MDMA: also known as Ecstasy, E, X (or for those keeners…3,4-methylenedioxymethamphetamine)

One of the most commonly used substances in the club scene, primarily for its stimulatory effects, euphoric properties and emotional openness. MDMA is usually taken in pill form but can be mixed with a variety of other substances.  Not surprisingly as it is mostly a stimulant, signs of intoxication are dilated pupils, tachycardia, hyperthermia, sweating, tremor and decreased LOA.  As far as medical cautions dehydration is the key component of a bad night on MDMA.

FUN FACT: Patients who are also on SSRIs/SNRIs/MAOIs run the risk of serotonin syndrome – beware of extreme hyperthermia and seizures.

KETAMINE: also known as K, Ketalar, Special K

Although classically used as a horse tranquilizer, ketamine has become a staple in the club scene for its dissociative properties.  Most commonly found in a powder form, it can be snorted, ingested and injected.  In small doses it causes relaxation and auditory/visual sensations.  In larger doses (aka a K hole) patients can become catatonic and even progress to apnea.  These patients need to be monitored very closely with special attention to their airway.  Luckily these symptoms are self-limited (~20-30minutes) as ketamine has a short half-life.

FUN FACT: Contrary to popular belief giving someone who is in a k-hole sugar will NOT make them come out of it any sooner.

GHB: also known as Gamma Hydroxy Butyrate, G, Liquid E, Liquid X

In it’s pure form it is a clear, colourless, salty liquid but can be coloured or made into a powder.  It is used for its euphoric properties BUT due its small therapeutic index the amount patients need to get their ideal high isn’t that much less than they need before they black out.  Watch for altered LOA, bradycardia, bradypnea, hypotension and seizures.  GHB can also be used maliciously for the means of sexual assault.

FUN FACT:  Prior to 2000 GHB was legally sold in Canada at health food stores as a sleeping aid.
Brodie Nolan is a 4th year medical student at the University of Toronto. Brodie has 6 years of experience as an Emergency Medical Responder, and has interests in both pre-hospital care research and Emergency Medicine.

Have you guys heard the one about the fire fighter, the police officer or the paramedic? Of course you have! We all have, and most of the time, it’s all in good fun.  As services that work together we poke fun at each other, but when these jokes and shots turn into resentment, arguments, even anger and hatred, they’ve gone too far. There is frustration and unwillingness to help each other, competition and even fighting between services. And who suffers the most from these disputes? The people we are there to help, patients and others in need.

Now I know it is a bit extreme to blame any inter-service rivalry on jokes alone, when there are a wide variety of factors at play.  That said, these jokes often highlight underlying legitimate feelings, even if they’re meant in good fun. Unfortunately this progression from professional banter to inter-service animosity can be seen quite clearly in events this fall in the city of Toronto. With budget cuts looming over emergency services, police, fire and paramedics a like are scrambling to justify their operating costs. This scramble seems to have brought out the worst in all of them, with each service trying to promote themselves at the expensive of the others. We’ve turned on one another; we’ve placed ourselves above our comrades in arms, even going as far as to deny they are our comrades at all. This isn’t the path of progression and this isn’t the path of accountability to the communities that we serve. We owe it not only to ourselves, but those communities, to provide a united front in the face of any adversity. Regardless of whether it’s providing the best medical care for a patient, or facing budget cuts and restructuring during difficult times, it is together, as a united front, that we should face these challenges.

Admittedly, even now, working as a paramedic, I struggle to always remain professional with other pre-hospital services, but it’s the little changes that we each make that cause the big changes to occur. We need to support each other, we need to work together, and we need to ensure that we face any adversity as a united front. If we don’t appreciate that the different responsibilities and skillsets we have all compliment and support each other, then we limit ourselves and deprive our communities of the best patient possible care. I want to finish with a quote from the great scholars Wilbert Harrison, Canned Heat, and George Thorogood & The Destroyers: “together we stand, divided we fall, come on now people let’s get on the ball and work together”. So what does it come down to? You are the cause of the change you want to see, so let’s all work together.

Dan Stein is a Primary Care Paramedic working in Simcoe County. He has been an Emergency Medical Responder for 6 years, and was a member of the Wilfrid Laurier University Emergency Response Team during undergrad. Dan is the current President of the Association of Campus Emergency Response Teams, a national organization that oversees first-aid teams on Canadian campuses.

Hand infections are important to recognize in the emergency setting. Prompt recognition and initiation of treatment are necessary to prevent loss of hand function. In the EMS setting, most infections will be seen in the context of traumatic injury.

