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May 11, 2006 EMCA Review Kevin Branch

There is about 95% success rate upon taking this course. Contact info (705) 698-9729 - [email protected] - www.paramedicaltrainingandconsulting.com EMCA exam template - 45%patho, 20% Anatomy, 15% Treatment, 10% legal, 10% documentation. Psychiatric Emergency 

Patients behaviour is disturbing to himself, his family, or his community.

Never assume as patient has a psycgological problem until the physical is ruled out 

Behavioural Change Causes  Low blood sugar  Hypoxia  Inadequate cerebral blood flow  Head trauma  Drugs, Alcohol  Excessive heat, cold  CNS infections Clues suggesting physical causes  Sudden onset  Visual, but not auditory, hallucinations  Memory loss, impairment  Altered pupil size, symmetry, reactivity  Excessive salivation  Incontinence  Unusual breath odours Anxiety Disorders      

Most common psychiatric illness (10% of adults) Painful uneasiness about impending problems, situations Characterized by agitation, restlessness Unpleasant emotional state Response to stress and may arise suddenly Frequently misdiagnosed as other disorders.

Anxiety Panic attack

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Intense fear, tension, restlessness Patient

Depression        

Mood disorder… affective disorder Remember sadness and joy are common in life Deep feelings of sadness, worthlessness, discouragement….out of proportion Factor in large percentage of suicides Typically begins 20s 30s and 40s Cause is not fully understood by lasts 6-9months Women are 2 times more likely to experience depression hormonal influences are contributing factors Can be caused by physical factors directly or from indirect causes

Signs and Symptoms         

Sad appearance restless, apathetic behaviour Crying spells Withdrawal Pessimism Loss of appetite Sleeplessness Despondence Severe restlessness

Manic Seasonal Post-Partum o Situational: - Follows a traumatic event .. temporary  Endogenous – Onset without an apparent precipitating event  Vegetative – Withdrawn, speaks little, and sleeps little  Agitated – Restless, visibly upset, may be preoccupied with guilt, indecisive, often the world becomes colourless. Ask all depressed patients about suicidal thoughts. Ask someone about suicide will not put the idea in their head. Be honest, empathetic and professional Mania      

Characeerixxed by elation or excessive physical activity grossly out of proportion Most mania occurs as part of a depressive illness Develops over a few days May feel better than normal, energetic May be impulsive, intrusive May have false

Bipolar Disorder  

Manic – depressive Swings from one end of mood spectrum to other

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Manic phase- inflated self image, elation feelings of being very powerful Depressed phase – Loss of interest, feelings of worthlessness, suicidal thoughts Delusions, hallucinations occur in either phase Cyclothymic – milder form (daily)

Usually on Lithium common medication for treatment Manic Depressive illness     

Treatment Antidepressants can cause swings from depression to hypomania Meds used from short term MAOI less likely to cause mood switching Prescribed Lithium

Suicide   

Suicide attempt = Any wilful act designed to end one’s own life Women attempt more often Men succeed more often

Take all suicidal acts seriously Risk Factors       Suicide  

Previous attempt Men greater than 40 years old Single, widowed or divorced Drug, alcohol abuse Obtaining means of suicide (gun, pills, etc)

Are they looking for attention Is often a permanent solution to a temporary problem

Violence to others       

Warning signs Nervous pacing Shouting Threatening Cursing Throwing objects Clenched teeth and fists

Assessment : Suicide Patients      

Injuries, medical conditions related to attempt are primary concern Personal safety, be wary on scene of gas stoves, cars running, electrical appliances and water Listen carefully Accept patients complaints Do not trust rapid recoveries Never challenge pt to go ahead, do it

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Autoerotic Asphyicia Masturbation hanging, happens more often than you think. Pharmacology Antipsycotic Agents Phenothiazine derivatives  Therapeutic effects are a result of dopamine blockage in CNS  Also produce alpha blocking and may peripherally inhibit the vagus  Anti-anxiety effect Other Derivatives    

Haldol Completely blocks D2 receptors and increased turnover of dopamine to produce it antipsychotic affect Less extrapyramidal effects Used to treat psychosis, behaviour

Loxapac – Few anticholinergic but high incidence of extrapyramidal Risperdal – Blocks both dopamine and serotonin , improves symptoms of schizophrenia Zyprexa – Dopamine and serotonin blocking agent, Low incidence of adverse effects. MAOI- nardil Tricyclics      

Inhibits norepinephrine and serotonin reuptake Used for depression and obsessive compulsive disorders OD life threatening, heart block, hypotension, respiratory depression, seizures = death Widening of the QRS may progress to T de P 70-80% of TCA OD do not arrive alive EG : Elavil, Sinequan,Tofranil, Surmontil

