|+Paramedic to assist caregivers or patient with self-administered emergency medications -- December 1, 2016
In this update I will:
- Discuss the authority for paramedics to administer emergency medication including hydrocortisone for patients with congenital adrenal hyperplasia (CAH).
- Define adrenal crisis and its causes
- List signs and symptoms of adrenal crisis
- Describe the appropriate field treatment for a CAH patient in the prehospital setting
Congenital adrenal hyperplasia or CAH are any of several types of genetic diseases (autosomal recessive) that can result in excessive or deficient production of sex steroids or cortisol. This can have a profound effect on the reactions of the body to stress including infection.
- The adrenal glands sit on top of both kidneys and produces hormones including cortisol, aldosterone, and testosterone.
Adrenal crisis is a life-threatening condition that occurs when there is not enough cortisol produced.
- Congenital adrenal hyperplasia (CAH) is an autosomal recessive genetic disorder which results in improper hormone synthesis resulting in, with stress such as an infection, adrenal crisis.
- Causes of adrenal crisis include deficiency anywhere along the pathway to cortisol production and release by the adrenal glands. CAH is one cause. Patients with dysfunction of the adrenal glands themselves (known as Addison’s disease), and those with disease of the pituitary may also have adrenal crisis with stressors.
Any of the following stresses to the normal physiology of a patient with CAH or other diseases of the adrenal gland can result in life threatening consequences:
Sudden discontinuation of medication
Injury to the pituitary or adrenal gland
Signs and symptoms are not specific for adrenal crisis – so a high level of suspicion for this condition should be maintained for a patient with CAH. These signs and symptoms may include:
IF LEFT UNTREATED CAN RESULT IN DEATH
Let’s illustrate what we are discussing by presenting a case:
Paramedics respond to the home of a 2 year-old boy
Teenage sister states the boy began to have fever, vomiting and diarrhea several hours ago
She states the child has congenital adrenal hyperplasia
He is wearing a medical alert bracelet that states “adrenal insufficiency”
The boy’s vital signs:
HR 180, RR-30,
Cap refill-delayed 3 secs
LOC- Responds to verbal by moving head and crying
Skins- Hot to touch
Sister states she tried to give the child a double dose (stress dose) of hydrocortisone (Solu-Cortef®) by mouth as prescribed by the physician, but the child immediately vomited it up.
She attempted to contact her parents but they did not answer her phone call.
Her mother usually gives him an IM injection of hydrocortisone (Solu-Cortef®) when he cannot tolerate medication by mouth.
She has his injection kit next to her.
What should the paramedic do?
What can the paramedics do?
Per State of California Title 22, Division 9, Prehospital Emergency Medical Services, Chapter 2, EMT 100063: Scope of Practice of EMT – (16) “Assist patients with the administration of physician prescribed devices including but not limited to, patient operated medication pumps, sublingual nitroglycerin, and self-administered emergency medications, including epinephrine devices”
Paramedics may perform any activity in the scope of practice of an EMT – therefore can assist patients in delivering normally self-administered medications – such as hydrocortisone in this case (other examples of emergency self-administered medications include albuterol, nitroglycerin, or epinephrine via autoinjector)
- If a patient has CAH has symptoms of adrenal crisis, the EMT or paramedic can assist the patient, or patient’s caregivers in administering the medication (hydrocortisone (Solu-Cortef®) IM) which falls under both EMT and paramedic scope of practice
- A paramedic should contact the base hospital with any questions
- These patients must be transported to the hospital for further evaluation/treatment
- This medication should be given as soon as possible and can be life saving
Please see attached Presentation for further information
+The End of Life Act (AB15) Impacts on EMS System -- June 20, 2016
TO: The EMS Community
As many of you are aware, in late 2015, the California Legislature passed the End of Life Act (AB 15), which became law on June 9, 2016. This Act allows for terminally ill patients in California who are mentally competent adults to voluntarily request and receive a prescription for medication to end the patient’s life at a time of their choosing. This allows for a patient to have some control over the end of their life and gives patients dignity and comfort at the time of their death.
The law outlines many safeguards for the patient and includes language that the patient may rescind his/her wish to take the “aid-in-dying” drug at any time.
In order to prepare the EMS system to care for these patients with respect for their wishes, there have been modifications to a number of key EMS Agency policies including Reference No. 814 – Determination/Pronouncement of Death in the Field and Reference No. 815 – Honoring Do Not Resuscitate Orders, Physician Orders for Life Sustaining Treatment, and the End-of-Life Option (Aid-in-Dying drug).
