The document provides an overview of Kelly McDonough's shift as an EMT, describing two medical calls - the first involving a man experiencing agitation and chest pain due to cocaine use, and the second an overdose of a woman who had ingested tricyclic antidepressants. Key details are provided on the patient assessments and treatments for cocaine intoxication and tricyclic antidepressant overdose.

1. RESCUE ROUNDS
KENT HOSPITAL
NOVEMBER 15, 2012
Kelly McDonough, DO
PGY2

2. A little about me….

5. Everything I need to know I
learned in EMS

6. Call #1
You arrive at the fire house at 6am for your day
shift and start checking out the back of your
truck. You finish re-stocking and just as
everyone is about to sit down to scrambled
eggs and coffee, the tones go out for your first
call of the day…
―Please respond to the Bank of America for the
person with altered mental status‖

7. Everything I need to know I learned
in EMS
Stop for coffee before
you get to work.

8. Call #1
 You and your partner hop in the truck and
respond down to the BOA. You are met on
arrival by the Police Lt. who tells you ―We got
called for this guy because he was trying to
break into an ATM. He’s been acting really
weird…I think something is wrong with him‖.

9. Call #1
 Convinced that this is either a turf job or a
case of acute incarceritis, you grab your
equipment and approach your patient, who is
sitting, handcuffed, on the curb in front of the
bank.

10. Call #1
At first glance:
 Male in his 30s
 Looks agitated, disheveled, sweaty
 Tells you he was not trying to steal the ATM, it
was ―his ATM‖ which he ―invented and built
himself‖ because he is ―the smartest person in
the world‖. He is speaking very fast.

11. Call #1
 Bloodshot eyes
 Pupils look like saucers
He agrees to let you take his vitals:
BP 180/100, HR 110, RR 28, O2 Sat 98%RA

12. Call #1
 While you are taking his BP, you notice track
marks. He starts yelling about wanting to make
a ―complaint against the f&%$ing cops‖ for
beating him up. He says they punched him in
the chest and now it hurts.
 You ask if he uses drugs– ―No, I don’t do that
stuff‖

13. Everything I need to know I learned
in EMS
People lie

14. Call #1
 Now what?
a) Turf him back to the police. This guy is just
high and your coffee is waiting for you.
b) Have him sign a refusal, he is only
complaining of chest pain because he wants
to file a lawsuit against the PD.
c) Do a quick PE & EKG to cover your butt.

15. Call #1
 Now what?
a) Turf him back to the police. This guy is just
high and your coffee is waiting for you.
b) Have him sign a refusal, he is only
complaining of chest pain because he wants
to file a lawsuit against the PD.
c) Do a quick PE & EKG to cover your butt.

16. Call #1
 PE
 Alert,oriented X3 but confabulating and paranoid
 Agitated, very sweaty
 Pupils dilated, equal, reactive to light
 LS clear, equal
 Heart regular but tachycardic
 No obvious trauma
 Tympanic temp: 102°

17. Call #1
 You are not able to get much more of an story
out of him…
 Can’t tell you how he got there
 Can’t tell you where he was coming from
 Can’t tell you what he was doing prior to the
police arriving

18. DDX?
 Hypoglycemia
 Hypoxia
 Trauma
 Stroke
 Thyrotoxicosis
 Seizure/postictal
 Heat stroke

19. Call #1

20. Call #1

21. Call #1
 He denies any PMH/MEDS/ALL
 He (still) denies drug use
 But, what about those track marks?
Reluctantly admits to shooting coke last night

22. Everything I Need to Know I
Learned in EMS
Crack is Whack.

23. Call #1
 Now what?
a) O2, fluids, & cool him
b) O2, fluids, cool him, NTG but not Aspirin
because CP is from vasoconstriction, not
thrombus
c) Give O2, fluids, cool him, NTG and Aspirin
d) Take a few minutes to get the rest of his
demographic information

24. Call #1
 Now what?
a) O2, fluids, & cool him
b) O2, fluids, cool him, NTG but not Aspirin
because CP is from vasoconstriction, not
thrombus
c) Give O2, fluids, cool him, NTG and Aspirin
d) Take a few minutes to get the rest of his
demographic information

25. Cocaine
 Inhalation (smoke)
 Intranasal
 Intravenous
 Intraoral (parachuting)
 Subcutaneous (skin popping)
 Per Rectum

