoms, or syncope, or GI
symptoms.

26. Anaphylaxis contd
• The Rx of choice is epinephrine.It should be
given in the thigh IM. Do not give it in the
arm, do not give it sub Q.
• Benadryl is slow in onset and has no effect on
BP, upper airways and lower airways.
• If the BP does not rise with the epinephrine a
fluid bolus of 1-2 liters is indicated.

27. Heroin Overdose and Cardiac Arrest
• Case

28. Epinephrine and Cardiac Arrests
• There has been a lot of question about the
utility of epinephrine in cardiac arrests. Three
recent papers should help guide our efforts.
Our resuscitation rates are 40 %. This is
markedly better than most communities.
Epinephrine is a part of our protocol and we
should continue to use it given our success.
But what does the recent literature and
scientific data reveal ?

29. Two recent papers from the AHA
database using the GWTG on adults
and children
• BMJ 5/2014 Donnino, Michael et al . They
studied 120,000 in patient PEA and Asystole
cardiac arrests to examine the question of timing
in administering epinephrine. What they found
was that if given at 1 minute 12 % survival was
seen and if given at 7 minutes there was only a
7% survival. Neurologically the patients who got
the drug early did much better neurologically.
There was a 10-20 % decrease in survival for
every 3 minutes in administration of epi. YOU
MUST GIVE IT EARLY.

30. Pediatric nonshockable arrests and
Epinephrine
• In JAMA August 2015, 1 month ago by Lars
Anderson [really !] et al . They had 1558
patients and again the time to epinephrine
was critical. If the time to epi was >5 minutes
the survival to discharge was 21 %. If the epi
was given in <5 minutes the survival to
discharge was 33%. There was a stepwise
decrease in survival, neurological outcome for
delays in administration of epinephrine just as
was seen in adults. GIVE IT EARLY

31. Epinephrine in Cardiac Arrests
• Newest data from North Carolina supports the
AHA suggesting that TIMING of use is
paramount. Vasopressin is out of the AHA
protocol. There is a 4 % decline in ROSC for
every minute of delay in the use of
epinephrine !!!

32. Post Medication Hypotension
• Use of opioids and benzos is more likely to
result in hypotension if the patient is
intubated [ 5 x increase] , needs a drug to
keep their pressure up [DUH] , or has a
surgical diagnosis [ like maybe they are
bleeding …] .

33. Accidental Hypothermia
• Hypothermia is defined as a core temperature
less than 35 C [95 F].
• The severity is defined by the temperature
• Mild [stage I], 32-35C, 90-95 F, accompanied by
shivering, tachycardia , usually awake and alert
• Moderate [stage II], 32-28 C, 89-82 F, NOT
shivering with altered mental status
• Much of this talk is derived from UP TO DATE and
a NEJM article from 2012 by Brown, Brugger,
Boyd and Paal.

34. Hypothermia stages cont’d
• Stage III, 28-24 C, 81-75 F, unconscious and not
shivering , these patients still have VS!
• Stage IV , 13.7-24 C, 75-56 F. No VS.
• Stage V temp ,13.7 C or 56 F is dead. Irreversible
hypothermia.
• The stages are paramount. If you have a
conscious patient who is cold and shivering …if
you have a conscious patient who is very cold and
not shivering , or a patient who is unconscious
and not shiveering , or a patient who has no VS
and is very cold...

35. Pathophysiology
• Body temperature is a result of production of
heat and loss of heat. Heat is generated by
metabolism , mostly of the heart and liver,
heat is lost mostly by the skin and lungs.
• Evaporation [sweat]
• Radiation
• Conduction [direct heat transfer from a body
to an adjacent cooler objet [like snow or
water]
• Convection [direct loss to the air]

36. Pathophysiology Cont’d
• The hypothalamus will attempt to stimulate
heat production through shivering, it will
minimize heat loss through vasoconstriction of
blood vessels in the periphery [your arms and
legs]. During the initial phase heart rate
,respiratory rate and metabolism will increase
. As the temperature declines below 35 C [95
F] neurologic function will decline , cardiac
output will decline ,and shivering will
eventually cease.

37. Clinical Presentations
• With mild hypothermia you will see shivering,
tachycardia, tachypnea , dysarthria , and impaired
judgment
• With moderate hypothermia you may see
decreased heart rate, cardiac output and BP,
lethargy, and loss of shivering. The patient may
paradoxically undress ! Afib may occur and
should not be treated.
• With severe hypothermia ventricular arrhythmias
may occur, eventually asystole ensues

38. Pearls
• Beware of VS inconsistent with the degree of
hypothermia! The level of consciousness
should be consistent with the temperature
• Risk factors for hypothermia also suggest
other diagnoses to be aware of: ETOH, IVDA,
Psychiatric disease [and the rx they take], old
patients [sepsis may present with
hypothermia],

39. Assessment
• See above, additionally a FS glucose and an
EKG are indicated, oximetry , capnometry .
The oximetry may be problematic , they are
vasoconstricted, try the ear.
• The Ekg may be slowed, may have Osborne
waves. There may be slowed conduction with
a bradycardia , prolonged PR, QRS and QT
intervals.

40. Osborne J Waves

41. Management
• ABCs, preventing further heat loss, initiation of rewarming
• Peripheral pulses can be very difficult to palpate in a
vasoconstricted , bradycardic patient . Check for a central
pulse for 60 seconds!.
• “Always assume that some perfusion is occurring if there is
any signs of life. CHEST COMPRESSIONS SHOULD NOT BE
DONE IF THERE IS AN ORGANIZED RHYTHM ON THE EKG.”
Even if you feel no pulse, don’t start CPR. The reasoning is
that the rhythm may be interrupted by chest compressions
and that the “PEA” is likely to be transitory.
• Asystole equals CPR
• Initiate 2 I/O lines or 2 large bore IV’s, these patients
typically get hypotensive .

42. Management Cont’d
• Full body insulation with warmed blankets etc,
cutting away any wet clothing, and initiating
rewarming . DO NOT DELAY CPR if indicated : no
signs of life and asystole.
• Heated O2, warmed IV fluids.
• Persistent movement or breathing should prompt
watchful waiting and delaying CPR.
• The longest reported survival with CPR and
rewarming was over 6 hours ! Remember they
are hypothermic and their cerebral oxygen
requirement are very low!

43. Rescue Collapse
• Rescue collapse is a cardiac arrest that occurs
during extrication . All of the literature
emphasizes the need to be very gentle with these
patients.
• The patient should be extracted in the horizontal
position, “even low intensity use of peripheral
muscles should be avoided… to avoid afterdrop of
temperature”. “Rough handling of the patient
may precipitate ventricular fibrillation.”

44. Other Pearls
• “Bradycardia may be physiologic in severe
hypothermia”
• “Ventricular arrhythmias may be refractory until
the patient is rewarmed”. The definitive rx of the
arrhythmia is focused on aggressively rewarming
the patient”, in conjunction with CPR [if needed]
• They suggest a single shock and no further shocks
until the temperature is one degree higher!

45. Other Interesting Information
• Avalanche burial. The burial time may be
estimated by the core temperature, a
temperature <35 C correlates with a burial time
of more than 35 minutes.
• Drowning in cold water has a better likelihood of
a good outcome than in warm water. The longest
submersion survival with intact neurological
outcome is 66 minutes in a child.
• The lowest body temperature recorded in a
patient with full recovery is 57 F!