Please review these updated policies on our website under Resources/Prehospital Care Manual. Note a couple of new resources within Reference No. 815: Reference No. 815.3 provides an example of an “attestation” that the patient intends to take the Aid-in- Dying Drug within 48 hours. An attestation may or may not be available at the time EMS arrives at a home of a patient who has taken the aid-in-dying drug. Reference No. 815.4 is an algorithm, which is intended to provide guidance on the management of these patients. The goal is to honor a patient’s end-of-life option and provide comfort and guidance to the family.
We must also work collaboratively as EMS and hospital-based providers to make the best decisions on care and transport for the patient, and their families.
Marianne Gausche-Hill, MD, FACEP, FAAP
Medical Director, LA County EMS Agency
Reference No. 814, Determination/Pronouncement of Death in the Field
Reference No. 815, Honoring Do No Resuscitate Orders, Physician Orders for Life Sustaining Treatment, and End of Life Option (Aid-In-Dying Drug)
Reference No. 815.3, Sample – Final Attestation for an Aid-In-Dying Drug to End My Life in a Humane and Dignified Manner
Reference No. 815.4, End of Life Options Field Quick Reference Guide
+Zika Virus -- June 15, 2016
Zika virus is a flavivirus spread by the bite of the Aedes mosquito and is related to denque, yellow fever and West Nile viruses.
Originally reported in Uganda, the virus has now spread to many parts of the world including the United States (See Figures).
Incubation is 2-12 days and only 20% of patients bitten develop symptoms. Transmission between humans can occur via blood transfusion or sexual activity. Symptoms include fever, rash, conjunctivitis, joint pain, headache, and generalized weakness.
One of the most publicized complications is microcephaly in babies born of women infected with the virus during pregnancy (generally in the first trimester of pregnancy). Greater than 4000 cases have been reported in Brazil and now in other areas of the world.
Treatment of the disease is symptomatic meaning treating the fever and symptoms with acetaminophen (Tylenol) and other supportive care such as IV fluids if dehydrated. Ibuprofen (Motrin) should be avoided as co-infections with dengue do occur and use of nonsteroidal anti-inflammatory agents, such as ibuprofen, may increase risk of progression to hemorrhagic fever.
Testing for the virus can occur from blood, urine or cerebrospinal fluid specimens sent to local health departments. http://www.cdc.gov/zika/hc-providers/index.html
EMS providers should use universal precautions or standard infectious disease precautions (gloves and mask) when evaluating and transporting these patients to the emergency department. Exposure to blood or bodily fluids should be reported per normal guidelines and no additional precautions are necessary. Questions regarding exposures can first be directed to the Medical Alert Center who can contact Public Health.
- United States Center for Disease Control and Prevention http://www.cdc.gov/zika accessed 7-11-16.
- Los Angeles County Department of Public Health http://publichealth.lacounty.gov/acd/vectorzika.htm accessed 7-11-16.
- Los Angeles County Department of Public Heath http://publichealth.lacounty.gov/acd/docs/ZikaCDRoundsMay2016.pdf accessed 7-11-16.
Check out these prior updates, click HERE
SYNCOPE – March 2017
Paramedics are called to a grocery store where a 32 year-old female had a syncopal event. She is now sitting up, and is alert and oriented x3. She recalls having palpitations and a feeling of anxiety just prior to passing out. Witnesses report loss of consciousness for 30 seconds, with no shaking or seizure-like movements. Her vital signs are HR 97, BP 134/83, RR 21, and O2 saturation 97% on room air.
+What are the possible etiologies of this patient’s syncope?
While young healthy individuals often have syncope from benign causes, such as vasovagal syncope and transient hypotension, they can also have more dangerous underlying conditions as a cause of their syncope. These include life-threatening dysrhythmias (i.e. ventricular tachycardia or ventricular fibrillation) resulting from cardiac ischemia, aortic stenosis (narrowing of aortic valve), prolonged QT syndrome, or other genetic abnormalities. Some other reasons for syncope include aortic dissection, subarachnoid hemorrhage, hypertrophic cardiomyopathy, pulmonary embolus, hemorrhage from trauma, or ruptured ectopic pregnancy. Hypoglycemia should also a consideration in patients that do not spontaneously return to baseline mental status
+What assessment should be performed in the field?
