Issues related to the use of Tourniquets on the Battlefield.

Clink on this link below to view an interesting article on tourniquet use. We all know that for the last 10 -15 years tourniquets have come back into protocol as the treatment of choice for severe hemorrhage that has failed to controlled by direct pressure and hemostatic gauze. In a hostile situation there might not be time or room to try homeostatic agents so a tourniquet might be the device of choice. This article, among other issues, examines the use of traditional 1 " wide tourniquets as compared to the newer pneumatic tourniquets. One issue identified was the difficulty in generating enough pressure on the average size male thigh to stop severe lower extremity hemorrhage. The other finding was that tourniquets wider than 1" accomplished hemorrhage control with less pressure and therefore had less tissue injury underlying the tourniquet. It seems that newer pneumatic tourniquets accomplished hemorrhage control quicker and with less complications compared to narrower 1 " tourniquets. Pneumatic tourniquets have been used extensively in orthopedic surgery so they have been well tested in regards to hemorrhagic control.  The issue, of course, is how hospital based devices will fare in more rugged conditions. The article mentions one particular device.  The Delpi Military Tourniquet.  See link below. 

The other issues examined was the loosening or removal of a tourniquet prior to surgery and the length of time before tourniquet application results in limb ischemia / damage. It seems that tourniquets applied for under 120 minutes do not result in any additional limb damage.  Removal or loosening is more conversational.  Protocols differ from region to region, so you must follow your regional protocol.  To this author it would seem reasonable to loosen a tourniquet that has achieved hemorrhage control if you are approaching the 120 minute mark and assess for resumption of bleeding.  If bleeding does not resume the tourniquet may remained loosened to prevent limb ischemia. Remember this is just a thought and does not constitute a treatment guideline.  You must always follow your protocols and Medical Directors guidelines. It would be rare in civilian prehospital emergency medicine to be with a patient who has had a tourniquet on for 120 minutes so the issue is probably not that pressing. Of course you might be performing a back county rescue, dealing with a lockdown / active shooter, or confined space situation so the issue should be addressed and protocols developed. 

Link to article

Delfi Emergency Military Tourniquet website

Delphi Military Tourniquet Brochure

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K2 Epidemic - Synthetic Cannabinoids

What are synthetic cannabinoids?

Synthetic cannabinoids refer to a growing number of man-made mind-altering chemicals that are either sprayed on dried, shredded plant material so they can be smoked (herbal incense) or sold as liquids to be vaporized and inhaled in e-cigarettes and other devices (liquid incense). 

These chemicals are called cannabinoids because they are related to chemicals found in the marijuana plant. Because of this similarity, synthetic cannabinoids are sometimes misleadingly called "" (or "fake weed"), and they are often marketed as "safe," legal alternatives to that drug. In fact, they may affect the brain much more powerfully than marijuana; their actual effects can be unpredictable and, in some cases, severe or even life-threatening.

False Advertising

Synthetic cannabinoid products are often labeled "not for human consumption." Labels also often claim that they contain "natural" material taken from a variety of plants. However, the only parts of these products that are natural are the dried plant materials. Chemical tests show that the active, mind-altering ingredients are cannabinoid compounds made in laboratories.

Synthetic cannabinoids are included in a group of drugs called Synthetic cannabinoids are included in a group of drugs called "new psychoactive substances" (NPS). NPS are unregulated psychoactive (mind-altering) substances that have become newly available on the market and are intended to copy the effects of illegal drugs. Some of these substances may have been around for years but have reentered the market in altered chemical forms or due to renewed popularity.

Manufacturers sell these herbal incense products in colorful foil packages and sell similar liquid incense products, like other e-cigarette fluids, in plastic bottles. They market these products under a wide variety of specific brand names; in past years, K2 and Spice were common. Hundreds of other brand names now exist, such as Joker, Black Mamba, Kush, and Kronic.

For several years, synthetic cannabinoid mixtures have been easy to buy in drug paraphernalia shops, novelty stores, gas stations, and through the Internet. Because the chemicals used in them have a high potential for abuse and no medical benefit, authorities have made it illegal to sell, buy, or possess some of these chemicals. However, manufacturers try to sidestep these laws by changing the chemical formulas in their mixtures.

