Being young and healthy ... can suck!

From time to time, viruses evolve that seem to kill a disproportionate number of the young and healthy. In certain cases  like the “Spanish Flu of 1918”, the SARS outbreak in Hong Kong, and the recent bird flu pandemics, a healthy immune system may have been a liability rather than an asset. Intuitively, this does not make sense.  Why would a healthy person be at greater risk? Well, I am glad you asked!

Have you ever heard of a cytokine storm?

When the body identifies a pathogen, an immune response ensues. Part of the immune system communication is a small cell-signaling protein molecule called cytokine, which tells immune cells like macrophages and T-cells to travel to the site of the infection. Cytokines also activates other immune cells, stimulating them to produce more cytokines in a process called a positive feedback loop.  Normally, this feedback loop is kept under control by some processes I do not understand; however, sometimes, the reaction becomes uncontrolled. This is known as a cytokine storm.

In other words, a cytokine storm causes an exaggerated immune response that can kill a person. The precise reason for this is not entirely understood but it is believed that this is the reason why a new and highly pathogenic invader causes higher fatality rates among young, healthy people with good immune systems.

How about … never mind, that sucks!

Dystonia - not a polish travel destination!

A recent case posted on an EMS related Facebook page asked providers if they can and would treat dystonic reactions in the field. Dystonia is a reversible extrapyramidal effect that can occur after administration of certain drugs, characterized by sustained involuntary contractions of muscles throughout the body. It is not a polish destination spot! With treatment, these symptoms can be alleviated quickly and safely - even in the prehospital setting.  So the answer to the question is: yes, a prehospital provider should treat dystonic reactions in the field!

However, I understand that many providers may not be familiar with this condition and how to treat it.  I am not certain if dystonia is listed in the teaching objectives of initial EMS classes, and therefore, continuous education may need to focus on more abstract conditions like dystonia and other disorders, especially if they are a potential side effect of medications we give in the field. As an example, dystonic reactions can be induced by a potent dopamine D2 receptor antagonist like haloperidol, and even by commonly given antiemetic medications like promethazine. A quick search on Medscape showed that “although dystonic reactions are occasionally dose related these reactions are more often idiosyncratic and unpredictable.” They reportedly arise from a drug-induced dopaminergic-cholinergic imbalance “which leads to an excess of striatal cholinergic output.”

The treatment is simple, and well within the scope of EMS providers – although medical control contact may be required for orders since this is not commonly mentioned in protocols. If you encounter a suspected dystonic reaction, IV administration of diphenhydramine 25-50 mg is repeatedly recommended by literature. The reason is that diphenhydramine, although an antihistamine also possesses significant anticholinergic properties. These properties may help by blocking striatal cholinergic receptors, therefore rebalancing cholinergic and dopaminergic activity.

How about that!!!

This effect or that!!!

Dr. Bryan E. Bledsoe, D.O., one of the foremost authors of EMT Text books stated: “The EMT of today must be knowledgeable in all aspects of prehospital emergency medicine. Nowhere is this more important than when administering medications.”  Every medication that we give to treat a disease exerts a biochemical effect on cells, tissues, or organs.  And we need to understand these effects to help us anticipate not only the local reaction, but the systemic responses from our drug administration.

Another reason to be deliberate at learning the mechanism of action of drugs, and learn to understand them at a cellular level, is to allow us to consider certain medications for “uncommon usages”.  But first, we need to understand that the medications we administer do not confer any new properties on cells or tissues; they only modify or exploit existing conditions.  To understand this fact and to learn the different pharmacodynamics of drugs can help us use certain medications for unusual circumstances.

Take Glucagon as an example. Besides the use of this medication in the hypoglycemia protocol, Glucagon can also be used for symptomatic bradycardia secondary to β-blocker overdose and Ca-channel blocker overdose, Steakhouse syndrome, and refractory anaphylaxis.

How? Well, I'm so glad you asked! The effects of Glucagon causes a “cascade of activations resulting in an increase of cyclic-AMP (cAMP). cAMP is an important intracellular messenger, responsible for carrying the signals of epinephrine and glucagon across the cell membrane. cAMP also regulates the flux of Ca2+ through ion channels independent of β-adrenergic receptors. This quality of Glucagon is what is thought to explain the various changes to the cardiovascular system seen after its administration.”