A thorough cardiac, pulmonary and neurologic assessment are necessary, including taking an appropriate history and physical examination.
For HPI – obtain signs and symptoms and their duration before and after the syncopal event. Was there any precipitating factors that could cause the patient to feel nauseated or upset.
For past medical history obtain information about other syncopal events in the past and what was the outcome; obtain information about family members ill with similar symptoms or if there has been a family member with sudden death or serious heart or pulmonary problem (e.g. hypertrophic cardiomyopathy, prolonged QT syndrome, Brugaga, or pulmonary emboslism); obtain information on pregnancy (e.g., ectopic pregnancy), and travel history (e.g., pulmonary embolism with long plane flights).
On physical exam listen for heart murmurs and check for equal pulses in the upper/lower extremities as well assess vital signs. The patient should be placed on the cardiac monitor. If a dysrhythmia is identified or there is a possible cardiac cause of syncope, a 12-lead ECG should be obtained. When reading the 12-lead ECG, look for signs of ischemia (ST-segment elevation or depression), dysrhythmias, and intervals that are prolonged or shortened (this includes the PR, QRS and, in particular, the QT interval). A blood glucose is important if the patient has not returned to his or her baseline mental status or remains unconscious.
The cardiopulmonary exam is normal, with normal lung sounds and no cardiac murmur. Her blood sugar is 132 mg/dL. The cardiac monitor shows a normal sinus rhythm. The paramedics then perform a 12-lead ECG, which is shown below.
Obtaining a high quality tracing is crucial to appropriate interpretation. In evaluating the ECG, the first step, after noting the rate, is to determine if it is a normal sinus rhythm: This ECG has a regular rate and rhythm, with a P wave before every QRS complex, a QRS after every P, and the P wave in lead II is upright, so the rhythm is sinus. Next, the paramedic must evaluate for signs of ischemia: There is no ST-segment elevation or depression, so STEMI criteria are not met. The next step is to look at the intervals. This is particularly important for patients presenting with syncope. The PR and QRS intervals are normal at 0.12 msec and 0.10 msec respectively. The QT interval is very prolonged. Grossly, it appears to be over half of the R-R cycle, which is a quick sign that it is abnormally long. Measuring the boxes, the QT is over 600 msec. A normal QT is ≤ 440 msec in men and ≤ 460msec in women, with QT >500msec raising particular concern.
Photo from: Life in the Fastlane. http://lifeinthefastlane.com/ecg-library/basics/qt_interval/
+What are the main causes of prolonged QT?
Congenital prolonged QT syndrome is a primary cause of a prolonged QT interval. There are also acquired abnormalities that can affect the QT interval including hypokalemia, hypomagnesemia, hypocalcemia, hypothermia, ischemia, and several medications (e.g. antibiotics such as azithromycin or psychiatric medications such as haloperidol).
+What is the significance of prolonged QT on the ECG?
QT interval prolongation is indicative of prolonged cardiac membrane repolarization. Prolonged repolarization increases the risk of premature depolarization during this refractory period. An impulse during the refractory period can trigger a dysrhythmia known as torsades de pointes, a French term that literally means "twisting of the points”. Torsades is a type of polymorphic ventricular tachycardia that appears to twist around the isoelectric line.
+What treatment should be initiated on this patient?
Since the patient had a syncopal event with prolonged QT on her ECG, she is at high risk for ventricular tachycardia, specifically for torsades de pointes. Paramedics should be prepared to manage a dysrhythmia should it occur during their period of management. It is appropriate to place defibrillator pads on the patient’s chest given her high risk of dysrhythmia, so that she can be immediately defibrillated or cardioverted as appropriate should a ventricular dysrhythmia occur. An IV saline lock should be established. IV fluids are appropriate if the patient appears hypovolemic, but there is no indication of dehydration or hypovolemia in this case. In addition to electrical cardioversion, IV magnesium sulfate will be administered in the emergency department to decrease the QT interval length and prevent recurrence of the dysrhythmia. Patients with syncope and any vital sign, exam, or 12-lead ECG abnormalities should be strongly advised against signing out AMA from paramedic care. Any AMA decision by these patients should be referred to the base station for discussion and counseling.