Easy access and the belief that synthetic cannabinoid products are "natural" and therefore harmless have likely contributed to their use among young people. Another reason for their use is that standard drug tests cannot easily detect many of the chemicals used in these products. 

How do people use synthetic cannabinoids?

Users usually smoke the dried plant material sprayed with synthetic cannabinoids. Sometimes they mix the sprayed plant material with marijuana, or they brew it as tea. Other users buy synthetic cannabinoid products as liquids to vaporize them in e-cigarettes.

How do synthetic cannabinoids affect the brain?

Synthetic cannabinoids act on the same brain cell receptors asdelta-9-tetrahydrocannabinol (THC), the mind-altering ingredient in marijuana.

So far, there have been few scientific studies of the effects of synthetic cannabinoids on the human brain, but researchers do know that some of them bind more strongly than marijuana to the cell receptors affected by THC, and may produce much stronger effects. The resulting health effects can be unpredictable.

Because the chemical composition of many synthetic cannabinoid products is unknown and may change from batch to batch, these products are likely to contain substances that cause dramatically different effects than the user might expect.

Synthetic cannabinoid users report some effects similar to those produced by marijuana:

• elevated mood
• relaxation
• altered perception—awareness of surrounding objects and conditions
• symptoms of psychosis—delusional or disordered thinking detached from reality

Foto, ©iStock.com/trendobjects

Psychotic effects include:

• extreme anxiety
• confusion
• paranoia—extreme and unreasonable distrust of others
• hallucinations—sensations and images that seem real though they are not

• What are some other health effects of synthetic cannabinoids?
  People who have used synthetic cannabinoids and have been taken to emergency rooms have shown severe effects including:
  • rapid heart rate
  • vomiting
  • violent behavior
  • suicidal thoughts
  Synthetic cannabinoids can also raise blood pressure and cause reduced blood supply to the heart, as well as kidney damage and seizures. Use of these drugs is associated with a rising number of deaths. 

  Are synthetic cannabinoids addictive?

  Foto, Humannet/©Shutterstock
  Yes, synthetic cannabinoids can be addictive. Regular users trying to quit may have the following withdrawal symptoms:
  • headaches
  • anxiety
  • depression
  • irritability
  Behavioral therapies and medications have not specifically been tested for treatment of addiction to these products. 

  Points to Remember

• Synthetic cannabinoids refer to a growing number of man-made mind-altering chemicals sprayed on dried, shredded plant material or vaporized to get high.
• Synthetic cannabinoids are sometimes misleadingly called "synthetic marijuana" (or "fake weed") because they act on the same brain cell receptors as delta-9-tetrahydrocannabinol, the mind-altering ingredient in marijuana.
• The effects of synthetic cannabinoids can be unpredictable and severe or even life-threatening.
• The only parts of synthetic cannabinoid products that are "natural" are the dried plant materials. Chemical tests show that their active ingredients are man-made cannabinoid compounds.  
• Synthetic cannabinoid users report some effects similar to those produced by marijuana:
  • elevated mood
  • relaxation
  • altered perception
  • symptoms of psychosis
• Synthetic cannabinoids can also cause serious mental and physical health problems including:
  • rapid heart rate
  • vomiting
  • violent behavior
  • suicidal thoughts
• Synthetic cannabinoids can be addictive.
• Behavioral therapies and medications have not specifically been tested for treatment of addiction to these products.