Location:
The most common hand infections involve the distal tip of the fingers. These include nail fold infections known as paranechiae and eponechiae and deep pulp infections of the finger tip. These infections are considered relatively minor. However they often require incision and drainage to remove pus and relieve pressure. These infections can also spread to the hand if not recognized and treated.

Distal finger infections may move into the tendonous sheath of the fingers and palm on the palmar side of the hand. This is known as flexor tenosynovitis. This condition is important to recognize as a pre-hospital care provider, as it is a surgical emergency and requires immediate treatment by a plastic surgeon. Patients with flexor tenosynovitis present with globally swollen fingers which are held in a semi-flexed position. Patients will not allow the examiner to extend their fingers straight due to pain. They will also be tender along the affected tendon.

“Fight bite” is a potentially serious infection which may be seen by EMS providers. In this situation, an individual punches another person impacting one of their knuckles on the victim’s teeth. Although this may appear as a simple laceration on the individual’s knuckle, it is important to suspect more serious injury. Due to the location, it is common for teeth to violate the joint capsule or injure the extensor tendon to the finger. Human saliva has especially virulent organisms which spread quickly and destroy tissue when a wound is inoculated. When assessing a patient who may have suffered a fight bite injury, it is important to assess the wound with the patient’s hand held in a fist to look for foreign bodies (i.e. toot fragments) and to irrigate the wound thoroughly in this position. Loose dressings should be applied and the hand should be splinted for comfort.

The hand has a number of potential spaces deep in the palm which may develop collections of pus. Again, the most common mechanism of infection is secondary to trauma. In this situation, the affected area is generally swollen and red and the patient has limited hand function. When comparing the affected hand to the unaffected hand, the examiner will note a loss of the normal concavity of the palm secondary to a collection of pus in the palm.

Animal Bites:
Animal bites are a common cause of hand trauma and infection. By far the most common are from dogs and largely affect children. Cats are also commonly implicated and generally these injuries are worse than those produced by dogs because of the depth that cat teeth pierce. Wild animals are also implicated. Animal saliva contains a variety of virulent organisms which often require prophylactic antibiotics. Additionally, rabies must be considered with animal bites. As an EMS provider, priorities include copious irrigation, loose dressing application, splinting of the hand and a detailed history of the circumstances of the animal bite. Animal control should be involved immediately. If possible, the animal should be captured for assessment as a potential carrier of rabies. If the animal is domesticated, it should be quarantined and observed for any symptoms of rabies.

Necrotizing fasciitis:
Necrotizing fasciitis (aka “flesh eating” disease) is a rapidly progressing, life threatening infection that can affect any area of the body. Prompt recognition by the EMS provider is potentially life-saving. Certain bacteria spread quickly through the planes of a patient’s tissue and progress to systemic illness and cardiovascular collapse. Clinical features that should prompt considering necrotizing fasciitis include rapidly progressing infection over hours, pain out of proportion to the size of the infection, presence of crepitations (crunching) because of gas in the tissues and black, necrotic looking tissue. This represents a patient who should be triaged for immediate treatment in the emergency department. Long off-load delay because of an underestimation of the severity of the infection may be life-threatening.

Infectious source:
An important component of the EMS provider’s assessment of hand infections involves determining the history of infectious exposure. This should include questions about nail biting, exposure to dirt/soil, impaled or embedded objects, fecal contamination or other bacterial exposures. This history can help the emergency physician in selecting an appropriate antibiotic for treatment.

Summary:
Hand infections can be minor and self-limited or potentially life or limb threatening. The pre-hospital care provider should obtain a detailed history to determine potential sources of infection. Additionally, treatment should include copious irrigation as soon as possible with normal saline. Lacerations and lesions should be loosely dressed to allow for continued drainage. Also, hand infections should be splinted and elevated for comfort and to prevent spread of infection during transport to hospital. If EMS providers suspect infections such as flexor tenosynovitis or necrotizing fasciitis, these concerns should be communicated to the triage nurse immediately and should prompt rapid assessment by the emergency physician.

Dr. Morgan Hillier is an emergency medicine resident with the division of Emergency Medicine, faculty of Medicine at the University of Toronto. Dr. Hillier has a research interest in pre-hospital care and holds and EMR Instructor Trainer status with the Canadian Red Cross.

As first responders and paramedics, we run into a seemingly endless variety of toxicological emergencies in the field.  Many of these emergencies are drug related, either due to misuse of prescription medication, or recreational drug use.  Given vast number of possible drugs, not to mention the exponential number of possible combinations/interactions, pre-hospital care providers need a way of organizing common signs and symptoms so they can be quickly recognized and the most appropriate care can be provided.

