4/29/2015. EMS Medicine Live! Fourth EMS Webinar

Transcription

1 Welcome EMS Medicine Live! Fourth EMS Webinar 1

2 EMS Medicine Live! Vision Community & Academic EMS Physician Education Information Sharing Board Preparation Group involvement Meet and see our peers Involve your unique experiences and skills EMS Medicine Live! Course Directors Christian Knutsen, MD, MPH Derek Cooney, MD Brian Clemency, DO 2

3 EMS Medicine Live Zoom During presentation Everyone will be muted Chat questions to Knutsen to be answered either during or at the end of the presentation Raise hand virtually in chat window Recording Upstate will record and post conferences online You can record at your site also Zoom EMS Medicine Live Questions Questions at the end Unmute yourself to ask a question or Message Knutsen if you have a question and I ll ask for questions in order. 3

4 Zoom EMS Medicine Live Technical Problems? Message me if you have a suggestion. If you have a serious problem, knutsenc@upstate.edu Speaker EMS Medicine Live Christian Knutsen 4

5 and Sudden In Custody Death Christian Knutsen What ExD is not Not universally recognized condition Not a medical diagnosis No ICD-9 code AMA does not recognize Not a psychiatric diagnosis No DSM V 5

6 What ExD is Descriptive Syndrome Accepted by ACEP/ED physicians, medical examiners, EMS, Police, Press You know it when you see it Appleton police encounter, Wisconsin 6

7 Three Components Delirium Psychomotor Agitation Physiologic Excitation Clinical Findings: g Agitated, Combative, Bizarre Pain Tolerance Super-Human Strength Hyperthermic, Sweating Naked Tachycardia, Tachypnea Hallucinations, Paranoia Hallucinations, Paranoia Attack objects Fight to exhaustion Police noncompliance 7

8 Hyperthermia Metabolic Acidosis Rhabdomyolysis Multisystem Organ Failure History 1650 appears in British literature 1849 Dr. Luther Bell (Bell s Mania) Acute exhaustive mania 75% mortality in institutionalized psychotic patients 1985 Dr. Charles Wetli (Miami) coined excited delirium to explain sudden death associated with cocaine 1998 review of 21 cases of unexpected deaths in people in a state of excited delirium 18 of which were people in police custody all suddenly lapsed into tranquility shortly after restraint. 8

9 Stimulant Abuse Psychiatric Disease Other Combination Traditional Stimulants Cocaine PCP Methamphetamines 9

10 Designer Stimulants Synthetic Cathinones Synthetic Cannabinoids Synthetic Cathinones 10

11 Synthetic Cathinones Khat (Catha edulis) Flowering Plant Native to East Africa and Arabian Peninsula Popular in Somalia, Yemen 11

12 Natural Cathinone Euphroia Alertness Hallucinations Synthetic Cathinone First Developed 1920s Methcathinone Medical Uses Antidepressants? Appetite Suppressants? 12

13 Synthetic Cathinone Medical Uses Bupropion (Wellbutrin, Zyban) Antidepressant, Smoking Cessation Similar to ecstasy and amphetamines MDMA, Ecstasy Methylone 13

14 Synthetic Cathinones Aura Black Rob Bliss Blizzard Bloom Blue Sil Charge Cloud 9 Drone Hurricane Charlie Ivory Wave Lovey Dovey Lunar Wave Maddie MCAT Meow Meow Monkey Dust MTV Ocean Snow Peeve Purple Wave PV Red Dove Scarface Sextasy Snow Leopard Stardust Super Coke Vanilla Sky White Lightning White Rush White Lady Zoom Synthetic Cathinones Flakka Gravel 14

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16 Synthetic Cannabinoids 16

17 Synthetic Cannabinoids THC Analogs K2 and Spice Better High? Legal Ambiguity? Synthetic Cannabinoids THC Analogs K2 and Spice Bag of plant material Sprayed with drug Labeled Not For Human Consumption 17

18 Recently in Syracuse Spike in synthetic cannabinoids cases ~15-20 patients per days High agitated, combative Straining Police, EMS, ED staff Synthetic cannabinoids mixed with synthetic cathinones? Type 1 Type 2 Bradycardic Mild Hypotension Lethargic/Coma Agitation with stimulation ±Seizures 5-10 mg Versed Intubation due to sedations and airway protection Tachycardic Hypertensive Highly agitated Highly combative Large pupils ±Seizures High dose benzos Intubation for patient control 18