26. Cocaine
 Other drugs similar to cocaine:
 PCP
 Amphetamines
 Meth
 Psuedoephedrine
 Bath salts

27. Cocaine Stimulates the ANS
Sympathetic Parasympathetic
“Fight or Flight” “Rest & Digest”
 Dilated pupils  Constricts pupils
 ↑Heart rate  Heart rate
 ↑Heart squeeze  Heart squeeze
 Piloerection  Vasodilation
 Vasoconstriction  Salivation
 Digestion
 Urination
 Defecation

28. Cocaine Stimulates the ANS
Sympathetic Parasympathetic
“Fight or Flight” “Rest & Digest”
 Dilated pupils  Constricts pupils
 ↑Heart rate  Heart rate
 ↑Heart squeeze  Heart squeeze
 Piloerection  Vasodilation
 Vasoconstriction  Salivation
 Digestion
Sympathomimetic
 Urination
 Defecation

29. Cocaine
 Rapidly fatal complications:
 Hyperthermia
 Psychomotor agitation
 Hypertension
 Vasoconstriction
 Cardiac Arrhythmias
 Sinus tachycardia
 SVT
 Brugada type pattern
 Myocardial Infarction

30. Other complications:
 Delirium
 From ↑GABA (excitatory NT in brain)
 Seizures
 Respiratory distress/failure
 Lungdamage from smoking crack
 Edema of airways/hemoptysis
 When intubating avoid succinylcholine
 Prolongs the effects of cocaine
 Effects of succinylcholine itself is prolonged
 Abscesses
 Endocarditis

31. Cocaine
 Cocaine induced chest pain
 ↑HR, ↑oxygen demand of the heart
 Vasoconstrictioncoronary artery spasmCP
 Chronic cocaine use can increase
atherogenesisthrombus formatonCP
 Consider the cath lab in STEMI
 DO NOT GIVE βblockers

32. Sympathetic NS
EPI/NE
α β
- Constriction of blood vessels - increased heart rate
-increased heart contractility
-relaxation of smooth muscle
in lungs
- relaxation of blood vessels

33. Sympathetic NS
EPI/NE
α β
- Constriction of blood vessels - increased heart rate
-increased heart contractility
-relaxation of smooth muscle
in lungs
- relaxation of blood vessels
*you can use Phentolamine,
which is a direct α blocker

34. Treatment
ABC

35. Treatment
 Hyperthermia
 Get those shears out
 Cold packs
 HTN/Tachycardia/Delirium/Seizures
 BENZOS!!!!!
 Diazepam 10mg q5min
 Lorazepam 1mg q5min
 Chest pain/Ischemic EKG changes
 MONA
 NTG will also help with HTN

36. Call #2
 You just finished your report from the last
patient you dropped off at the hospital and as
you are standing in the ambulance bay trying
to explain what an awful awful is to the Kent
resident riding along with you, your radio goes
off…
―Please respond to the private residence for the
question of an overdose‖

37. Call #2
 You respond to the scene where you are
frantically being flagged down by a woman
standing outside a three family home. As you
get out of your truck she is yelling, ―HURRY!!
She took some pills…I think she is really sick!‖
You and your partner grab your equipment and
are lead up to the 3rd floor.

38. Everything I need to Know I
learned in EMS
Patients who need to be
carried live on the top floor.
Healthy, ambulating patients
live on the bottom floor.

39. Call #2
 You are lead to a back bedroom where you
find a woman in her 20’s laying on a bed,
semi-conscious, with an empty pill bottle next
to her. You ask her friend what happened…
―I’m not sure, I don’t really know her…she said
she wanted to kill herself‖

40. Call #2
 At first glance:
 Patient is obtunded but RR is approx 18
 No obvious trauma
 Skin color is pink, dry
You yell ―Ma’am, wake up‖ but she does not open
her eyes

41. Call #2
 You give her a sternal rub. She pushes your
hand away and opens her eyes. You ask her
what happened and she mumbles, ―Leave me
the hell alone and let me die‖ and then closes
her eyes again.

42. Call #2
 Now what?
a) Drop an oral airway and assist ventilations with
BVM
b) Check a finger stick
c) Do a primary survey
d) Scoop and screw—lets get to the hospital, this
lady won’t talk to us anyway

43. Call #2
 Now what?
a) Drop an oral airway and assist ventilations with
BVM
b) Check a finger stick
c) Do a primary survey
d) Scoop and screw—lets get to the hospital, this
lady won’t talk to us anyway

44. Call #2
 ABCs
 Airway
 Patent—she’s talking
 Lung sounds are clear bilaterally
 Breathing
 RR 18
 O2 sat is 97%
 Circulation
 HR 140
 BP 90/52