With that in mind, understanding the common causes, basic pathophysiology and the signs and symptoms for the major TOXIDROMES is of huge benefit all levels of healthcare providers

A drug overdose is the ingestion or application of a substance that is above and beyond the recommended or generally used amount.  Not all overdoes are fatal, and they can happen to anyone; first time or veteran drug users, purposefully or accidental, adult or child.

This 2-part article will discuss the common causes, signs and symptoms and general treatment for the 6 major Toxidromes; Anticholinergic, Cholinergic, Sympathomimetic, Opiate, Sedative/Hypnotic, Hallucinogenic.

Anticholinergic

The signs and symptoms of this toxidrome are caused by the anticholinergic substance blocking the neurotransmitter acetylcholine in the central and peripheral nervous systems.  Colloquially, patients in this toxidrome “dry up”.  A helpful rhyme to remember the signs and symptoms of this toxidrome is: “Blind as a bat, mad as a hatter, red as a beet, hot as hell, dry as a bone, the bowel and bladder lose their tone, and the heart runs alone.”  This toxidrome generally causes an increased heart rate, increased temperature, and increased pupil size.

Common substances that may cause the Anticholinergic toxidrome are; Tricyclic antidepressants, anti-nausea medications, cough medications, sleeping medications, anti-histamines, and muscle relaxants.

Cholinergic

As the name would suggest, the Cholinergic toxidrome is the opposite of the Anticholinergic discussed above.  The signs and symptoms caused by substances in this toxidrome are due to an overly active parasympathetic response (due to the flooding of the CNS with acetylcholine).  Signs and symptoms of this toxidrome can be remembered using the pneumonic “SLUDGE”, which stands for; Salivation, Lacrimation, Urination, Diarrhea, Gastrointestinal distress, and Emesis.

The substances that cause a Cholinergic toxidrome are much less common than other discussed in this article.  Organophosphates (most commonly found in pesticides) and nerve agents (in chemical weapons / accidents) are the most “common” cause of this toxidrome.

Sympathomimetic

Substances causing an increase in sympathetic nervous system activity are classified as Sympathomimetics (hence the name of this toxidrome).  These substances either mimic or increase the levels of circulating catecholamines (eg. epinephrine and norepinephrine) in the body.  Signs and symptoms of this toxidrome are similar to the “fight or flight” response.  Increased heart rate, respiratory rate, blood pressure, temperature, pupil size and diaphoresis.  More serious complications include; tremors, agitation, hypertension, tachycardia/dysrhythmias, tachypnea, altered LOA, seizure, coma, death.

Some common sympathomimetics are salbutamol, amphetamines, cocaine, methamphetamines and ephedrine.

That’s it for this month.  Be sure to check out Part 2 of this article next month where Opioid, Sedative/Hypnotic and Hallucinogens will be discussed.

My thanks to Blair Bigham for the use of his “Drugs for CERTs” presentation, and the kids from the Toronto rave scene I treated this weekend for the inspiration to write these articles.

EMSstudent started as a fairly straightforward project.  A few classmates and I realized early into our education that there were a lot of online resources available for paramedic students, but they were scattered all over the Internet.   Even more importantly, very few students knew they existed, so they were largely (in our opinion) underutilized.

This website started as a way to amalgamate those resources, and make them easily accessible to our fellow students…but has since grown into much more.

Over the last few months, our focus has been to develop and organize as much content as possible.  We’ve collected over 50 12-lead and lead II ECGs, large number of quizzes (pharmacology and general knowlege), and more recently, a monthly Digest made up of articles from students, paramedics, pre-hospital care researchers and physicians.  The site has grown and changed in ways we hadn’t imagined, and it’s been an exciting experience along the way.

Over the next few months there are going to be some changes to the site.  We’ve decided that the best focus of our time and energy will be to develop a database of scenarios (both online and in printable format) that will highlight specific skills, situations and pathophysiology for First Responders, PCP students, and Paramedics alike.  These scenarios will be presented in an interactive format online, but will also have the option to be printed so they can be used in hands-on, practical training.  We’re excited to start building a database for students and educators to draw from, and are looking forward to the continued feedback and input from the EMS community to make these scenarios the best they can be for future paramedics.

We are also planning to expand our monthly Digest and will continue recruiting leading authors in the Emergency Medicine and Pre-Hospital Care community to provide the highest level articles and information for the site.  Upcoming Digest projects include interviews with Base Hospital physicians, Ornge paramedics, and recently hired PCPs who will share their insight into the AEMCA, the hiring process, and some of the common obstacles they’ve faced entering this profession.