• Treatment Overview:

  INHALATION EXPOSURE A) MANAGEMENT OF MILD TO MODERATE TOXICITY 1) For mild and moderate toxicity, treatment consists primarily of supportive care. Most patients do not require any specific treatment and, especially with an inhalational exposure, symptoms should resolve in a few hours. B) MANAGEMENT OF SEVERE TOXICITY 1) Treatment is symptomatic and supportive. Administer benzodiazepines for agitation or delirium. Consider diphenhydramine for dystonia or rigidity. SEIZURES: Initially treat with benzodiazepines, add propofol or barbiturates if seizures persist. Airway support as needed. TACHYCARDIA: In agitated patients, tachycardia usually responds to benzodiazepine sedation. Obtain a baseline ECG and institute continuous cardiac monitoring. CHEST PAIN: Myocardial infarction has been reported in adolescents abusing THC homologs. Perform serial ECGs, institute continuous cardiac monitoring and obtain serial troponin concentrations. Treat with aspirin, nitroglycerin and benzodiazepines. ABSTINENCE SYNDROME: Abrupt discontinuation of chronic use can cause profuse sweating, tremors, palpitations, insomnia, headache, depression, diarrhea, nausea, and vomiting. Treat with benzodiazepines. C) ABSTINENCE SYNDROME 1) Abrupt discontinuation of chronic use can cause profuse sweating, tremors, palpitations, insomnia, headache, depression, diarrhea, nausea, and vomiting. Treat with benzodiazepines D) DECONTAMINATION 1) Primary route of exposure is via inhalation; gastrointestinal decontamination is not necessary even if these substances are ingested. E) AIRWAY MANAGEMENT 1) Rarely necessary, but perform early if life-threatening cardiac dysrhythmias, significant agitation/delirium or seizures develop. F) ANTIDOTE 1) None. G) DELIRIUM 1) Treat agitation/delirium in patients with suspected exposure to THC homologs with oral or IV benzodiazepines.

Pelvic Fractures

Pelvis Fractures

Anatomy

The pelvis is a ring-like structure of bones at the lower end of the trunk. The two sides of the pelvis are actually three bones (ilium, ischium, and pubis) that grow together as people age. Strong connective tissues (ligaments) join the pelvis to the large triangular bone (sacrum) at the base of the spine. This creates a bowl-like cavity below the rib cage. On each side, there is a hollow cup (acetabulum) that serves as the socket for the hip joint.

Many digestive and reproductive organs are located within the pelvic ring. Large nerves and blood vessels that go to the legs pass through it. The pelvis serves as an attachment point for muscles that reach down into the legs and up into the trunk of the body. With all of these vital structures running through the pelvis, a pelvic fracture can be associated with substantial bleeding, nerve injury, and internal organ damage.

Management of Exsangunating Pelvis Injuries

Introduction

Trauma patients who present with unstable pelvic fractures have sustained a high energy injury that is commonly associated with disruption of arteries and veins resulting in major hemorrhage. Patients with pelvic fractures who present in shock have a mortality of 30-50%. When combined with injuries in other body regions such as the abdomen, the mortality rises even higher, approaching 100% in some series. However a systematic multidisciplinary approach to these injuries, directed initially only at hemorrhage control, can lead to significant improvements in survival.

Key Points

Pelvic Injury

• An unstable pelvic injury with signs of shock should be treated as a vascular injury.
• Hemorrhage may be from fractured bone and disrupted veins and arteries.
• High energy trauma is associated with multi-cavity injury, and there may be hemorrhage in the chest or abdomen as well as the pelvis and long bones.

Management

• A multidisciplinary approach is essential. All team members must know their roles and key decisions.
• Appropriate resuscitation maneuvers are as important as hemorrhage control interventions.
• Management of massive transfusion, coagulopathy and hypothermia are vital for success.
• A damage control approach should be adopted for all these patients: do the minimum necessary to save life.

Potential dangerous side effects with the over administration or rapid administration of Naloxone.

While Naloxone has been proven to be an effective treatment in the patients suffering from respiratory depression secondary to Opioid use; there is a growing and troubling number of reports of potentially life threatening side effects with excessive dosing or rapid administration of Naloxone. 

It has been well documented that patients receiving Naloxone may experience symptoms of Opioid withdrawal. These symptoms may include: nausea, vomiting, headache and irritability.  

The administration of high-dose Naloxone and/or rapidly infused Naloxone may cause catecholamine release and consequently pulmonary edema, hypertension, and cardiac arrhythmia. These risks warrant the cautious use of Naloxone and adequate monitoring of the cardio-respiratory status of the patient after Naloxone administration is indicated. 