19 Psychiatric Disease Untreated exacerbation of illness New onset psychiatric illness Suddenly stopping psychiatric medications Withdrawal Syndrome? CNS adaption of therapy? Reemergence of underlying disease Medical Sepsis Meningitis Encephalitis Diabetes Other endocrine Stroke Dementia Medications Trauma Head injury Hypoxia Hypovolemia Toxicology Alcohol 19

20 Principles of care Management Protect your team! EMTs, paramedics, ED techs, nurses, residents, other providers, and yourself! Protect the patient Facilitate rapid diagnosis and management 20

21 Management RODEOS Restraint Oxygen Detrose Examination (PE, EKG, etc) Observation Serial assessment Physical restraint Management Temporizing Anything that doesn t get tighter Multiple people as a team Back away if resources not available 21

22 Chemical restraint Management IV, IO, IM, IN, Blow Dart Options Benzodiazepines Antipsychotics Ketamine Chemical restraint Management Intubation Indications Significant coma, airway protection Unable to control with sedatives safely Escalating doses of sedatives Hyperventilation? High dose sedation 22

23 Management Examination Trauma? EKG changes? Hyperkalemia, Long QTc CMP, CK, Troponin Observation & Metabolize To Freedom vs. Admission i Serial assessment Cooling Management Follow core temperature Sedation helpful Paralysis? Continuous EEG? IVF Cooling Blanket, Fans Cold packs 23

24 Prehospital Care Proper training Management Patient Recognition Coordination of Care Restraint Techniques Proper protocols Proper online medical control Management CNY EMS Regional Protocol Required med control order for sedation Increased time from physical to chemical restraint Difficult communications with crew Two paramedics hurt in first 48 hours of our new Spike epidemic 24

25 Management CNY EMS Regional Protocol NYSOH BEMS granted CNYEMS emergency protocol change Midazolam 10 mg IM or 5 mg IV as standing order. Close chart review Sudden In Custody Death 25

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27 Sudden In Custody Death Law Enforcement Perspective Irrational and combative persons Danger to self Danger to officers Danger to community Must be subdued Sudden In Custody Death Law Enforcement Perspective Means of control Compliance by command Compliance by pain Battons Joint Lock Maneuvers OC Spray Compliance by Taser Compliance by group force 27

28 Sudden In-Custody Death Progression Symptoms Significant Restraint Acute Dyspnea Suddenly Quiet Death (bradyasystole) Sudden In-Custody Death Hypotheses Catacholamine Surge and Drop Hypokalemia Cardiovascular Disoder Genetic Long QT Syndrome Drug Abuse Induced Heart Damage Drug Abuse Induced Heart Damage Brain Biochemically Damaged Uncompensated Acidosis 28

29 Sudden In-Custody Death Hypothesis: Uncompensated Acidosis Metabolic acidosis Compensatory alkalosis Sudden In-Custody Death Hypothesis: Uncompensated Acidosis if ventilation compromised Respiratory acidosis or Uncompensated metabolic acidosis Cardiovascular Collapse 29

30 Sudden In-Custody Death SICD Prevention Minimize struggle Patient monitor Early Involvement of EMS Sudden In-Custody Death SICD Prevention Cardiac Monitoring Watch Respirations Expect Decompensation Rapid Transport Early, effective CPR 30

31 Sudden In-Custody Death October 2005 Donald Lewis found by the side of the road by Officer Raymond Shaw Sudden In-Custody Death 4:45 Startt 4:45.40 Into Road 4:50.45 Restraint Starts 31

32 4:49.30 Out of Road 4:49.50 Less Restraint Sudden In-Custody Death 4:51.00 Hog Tie Startst Increasing Restraints 4:51.15 Movement to improve restraint 4:51.30 Breathing 32

33 Sudden In-Custody Death 4:51.40 Not Breathing 4:51.58 Recognized Arrest 4:51.30 Pulse Check Sudden In-Custody Death 4:53.30 Rescue Breathing Started 33

34 4:53.45 No pulse? 4:54.30 CPR started 5:2 4:55.10 SROC 4:55.30 Breath slower? 4: Pulse Sudden In-Custody Death 4:56.51 EMS arrives 4:59.30 CPR Started? Quality? 5:00 Intubation 5:00.20 Ongoing Intubation 34

35 Sudden In-Custody Death 05:01 Still Intubating ti No CPR 5:01.22 Office Mental State Summary EMS Medicine Live April 2015 : Clinical Findings, Etiologies, Management SICD: Progression, Hypotheses of Cause, Treatment, Case Presentation 35