Signs Widened QRS complex Hypnotics  Used as sleep aids with or without a prescription  Deep relax allows less dreaming = deeper sleep  OD may cause respiratory depresson, altered LOA, hypotension  EG, Dalmane, Restoril, Noctec

Anti anxiety    

Largest group is benzodiazepines Bind in various areas of the CNS which inhibit nerve transmission OD – drowsiness, confusion, stupor ,N/V, respiratory depression, apnea EG- Xanax, Valium, Serax, Ativan

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Toxicology Most people only need supportive care. Supportive Care   

O2/Monitor Airway support…OPA BP support ..postion

CNS Toxidromes Sympthomimetic (Sympathetic) o Alpha elevates BP o Beta 1 elevates HR o Beta 2 decreases smooth muscle tone airways and vasculature Amphetamines Ecxtancy Thermogenics Coke Coffee Delusions paranoia Tachycardia Hypertenison Diaphoresis Dilated pupils o Seizures and Hypotension  Cholinergic (Parasympathetic Anticholingergic  Salivation  Lacrimation  Urination  Defacation  G  Emeisis 

Anticholinergics  

TCA’s , Atropine, Antihistamines, Mad as a hatter, hot as a hare, dry as a bone, red as a beet, blind as a bat

Present       

Delirium Tachycardia Dry, flushed skin Dilated pupils Urinary retention and decreased bowel sounds Seizures and dysrhythimias Slightly elevated temp

Gravol, Anti histamines, Antipsychotics, Antidepressants, Muscle relaxants, Antiparkinson, Antiemetics , Many plants TCA’s

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(Tricyclics)  Talking one minute, respiratory arrest the next minute  Anticholinergic effects  Blockage of nor-epi  Sodium channel blocker  Peripheral alpha blocker  Inhibition of SNS reflexes  Increased refractory period  Raise in stimulation threshold with decrease in cardiac conduction velocity  Watch for widening of the QRS complex!!! Autonomic Nervous System  Sypathetic  - Alpha – elevates BP  Beta 1 – elevates HR and contractility  Beta 2 – decreases smooth muscle tone in airways and vasculature Eg, cocaine, weight control pills, coffee, Present       

Delusions Paranoia Tachycardia (usually) Hypertnesion Diaphoresis Dilated pupils , piloerection Seizures and hypotension if severe

Too lower body temperature can use cold packs Cholinergics Pesticide overdose Parasympathetic  Sludge  Slowing of HR  CNS depression  Increased GI Transit  Salivation, lacrimation      

Sludge Salivation Lacrimation Urination Defecation GI Cramping

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Organophosphates Carbamates Physostingmine Mushrooms

Treatment – Atropine , supportive

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Sedative/Hypnotics/Opioids /EtOH(booze)  Most common toxidrome  Obtundation,respiratory depression, progressing to deterioration of all vital signs  Many meds in this classification are often mixed  Barbiturates  Benzodiazepines  Morphine/oxycodone  Antihistamine Key to clinical exam is pupils and skin CNS stimulated – diaphoresis CNS depressed – dry skin Pupils normal – no CNS toxdromes taken Party drugs  Cocaine  Cannabis  Ecstasy  GHB  Ketamine Cocaine  Hydrochloride salt of naturally extract of Erythroxylon coca plant,  Indirect sympathomimetic drug – inhibits reuptake of noradrenaline/serotonin/dopamine presynamptic  Smoked, swallowed, injected, applied topically Onset and duration different with route , IV fastes with peak 30 seconds to 2 minutes Crack Cocaine – ether extract yields a heat    

Diffuse sympathetic activation Characteristic findings of mydriasis, tachycardia, hypertension, diaphoresis Sympathomimetic toxidrome Cocaine produes euphoric senstation

Cardiac         

Myocardial ischemia/infarction Diffuse or local coronary artery spasm Increased myocardial demand Endothelial damage Arthrosclerosis acceleration Irreversible dilated cardiomyopahty Non – cardiac pulmonary edeema Arrhythmias Withdrawl can precipitate coronary spasms

CNS    

Seizures Intercranial infarctions/hemorrhages Transient hypertension Central retinal artery occlusion (blindness)

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Respiratory  Pumonary hemorrhage  Pneumonitis  Asthma  Pulmonary edema  PE  Forced valsalva  Pnuemothorax GI - intestinal ischemia -Bowel necrosis - GI perforation Obstectrical - Abruptio placentae -Prematurity Treatment - Monitor , vital signs -Sedation - Beta blockers - Nitrates Cannabis THC (Tetrahydrocannabin) - 30 minutes for peak effect and decline after 1-2hours -Mild euphoria -Relaxation - Impaired Memory - Tachycardia, diaphoresis