The best treatment is prevention. Administer Naloxone slowly and give it 1-3 minutes to be absorbed. If your patient's respiratory status is poor use the BVM to support ventilations until the Naloxone begins to work.  

Remember that Naloxone has a short half life so it may be necessary to administer a 2nd dose if you are still with your patient after 20 to 30 minutes and they show signs of the Naloxone losing its reversal effects. 

DABBING: WHAT YOU NEED TO KNOW ABOUT THE LATEST MARIJUANA CRAZE

Have you heard of dabbing? Dubbed the "crack of pot,” dabbing is a form of consuming highly concentrated marijuana in a vaporized form and has been described as freebasing marijuana in popular media outlets. Once an underground practice, this dangerous trend has gained popularity in recent months and could change the culture of marijuana use. 

What is dabbing?

Dabbing allows the user to ingest a high concentration of Tetrahydrocannabinol (), the psychoactive ingredient in marijuana. Butane Hash Oil (BHO), an oil or wax-like substance extracted from the marijuana plant, is placed on a “nail” attached to a specialized glass bong called a “rig.” A blow torch is used to heat the wax, which produces a vapor that can then be inhaled. This ingestion method means the effects of dabbing can be felt instantaneously.

A practice related to dabbing includes placing hash oil in vaping devices, which look like e-cigarettes and don’t emit any smoke. This decreases opportunities to get caught using hash oil, and gives middle and high school aged youth the opportunity to get high in increasingly public places, even at school.

Popularity with inhaling hash oil is increasing because it is the fastest way to get an intense high. Smoking a tic-tac sized drop of BHO, or “hash oil,” is equivalent to two or three typical sized portions of marijuana hitting the system all at once.

In some states you can buy hash oil at medical marijuana dispensaries. Other states have black market services that deliver the hash oil right to your door. When all else fails, people can make it themselves using flammable solvents such as alcohol or butane, which can lead to explosions and serious injuries. Step-by-step instructions with pictures and videos are available online and only require a quick Google search. The ability of teens to easily access the supplies and information needed for dabbing is a cause of great concern.

Dangers of dabbing

Making hash oil may be one of the most dangerous aspects of dabbing. BHO is extracted by blasting butane, also known as lighter fluid, through the marijuana plant.

There have been increasing news reports of houses and apartment buildings exploding as a result of the extraction process, leaving individuals in need of skin grafts and reconstructive surgery for severe burns, broken bones or can even lead to death. The increase in explosions was severe enough for the Federal Emergency Management Agency (FEMA) to issue a special warning about the dangers of manufacturing hash oil. As of November 2014, the Los Angeles Division of the Drug Enforcement Administration (DEA) confirmed 49 explosions nationwide related to marijuana extraction. In addition, contaminants in the hash oil, including butane and other neurotoxins, can lead to serious allergic reactions and even poisonings.Dabbing comes with a slew of negative side effects, including a rapid heartbeat, blackouts, feeling like something is crawling under the skin, loss of consciousness and psychotic symptoms, including paranoia and hallucinations.

As this trend grows, more YouTube videos are being uploaded by teens chronicling their dabbing experiences. These videos showcase teens dabbing for the first time or experimenting with higher and higher doses trying to outdo their peers on the Internet. Many of these videos feature the individuals falling out of chairs, unable to move on their own and pleading with their friends to call for medical assistance.

What we still don’t know about dabbing

Most research on marijuana has been conducted with much lower concentrations of THC than what is found in BHO. Research already shows that smoking marijuana is harmful for teens. While a typical marijuana joint has 15 percent THC, reports suggest that hash oils can have THC concentration levels as high as 60-90 percent.

We do know that marijuana can be addictive, especially for those who begin experimenting at younger ages. A preliminary study found that people who report daily use of marijuana and occasional dabbing have a harder time cutting back or quitting, need to use more of the substance to get the same effect and find it difficult to switch back to smoking marijuana with lower THC concentrations.

As more states legalize medical or recreational marijuana, it appears likely that dabbing will become more widespread among teens. It is important that parents understand the dangers and know the warning signs so they can intervene if needed.