Want some more details on this, then check out my good buddies blog at “My Variables Only Have 6 Letters” and read his Glucagon 2.0 section.

How about that!!!

To the right, or to the left?

The art of ECG interpretation has become a mystery to me.  I know the basics.  I can pass the National Registry exam with flying colors. But since I have met some real masters of ECG interpretation, I realized that there is so much more to know – so much more to understand.  A good friend, and ECG wiz kid, told me: “You need to read things with some meat to it.”  This is so true!  ECG interpretation is so much more than just pattern recognition. You have to have a deeper understanding of what actually happens in the heart.

For an example, let us talk about ventricular ectopies for a minute.  We are all familiar with a premature ventricular contraction, more commonly referred to as simply a “PVC”.  A PVC is a relatively common event where the electrical complex of the heart is initiated by Purkinje fibers in the ventricles rather than by the sinoatrial node.  To recognize it on an ECG is easy – look for the “funny looking beat” (FLB) that is wide and ugly.

From Wikipedia, the free encyclopedia

However, if you want to determine if a PVC originated from the right or the left ventricle, then head on over to ems12lead.com and learn from real masters of ECG interpretation. Not only will you learn that “… ventricular complexes that originate in the left ventricle show RBBB morphology in lead V1. Conversely, ventricular complexes that originate in the right ventricle show LBBB morphology in lead V1.”  You can also bite into some of that proverbial “meat” of ECG knowledge.

How about that!

Can you smell the "bitter almonds"???

As long as there are legitimate uses of chemicals in our society, there is a high potential for first responders to encounter situations where chemicals will provide a life threat to the public and themselves.  A recent situation in my neighboring town forced paramedics to withdraw from a residence following the detection and identification of potassium cyanide, a highly lethal substance that an individual used to commit suicide with. 

Potassium cyanide is a solid compound that when moistened emits hydrogen cyanide due to hydrolysis - which smells like bitter almonds. Unfortunately, the ability to detect the “bitter almond” smell is limited to people with a certain genetic trait.  Thank goodness, from the reports I received, one of the lead medics on the scene detected an obnoxious smell which lead to the rapid evacuation from the residence and subsequent decontamination of the crew.

Cyanide is a potent inhibitor of cellular respiration, which prevents the body from oxidizing food to produce useful energy. This is what presents initially in acute cyanide poisoning as the classic red complexion in the victim because the tissues are not able to use the oxygen in the blood. The person loses consciousness, and death by hypoxia of neural tissue follows quickly.

Let’s hope that if you do not possess this genetic trait of being able to detect that smell of“bitter almond”, one of your partners does ….

How about that!

Close the Eyes

As a first responder, I hope you have heard of the Subway Sarin Incident in Tokyo on March 20, 1995.  There are many lessons to be learned in a case review of this terrorism incident perpetrated by members of a Japanese religious cult called Aum Shinrikyo.  If you have not, look it up… it will be worth your time.

A really interesting fact from this incident is that the most common complaint of victims and first responders alike was the sensation that "everything was going black, like they are entering a tunnel."  In a medical assessment, when we inspect the pupils in this event, we would find miosis.

Miosis is a term derived from the ancient Greek that means "to close the eyes".  It is a medical term that denotes a constriction of the pupils to an abnormal or excessive degree, caused, in this case, by exposures to an organophosphate based chemical weapon known as Sarin Nerve Gas (GB).

Nerve agents attack the nervous system by inactivating acetylcholinesterase (AChE), producing a toxic accumulation of acetylcholine (ACh) at the muscarinic, nicotinic, and CNS synapses. This causes an end organ overstimulation, which is often referred to as a cholinergic crisis. Vapor exposure of these nerve agents provides the most rapid onset of symptoms, and since the most exposed muscarinic receptors are found in the eyes, nerve agent vapor easily crosses the cornea and produces miosis.

So if you are ever responding to such an attack or another organophosphate based toxicological event, and you start to get literal “tunnel vision”, you know why!

How about that!