45. Call #2
 Disability
 GCS= 11
 Pupils equal, reactive, dilated
 FSBS=108
 Now lets get an EKG…

46. Call #2

47. Call #2
•Right Axis deviation
•Prolonged QRS
•Prolonged QT

48. Call # 2
 You put the patient on oxygen, secure her to
your stair chair and begin extrication. While
you and your partner are carrying her down
the stairs, you try to remember what it was that
you learned about overdoses with prolonged
QRS complexes in rescue rounds…
And then she starts to seize

49. Tricyclic Antidepressants
 So named because of their shape
 Used to treat:
 Depression
 ADD
 Anxiety
 Examples:
 Amitriptyline
 Nortriptyline

50. Tricyclic Antidepressants
 How they work:
 Block the reuptake of Serotonin & Norepi in the
central nervous system (SNRI)
 These neurotransmitters make us feel happy and
focused
 But in large quantities can cause delirium, seizures

51. Tricyclic Antidepressants
 4 major effects of TCA OD:
 Anticholinergic
α adrenergic blockade
 Inhibits Norepi reuptake
 Na+ channel blockade

52. Remember this?
Sympathetic Parasympathetic
“Fight or Flight” “Rest & Digest”
Epi/Nepi Acetylcholine
α β Cholinergic Receptors
Vasoconstriction ↑Heart rate
 Constricts pupils
Piloerection Vasodilation
 Heart rate
Dilates pupils Relaxes bronchioles
 Perspiration
 Vasodilation
 Salivation
 Digestion
 Urination
 Defication

53. TCAs are anticholinergic
Sympathetic Parasympathetic
“Fight or Flight” “Rest & Digest”
Epi/Nepi Acetylcholine
α β Cholinergic Receptors
Vasoconstriction ↑Heart rate
 Constricts pupils
Piloerection Vasodilation
 Heart rate
Dilates pupils Relaxes bronchioles
 Perspiration
 Vasodilation
 Salivation
 Digestion
 Urination
 Defication

54. Anticholinergic
 No more ―rest & digest‖
 ―Can’t
pee, can’t see, can’t spit, can’t sh%!‖
 ―Blind as a bat, hot as a hare, mad as a hatter,
red as a beet, dry as a bone‖
 Plus, unopposed ―fight or flight‖

55. TCAs Block α Receptors
Sympathetic Parasympathetic
“Fight or Flight” “Rest & Digest”
Epi/Nepi Acetylcholine
α β Cholinergic Receptors
Vasoconstriction ↑Heart rate
 Constricts pupils
Piloerection Vasodilation
 Heart rate
Dilates pupils Relaxes bronchioles
 Perspiration
 Vasodilation
 Salivation
 Digestion
 Urination
 Defication

56. TCAs Block α Receptors
Sympathetic Parasympathetic
“Fight or Flight” “Rest & Digest”
Epi/Nepi Acetylcholine
α β Cholinergic Receptors
Vasoconstriction ↑Heart rate
 Constricts pupils
Piloerection Vasodilation
 Heart rate
Dilates pupils Relaxes bronchioles
 Perspiration
 Vasodilation
Refractory Hypotension!  Salivation
 Digestion
 Urination
 Defication

57. TCAs block Norepi reuptake

58. TCAs Block α Receptors
Sympathetic Parasympathetic
“Fight or Flight” “Rest & Digest”
Epi/↑Nepi Acetylcholine
α β Cholinergic Receptors
Vasoconstriction ↑Heart rate  Constricts pupils
Piloerection Vasodilation  Heart rate
Dilates pupils Relaxes bronchioles  Perspiration
 Vasodilation
 Salivation
 Digestion
 Urination
 Defication

59. Let’s review…

60. Cardiac Effects of TCAs
 Block fast Na+ channels in heart cells slowing
conduction, prolonging QRS

61. Why its bad:

62. Treatment of TCA OD
So what about our patient?
 ABCs
 Seizures
 Benzos (again)
 Hypotension
 FLUIDS

63. Treatment of TCA OD
 Prolonged QRS/QT
 FLUIDS (NaCl), Bicarb (NaHCO3)
Why?

64. Treatment of TCA OD
 Prolonged QRS/QT
 FLUIDS (NaCl), Bicarb (NaHCO3)

65. Treatment of TCA OD
 Prolonged QRS/QT
 FLUIDS (NaCl), Bicarb (NaHCO3)

66. Treatment of TCA OD
 Prolonged QRS/QT
 FLUIDS (NaCl), Bicarb (NaHCO3)

67. Treatment of TCA OD