Herion laced with Xylazine

Attached is information that the HVREMS put out last Friday; forwarded to them by the Susquehanna Regional office. I did a quick look online and this does not seem to be a new issue, but it may be new to our area.

Naloxone would still be effective in reversing the Opioid, but the patient may remain in respiratory depression / arrest from the Xylazine.  Management for this would be to support ventilations. There is a higher incident of cardiac arrest due to Xylazine negative chronotropic effect and a decrease in cardiac contractility.    If anyone has any experience with managing this type of patient please let me know.

Click on  the link below for more information:

Link to article

Thanks,

 

Frank

 

 

FDA Advisory on Heartmate and Heartware LVADS

Please see the FDA advisory below. The advisory seems to indicate that the rate of complications from bleeding and embolic events is higher in  actual use than it was during the clinical trials. Both events are known complications of LVAD use.  Since there is no alternative for the patient with a severely damaged left ventricle LVADS will continued to be utilized, but these issue will be more carefully studied.

For the complete advisory click on this link.

http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm457327.htm?source=govdelivery&utm_medium=email&utm_source=govdelivery

Thanks,

Frank

Serious Adverse Events with Implantable Left Ventricular Assist Devices (LVADs): FDA Safety Communication

Date Issued: August 5, 2015
Audiences:

• Health care providers treating heart failure patients
• Patients with a LVAD
• Caregivers of patients with a LVAD

Specialties: Cardiology, Cardiac Surgery, Heart Failure, Heart Transplantation
Product:
Implantable LVADs help the left ventricle (the main pumping chamber of the heart) circulate blood throughout the body in patients with advanced heart failure. The devices consist of a blood pump, power pack and controller. The blood pump is implanted inside a patient’s body and attached to the heart’s left ventricle and to the aorta. The power pack and controller are connected to the blood pump and carried by the patient outside the body.
LVADs are approved for bridge-to-transplant (BTT) or destination therapy (DT). BTT refers to providing circulatory support to a patient at risk of imminent death from non-reversible left ventricular heart failure until a donor heart becomes available for a heart transplant. DT refers to providing circulatory support to a patient with end-stage left ventricular heart failure who is not candidate for a heart transplant.
To date, there are two implantable LVADs approved by the FDA:

• The HeartMate II Left Ventricular Assist System manufactured by Thoratec Corporation, approved for BTT in 2008 and DT in 2010 and
• The HeartWare Ventricular Assist System HVAD manufactured by HeartWare, Inc., approved only for BTT in 2012.

Purpose: The FDA is alerting health care providers, patients, and caregivers about serious adverse events associated with LVADs. These adverse events include an increased rate of pump thrombosis (blood clots inside the pump) with Thoratec’s HeartMate II and a high rate of stroke with the HeartWare HVAD since approval of the devices. We are also aware of bleeding complications associated with both devices.
Summary of Problem and Scope:
The FDA is aware of serious adverse events associated with both devices.

Thoratec HeartMate II:
The FDA has received reports and information from a variety of sources indicating an increase in the rate of pump thrombosis events in patients implanted with the HeartMate II. Information also shows that patients are experiencing pump thrombosis events earlier than observed during the clinical trials conducted to support the product’s approvals in 2008 (BTT) and 2010 (DT). For example, two analyses in the scientific literature reported the confirmed (after explant) HeartMate II pump thrombosis rate as high as 8.4% of implanted devices at 3 months (Starling et al, 2013) and 6% of implanted devices at 6 months (Kirklin et al, 2014). This is compared to 1.6% of implanted devices at one year during the BTT clinical trial and 3.8% of implanted devices at 2 years during the DT clinical trial.
Pump thrombosis is a serious complication that can require repeat surgery to replace the pump or can lead to death.
HeartWare HVAD:
The FDA is aware of recently reported results from a clinical trial designed to evaluate the safety and effectiveness of the HeartWare HVAD when used for the DT indication. Investigators reported 28.7% of HVAD patients experienced one or more strokes over two years, compared to 12.1% among patients implanted with the control device (HeartMate II). Although the HVAD is not currently approved for DT, it is the same device approved for the BTT indication.
Stroke is a serious complication that can lead to permanent patient disability and death.
Thoratec HeartMate II and HeartWare HVAD:
The FDA is aware of bleeding complications related to both the Thoratec HeartMate II and HeartWare HVAD, through adverse event reports and information from a variety of sources. The cause of bleeding complications is not fully understood, but is likely due to many different factors. One possible factor may be modification to blood thinning (anticoagulation) therapy in an attempt to lower the risks of pump thrombosis and embolic stroke.
Bleeding is a serious complication that can lead to death.