All the previous content posted on the site will stay on our servers, and we encourage new visitors to the site to spend some time going through the archived ECGs, Quizzes and Articles.  At the end of the day, I’m tremendously excited at how far this site has come in a few short months, and I look forward to what the future will bring.  As always, your feedback, contributions and support are appreciated.  Please leave a comment below or email me directly at mike@emsstudent.ca with any thoughts you may have.

Mike

For a cardiac arrest patient to survive, many things need to be done quickly and correctly.  While I could have written about good quality CPR, defibrillation, ALS etc. (which I might save for another digest), I thought I would talk about something a little more sexy and novel.

Achieving a ROSC is the ultimate goal of prehospital resuscitation.  Since this only happens about a third of the time, providers might be tempted to stop and exchange high-fives.  While this may represent a successful resuscitation for paramedics, the road to recovery for the patient is long from over.  After their sustained ROSC, a sepsis-like post arrest syndrome ensues…a condition that is fatal in over 50% of patients.  This condition involves multi-organ dysfunction caused by lack of oxygen, which can include brain injury, myocardial dysfunction, systemic inflammation and the underlying pathology preceding the arrest.

Until a couple of years ago, treatment options for these post-arrest patients were limited.  Patients with a coronary occlusion were sent for an urgent trip to a percutaneous coronary intervention (PCI) center while others were assessed an ICD.  But other than those tested and true interventions, there wasn’t much that could be done for the post-arrest patient.

One of the more novel interventions actually came from “old fashion” medicine.  The idea of cooling injured patients was first coined by Hippocrates when he packed wounded soldiers in ice and snow nearly 2000 years ago.  But it wasn’t until the early 1950’s that the modern use of hypothermia specifically for cardiac arrest patients was started.  However, its use was quickly abandoned due to lack of scientific literature and the challenges associated with implementing and maintaining hypothermia with the limited technology of the time.

As we moved into the 20^th century, science advanced and so did the treatment and technology options available.  Therapeutic Hypothermia (TH) was reborn and brought back into the limelight.  Scientists (and the funding organizations that pay them) realized that there was room for improvement in post-arrest survival.  So some research was done and two randomized trials showed an improvement (both clinically and statistically) for post-arrest survival when patients were treated with TH.  Now before I continue, I feel I should point out that these studies weren’t the end all and be all type of study (due to small sample sizes and only patients with an initial rhythm of VF or VT were included), but they were a start.  Since those two studies almost 10 years ago, there has been a growing body of research in favour of cooling post-arrest patients.  Hypothermia has become an international standard of care as part of both the 2005 and 2010 AHA treatment recommendations and is a critical competent of the integrated post-arrest link in the “Chain of Survival”.

So to getting into a little bit of the nitty gritty, when a patient is successfully resuscitated (with a ROSC > 20 minutes) and remain comatose, they are ideal candidates for hypothermia.  The sooner hypothermia is initiated the better, but starting within 6 hours of ED arrival is deemed to be good enough.  Patients are to be cooled to about 33°C (32-34°C is acceptable) for 24 hours.  This can be done simply administering cool saline IV and placing ice bags around the head, axilla and groin.  Or the process can be more “high-tech” by using commercial cooling blankets and catheter cooling.  Narcotics, sedatives and paralytics given as needed for pain and to prevent shivering and agitation while vasopressors are given to maintain adequate MAP.  Following 24h at 33°C patients are passively re-warmed and rehabilitation begins.  And the intervention is quite successful.  Only 6 patients need to be cooled to get one survivor (which is pretty good in comparison to other interventions when NNT = 1 is the best).

Now one might say that this protocol seems so simple.  And it is in theory simple to describe the optimal way to cool a post-arrest patient.  But in actual fact there are lots of complications associated with hypothermia.  Some physicians are not aware of detailed cooling procedures or don’t have extensive experience with cardiac arrest patients.  While sometimes the hospitals don’t have a standard TH protocol.  Or there can be patient complications as well from non-cardiac etiology to not responding to treatments.  Despite some problems, the intervention is showing promise. Hypothermia is becoming more wide spread locally, nationally and internationally. More patients are being cooled…and more patients are surviving to hospital discharge.  The big next step for this protocol will be to figure out how to improve delivery and cool more patients sooner.  The early initiation of this treatment will provide EMS with an opportunity to make a vital difference in the survival rate of post-arrest patients.

Jason Buick is a researcher at Rescu, the resuscitation science program at St. Michael’s Hospital and is completing his Masters degree in Health Research at the University of Toronto.  His research interests focus around prehospital care, specifically bystander CPR and out-of-hospital cardiac arrests.

09/27/2011

The answer to last week’s Lead-II ECG was:

09/22/2011

The answer to last week’s 12-lead ECG Challenge was: Wolff-Parkinson-White Syndrome