GHB - Clear thicker than water, odourless tasteless -bubbles when shaken - takes effect 15 to 30 minutes lasting 3 to 6 hours, Acts as a relaxant 1-2gram - slows the heart hypotension 2-5grams - Motor and speech impairment - Respiratory depression LOC, coma Amnesia, seizures Ecstasy on EXAM - Developed in Germany as an anorexiant Derivative of amphetamine

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- Purity can vary from lab to lab - May contain Ketamine, diphenhydramine - Disintegrates in the stomach - Some molecules absorbed by the stomach into the bloodstream - Majority move from stomach after picking up H+ from stomach - Now polar charged and is not absorbe through stomach , absorbed in the brain -At liver some metabolized -Remainder to the heart and then oxygenated at the lungs - Carried to brain and other organs - MDMA able to cross brain barrier 90 % is metabolized in the brain thus the attracts and addiction      

Eupohoria Disinhibitation Heightened sexuality Energy Increased self esteem Anxiety, irritability

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Sympathetic stimulation Tachycardia, Vasoconstriction, arrhythmias Intracerebral hemorrhage Hyponatremia Seizures Negative psychological effects Hyperthermia

Death due to MDMA  Dehydration  Hyperthermia  Rhabdomyosis  Acute renal failure  Tachycardia  Arrhythmias  Convulsions  Dilutional hyponatremia – water intoxication OBSTETRICS Pregnancies       

Most are uncomplicated Complications can arise from Diabetes Eclampsia / Preeclampsia Hypo/hypertension Cardiac Abortions

Remember that you have two patients. Presumptive signs of pregnancy vs. Probable signs of pregnancy - N/V, missed periods

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Positive signs - hearing fetal heart beat (around 4 weeks) Look at Physiolgic changes during pregnancy – BLS - Blood volume increases by 48%  Hr increase by about 15bpm in 3rd trimester  Blood pressure decreases by 5-15 in 2nd trimester  Respiratory rate increases  Maternal o2 consumption increases by 20%  Gastric emptying delayed Gravida – number of pregnancies Para- number of deliveries Fetal Growth Process – 280 days or 10 months First trimester – 2nd – 12-24 weeks Third – last 3 months ,weight gain present, these babys are viable, at 36 weeks fat stores increase, At term 3-3.5kg and 8-10 cm in length Maternal conditions affecting pregnancy A/P - Placenta - begins development by the 3rd week Completely function by the end fo the 1st trimester Disc shape with two sides Umbilical cord o lifeline between placenta o two arteries and one vein Amniotic Sac Membrane surrounding fetus 500-1000cc after 20weeks Should be pale or straw colour Provides even pressure on fetus, protection, temp control Obstetric patent assessment Hx questions Pneumonic – GTPAL  Gravida (number of pregnacys)  T – number of term babys  P- Premature (before 37 weeks)  A – Abortions (Spontanous or therapeutic)  L- Living Presence of fetal movements around 20th week Presence of fetal heart tones – 20th week Normal 120-160 bpm Braxton – Hicks Contractions

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Usually occurs in the third trimester Benign phenomenon that simulates labour Contractions are generally painless Walking may help

Stages of Labour 1- Onset of contractions to dilation of cervix 2- Full dialation of cervix and delivery of new born 3 – Delivery of placenta duration Length of contraction 1st stage

5 to 8 hours

30 to 40 sec/acive 1 min

2nd stage 3rd stage

15 min to 2 hours 20 to 30 minutes

1 to 11/2 min mild

Intervals between contraction Early 5 to 20 min Acitve 2 to 4 min Trans ½ to 1 min 2 to 3 min variable,

Signs of imminent delivery  Crowning  Rupture of Amniotic Sac  Need to bear down  Sensation of needing to bowel movement  Contractions 1-2 minutes apart  Regular  Lasting 45-60 seconds Delivery 

Contractions 1-2minutes apart, intense and lasting for 50-90 seconds

Delivery - Place gloved hand on presenting part to prevent “explosive” delivery On delivery of head, suction mouth then nose - Have mom pant! - if cord wrapped around neck tightly, clamp and cut  

Control slippery baby Wrap and dry

Cold stress results from increased metabolism from thermogenesis May be  Mottled  Lethargic  Hypoglycemic  Metabolic acidosis Clamp and cut cord Rub back to stimulate Blow by O2 If HR less than 100 Persistent central cyanosis present Below 60 bpm – CPR