Recommendations:
The FDA recognizes that LVADs are life-sustaining, life-saving devices for patients with advanced left ventricular heart failure. When used for the currently approved indications in appropriately selected patients, we believe the benefits of these LVADs continue to outweigh the risks. However, the FDA also believes it is important for health care providers and patients to be aware of this important information when considering the use of these devices and clinical management of their patients.
Health Care Providers:

• Perform a thorough clinical evaluation, assessing the benefit-risk profile of each patient in determining the most appropriate treatment plan and, if necessary, selecting a device.
• Consider the risks for pump thrombosis, stroke, and bleeding when determining the appropriate therapy for individual patients.
• Review the current device labeling prior to making treatment decisions if you are considering using either of these devices.
• Return all explanted LVAD devices and components to their respective manufacturer. In the case of LVAD-related pump thrombosis and other adverse events, manufacturer evaluation of the affected device is critical to better understand the reasons for these adverse events.
  

Patients/Caregivers:

• Discuss openly and in detail the benefits and risks of any therapy being considered by your heart failure specialist, cardiologist and surgical team. This discussion should include:
  • your risks of developing an adverse event like a blood clot or stroke and the potential side effects if you do experience an adverse event.
  • how the benefits and risks of the device compare to other non-LVAD medical therapies.
• If you have any concerns regarding your device, discuss them with the health care providers managing your heart failure.

FDA Actions:

Thoratec HeartMate II:
The FDA has extensively evaluated all available information, including adverse event reports received by FDA, data from Thoratec, data from the scientific literature, and data from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). Our analysis did not identify discrete, device-specific reasons for the reported rise in pump thrombosis. The FDA acknowledges the risks of pump thrombosis for HeartMate II have increased since the time of approval. However, careful review of all available data suggests the benefits of the device, when used in appropriately selected patients, continue to outweigh the risks for the currently approved indications.
The FDA has been working with Thoratec to better understand and explain the increased incidence of pump thrombosis. On August 5, 2014, the FDA approved updated labeling for the HeartMate II that includes the risk of pump thrombosis.
Thoratec is currently conducting a prospective, multi-center, non-randomized study designed to assess the incidence of HeartMate II pump thrombosis and to identify the risk factors associated with pump thrombosis events. Details of this study can be found on the National Institutes of Health ClinicalTrials.gov website: https://clinicaltrials.gov/show/NCT02158403.
HeartWare HVAD:
The FDA is concerned about the reported stroke rates but at this time, believes the benefits of using the device continue to outweigh the risks for the currently approved BTT indication. The FDA also believes it is appropriate to continue the clinical investigation of this device in the DT population with the careful monitoring procedures currently in place. The FDA continues to evaluate all available information, including adverse event reports received by FDA, data from HeartWare, data from the scientific literature, and data from INTERMACS for the currently approved BTT indication, as well as the data from the DT clinical trial. As more information about the risks associated with the device becomes available, the FDA will work with HeartWare to identify any future actions that may be appropriate.
HeartWare is currently conducting a prospective, randomized, controlled, un-blinded, multi-center study to assess whether optimal blood pressure management can help lower the incidence of stroke in DT patients implanted with an HVAD. Details of this study can be found on the National Institutes of Health ClinicalTrials.gov website: https://clinicaltrials.gov/show/NCT01966458.