The patient signed out AMA from paramedic care, because she had her 2 small children with her. Later that week, she had another sudden loss of consciousness. This time she was found pulseless and apneic; a witness started CPR. When paramedics arrived, she was in pulseless ventricular tachycardia. She was defibrillated and had return of spontaneous circulation (ROSC). Thanks to early bystander CPR and rapid defibrillation to normal sinus rhythm, she recovered and is neurologically intact. She was diagnosed with congenital prolonged QT syndrome. She had an internal defibrillator placed and is doing well.
Take Home Points
- Patients with prolonged QT (QT interval >440 msec or greater than half the length of the R-R interval) are at risk for torsades de pointes, a polymorphic ventricular tachycardia.
- Have a low threshold to obtain a 12-lead ECG in a patient with syncope, particularly if the patient is refusing transport.
- When reviewing a ECG rhythm strip and/or 12-lead ECG for a patient with syncope, in addition to evaluating for dysrhythmia, look for prolonged intervals, especially the QT interval.
- Patients with syncope and/or abnormal ECG intervals require ALS monitoring en route to the emergency department. Be prepared to treat the patient with defibrillator pads in place if ECG abnormalities are noted.
Moskovitz JB, Hayes BD, Martinez JP, Mattu A, Brady WJ. Electrocardiographic implications of the prolonged QT interval. Am J Emerg Med. 2013 May;31(5):866-71.
El-Sherif N, Caref EB, Yin H, Restivo M. The electrophysiological mechanism of ventricular tachyarrhythmias in the long QT syndrome: three-dimensional mapping of activation and recovery patterns. Circ Res79: 474-492, 1996.
|Acknowledgements: The EMS Agency would like to thank Dr. Ashley Sanello for her contribution of the above case
ECG -- February 2017
A 57 year old man complains of mid-sternal sharp chest pain radiating to his back and jaw. The pain started while he was watching a football game on television, approximately 2 hours prior to calling 911. The patient denies any medical history. However, his wife endorses a history of untreated hypertension.
+What does this ECG show?
+How would you manage this patient?
||Sinus vs Accelerated Junctional rhythm
|ST Elevation >1mm in two or more contiguous leads?
||V2, V3, II, aVF
||PVC noted (see V4-V6) with wavy baseline
In the following diagrams, the green lines connecting adjacent P waves to T waves indicate the electrical baseline. ST elevations are shown in V2 and V3, representing an acute myocardial infarction (MI) in the anterior wall of the left ventricle.
ST elevations are more subtle in II and aVF, leads representing the inferior wall of the left ventricle. ST elevation is also noted in lead III, although it does not meet the >1mm criteria. While looking at lead II, one can also note that P waves are not reliably noted. While the rate argues for a sinus rhythm, this may alternatively represent an accelerated junctional rhythm. The choice between these two should not change management or additional interpretation of the ECG.
There were no obvious reciprocal changes on this ECG. Close examination of the ECG demonstrates an isolated PVC recorded on the ECG. While not inherently dangerous, the presence of ectopy (abnormal beats) in the setting of cardiac ischemia should be monitored closely. Acute MI may lead to a variety of conduction abnormalities, including heart blocks, ventricular tachycardia, or ventricular fibrillation.
The paramedic should be aware of this risk, and closely monitor the patient for early intervention if they should develop cardiac dysrhythmia.
The patient is having chest pain of a presumed cardiac cause, and the ECG shows STEMI. He should receive 162mg or 324mg PO aspirin, and may be given NTG 0.4mg SL every 5 minutes as needed for chest pain. The ECG should be transmitted to the STEMI Receiving Center for advance notification. Frequent patient reassessments en route should include repeat vital signs, assessment of mental status, and monitoring for changes in rhythm.
By Shira A. Schlesinger MD, MPH, Los Angeles County EMS Agency
* November 2016
* October 2016
* September 2016
Cheecgck out these prior ECG cases, click HERE
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*Suggestions for future cases and ECGs
Marianne Gausche-Hill, MD, FACEP, FAAP
EMS Agency Medical Director
Tel: (562) 347-1600
Fax: (562) 941-2306
Nichole Bosson, MD, MPH
Assistant Medical Director
Shira Schlesinger, MD, MPH
Tel: (562) 347-1570
Fax: (562) 944-6091
Kevin Andruss, MD
Paula Whiteman, MD
Millicent Wilson, MD
Disaster Training Unit Medical Director
Tel: (562) 347-1609
Translation in progress.....