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60-100 – breath for them greater than 100 look at them APGAR – Useful in identifying infants needing for resesitation KNOW the APGAR SCALE Determine Apgar within 1-5 minutes Maternal Care – Post partum Bleeding – place sterile pad over vaginal opening If bleeding is excessive – Rapidly transport to hospital, fundus massage, encourage breast feeding. Breech Delivery  Management  High concentration O2  Rapid Transport Breech Presentation Management  If head does not deliver within 3 minutes of body  Insert gloved hand into vagina forming V around babys nove and moth  Push vaginal wall away from babys face to create airway  Slide hand into vagina over infants occiuput and apply pressure downward  Place free hand behind maternal symphysis pubis and exert steady pressure with heel of hand  Rapid transport Limb Presentation Management  High 02  Transport Prolapsed Cord - check for a pulse - no pulse have mom reposition - left lateral position - pressure of head on cord occludes blood flow and o2 to fetus - if there is a pulse, good transport Management - O2 - Knee to chest position - Place gloved hand in vagina - apply gentle pressure inward to presenting part, relive pressure on cord Call for addition crew to unload 35P Meconium make sure you suction mouth then nose Multiple Births   

Consider this is mother has unusually large abdomin Mothers abdomin remains large after first birth Contractions continue after first baby

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Delivery   

Babys are usually smaller Metabolism is usually highter Cold stress is a greater factor

Ectopic Pregnacy 

Pregnacy outside of the uterine cavity – most in the falopean tubes

History – lower abdo pain , sharp or dull Physical Exam - S/S of hypovolemic shock - positive tilt test – pressure lying down, sitting and standing blood pressure difference of 10 % A woman having abdo pain in child bearing years always has an ectopic pregnancy.

Pre-Eclampsia 

Affects about 7% of pregnancies

Risk factorys - first pregnancy - Multiple gestations  Excessive amniotic fluid  Diabetes mellitus  Renal disease  Pre-exixting hypertension Signs          

Edema to hands and face in the morning Elevated blood pressure Rapid weight gain with no additional intake and decreased urine output Proteinurea Swelling Decreased urine output Severe headache Blurred Vision N/V Pulmonary edema

Eclampsia – is preeclampsia with seizures Maternal mortality rate 10% Fetal mortality rate 25% Eclampsia Management – LLR Reduce light Emergency transport

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Abruptio Placenta Premature placental separation from uterus 0.4-3.5 % of pregnancy mild to moderate vaginal bleeding continuous , knife like abdominal pain Third trimester pain = abruption until proven otherwise Rigid tender uterus Hypovolumia out of proportion to visible bleeding

Placenta Previa        

Placenta implantation over cervical opening Increasing age Fetal hypoxia 0.5% of pregnancies Painless bright red vaginal bleeding Soft, non-tender uterus No contractions S/S of hypovolemia

RESPIRATORY BLS standards Rates on exam Age Adult

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Breathing Rates

Less than 8 to 10 breaths per minute should be assisting ventilations Or Greater than 28-30. OPA purpose of protecting the airway, by moving the tongue out of the way Greater then 500 cc per breathe BVM 1500 cc Right and left main stem bronchioles right stem angles more there for left is blocked more often Study anatomy of the upper respiratory tract, I.E Trachea, Tongue Compliance, what is it like, is one side paradoxical to the other, flail chest. One cell thick at the alveoi level. Allow for gas exchange at the cellular level, they have external respiration, internal is where we have haemoglobin perfusing our tissue. Right lung is divided into 3 lobes divided by fissures, Left is two lobes Diaphram # 1breathing muscle and is controlled by the phrenic nerve if severed diaphram will not work Apnea if nerve C 1 C2 atlas and axis to C4 cessation of breathing Dermatones levels Diaphram - Appendix 71,72 spinal cord injurys C1-C2

At rest we should be breathing at 12-15 breaths per minute, quiet.

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Oxygen Hemoglobin Dissociation curve small roll on exam When blood is in the venus return it is about 75% o2 (at rest) goes to the lungs and picks up 25 more percent and returns to the tissue 02 and more carbon monoxide creating acidosis smoking bronchospasms pulmonary edema pus filled airways effect the uptake of 02 A pt who is exercising or having an Asthma attack will only have 25% return. The lungs have to work hard to compensate. Will not see a chart or graph on exam, a question or two Ventilation/Diffusion/Perfusion Ventilation – refers to the movement of air into and out of the lungs. It depends on the following  Neurological control to initiate ventilation. - medulla and pons respiratory centre and picks up ventilatory rate  Chain Stoking respirations happen with a head injury  Nerves between the brain stem and the muscles of respiration  Functional diaphragm and intercostals muscles  Patent upper airway  Functional Lower airway. - > aveoli (anatomical deadspace airways that do not perfuse) to increase deadspace by adding an airway Look for fact...