Reporting Problems to the FDA:
Prompt reporting of adverse events can help the FDA identify and better understand the risks associated with LVADs.
If you suspect or experience a problem with an LVAD, we encourage you to file a voluntary report through MedWatch, the FDA Safety Information and Adverse Event Reporting program. Health care personnel employed by facilities that are subject to FDA's user facility reporting requirements should follow the reporting procedures established by their facilities.
Additional Resources:

• Thoratec Corporation: HeartMate II Instructions for Use and Manuals (USA)
• HeartWare, Inc.: HVAD System Instructions for Use and Manuals (USA)
• 
  

Legionnaires’ Disease Outbreak Hits South Bronx

New York City health officials are tracking an outbreak of that has killed two people and sickened dozens of others in the South Bronx, Mayor Bill de Blasio’s administration said Wednesday.

The Department of Health and Mental Hygiene said 31 cases have been reported since July 10.
Most of the cases have been reported from the South Bronx neighborhoods of Highbridge, Morrisania, Hunts Point and Mott Haven, officials said.

“We are conducting a swift investigation to determine the source of the outbreak and prevent future cases,” said Mary Bassett, the health commissioner.

Dr. Bassett said officials are “concerned about this unusual increase” in cases in the South Bronx. She described the outbreak as an “evolving situation in which the numbers may change.”

Legionnaires' Disease (Legionellosis) Download a PDF version of the Legionellosis FAQs What is Legionnaires’ disease? Legionnaires’ disease (or Legionellosis) is a type of pneumonia. It is caused by a type of bacteria (Legionella) that grows in warm water.  Is the disease contagious? No. Legionnaires’ disease is not spread from person to person. People only get sick by breathing in water vapor containing the bacteria (for example, by inhaling contaminated mist from faucets, showers, whirlpools or cooling towers). People who are sick cannot make others sick.  Who is at risk? Groups at high risk include people who are middle-aged or older—especially cigarette smokers—people with chronic lung disease or weakened immune systems and people who take medicines that weaken their immune systems (immunosuppressive drugs).  What are the symptoms of Legionnaires’ Disease? Symptoms resemble other types of pneumonia and can include fever, chills, muscle aches and cough. Some people may also have headaches, fatigue, loss of appetite, confusion or diarrhea. What should I do if I think I have Legionnaires’ disease? If you have symptoms such as fever, chills and cough, call a doctor and get checked for pneumonia. If you have a medical condition that affects your breathing, like emphysema, or if you are a smoker, ask your doctor about testing for Legionnaires’ disease.  What is the treatment for Legionnaires’ disease? The disease is treated with antibiotics. Most people get better with early treatment, although they may need to be hospitalized. In rare cases, people may get very sick or even die from complications of the disease. The Health Department is currently investigating an outbreak of Legionnaires’ disease in the South Bronx. The Health Department is actively investigating and is testing water from cooling towers and other potential sources in the area to determine the source of the outbreak. If you live in the area and experience respiratory symptoms, such as fever, cough, chills and muscle aches, seek medical attention right away.

Clarification on the use of Nitroglycerin by NYS EMTs

The other night one of our hospitals sponsored a CME on cardiac emergencies.  A local cardiologist spoke to a group of EMTs from New York and New Jersey about the in-hospital management of the STEMI (ST elevation myocardial infarction) patients at this hospital.  In the course of the discussion the use of nitroglycerin was discussed.  In less than a minute it became clear that confusion exists on the pre-hospital BLS use of nitroglycerin in NYS by EMTs. Hopefully this post will clear up some of the confusion.

Let’s review:

The NYS BLS Protocol (Adult Cardiac Related Problem) allows NYS EMTs to assist a patient with the use of THEIR previously prescribed nitroglycerin in certain situations.

This means that we are assisting a patient with taking their own prescribed nitroglycerin. NYS EMTs and NYS BLS EMS units do not carry nitroglycerin.  If the patient does not possess their own prescribed nitroglycerin at the time of their cardiac event we would therefore be unable to assist them in taking nitroglycerin. In other words, you cannot use anyone else's nitroglycerin on your patients.

The situations where it may appropriate for NYS EMT's to consider the use of nitroglycerin include Angina Pectoris and Acute Myocardial Infarction.

So to assist a patient with nitroglycerin the following criteria should exist:

1.  The patient should be experiencing signs and symptoms of symptomatic Angina Pectoris or Acute Myocardial Infarction.  This may include but is not limited too.  Chest, back and/or abdominal pain and/or discomfort from myocardial ischemia. (Lack of O2 to the myocardium), difficulty in breathing, nausea / GI complaints, diaphoresis (cool, pale, clammy skin), Always beware of atypical presentations in some patients, especially the elderly, diabetics, and women. Some patients may only present with fatigue, weakness, mild shortness of breath, and pain to the jaw / arm.

2.  The patient must consent to treatment.

3.  The patient's systolic blood pressure must be higher than 120 mmHg.

4.  The patient must not have taken Sildenafil citrate (Viagra, Levitra, or Cialis) or similar medications within 72 hours. These medications are primarily used to treat erectile dysfunction in males; but may used to treat pulmonary hypertension in both males and female patients.

5.  Use nitroglycerin with caution in suspected nitroglycerin.   An inferior wall myocardial infarction occurs when the inferior myocardial tissue supplied by the right coronary artery (RCA), is injured due to thrombosis of that vessel. When an inferior myocardial infarction extends to posterior regions as well, an associated posterior wall myocardial infarction may occur. Inferior wall myocardial infarction involves the lower (inferior) wall of the heart which sits above the diaphragm / stomach. Because of proximity to the abdomen many patients experiencing an inferior wall MI have more abdominal versus cardiac complaints. The reason why nitroglycerin should be used with caution is that approximately 40 % of inferior wall MIs have what is called right ventricular extension.  Right ventricular extension means that the myocardial damage has extended from the inferior wall to include the right ventricle also. The right ventricle is pre-load dependent.  Pre-load is the amount of de-oxygenated blood that is returning to the heart via the inferior and superior vena cava. Nitroglycerin causes vaso-dilation, which pools blood in the venous system.  This pooling reduces the amount of blood available to return to the heart (pre-load).  If we reduce pre-load we reduce cardiac output which leads to decreased blood pressure.  Reduction to pre-load and blood pressure may reduce blood flow to the coronary arteries which may lead to larger damage in the myocardium. To summarize, if we give nitroglycerin to a patient who is experiencing an inferior wall MI we may drop perfusion to the heart muscle which may cause a larger amount of heart damage.  

The next question should be:  How do we suspect an inferior wall MI on a BLS level?  If you have a suspected AMI patient who has more GI / Abdominal complaints then chest complaints think inferior wall.  There may also be an associated bradycardia with inferior wall MI.  Most AMI patients have an increase in their heart rate to the chest pain and anxiety about their medical condition. Some inferior wall MI patients will have bradycardia (HR 50 to 60) from ischemia to the AV node or increased vagal tone. Suspected AMI patients with abdominal symptoms / Complaints and bradycardia should receive nitroglycerin with extreme caution even if their blood pressure is above 120mmHg.  If in doubt about what to do, start transport, and contact medical control while enroute to your PCI (angioplasty) center.  What’s amazing is that the NYS protocol does not even address this, nor do most BLS instructors even mention this.

Some facts about inferior wall MIs:

• Inferior MIs account for 40-50% of all myocardial infarctions.
• Up to 40% of patients with an inferior STEMI will have a concomitant right ventricular infarction. These patients may develop severe hypotension in response to nitrates and generally have a worse prognosis.
• Up to 20% of patients with inferior STEMI will develop significant bradycardia due to second- or third-degree AV block. These patients have an increased in-hospital mortality (>20%).
• Inferior STEMI may also be associated with posterior infarction, which confers a worse prognosis due to increased area of myocardium at risk.

6.  If symptoms persist you may administer up to 3 doses of nitroglycerin, 5 minutes apart, as long as the B/P remains above 120 mm/Hg systolic.  Just remember the more nitroglycerin a patient receives the more likely it is for them to drop their blood pressure.

7.  Never give nitroglycerin to a standing patient, wait to get them on the stretcher. 

8.  Sublingual nitroglycerin is carried in spray or tablet (pill) form.  Tablet form does not have a great shelf life. One spray or one tablet is the same dose (0.4mg or 1/150th of a grain).  If a patient took their nitroglycerin prior to your arrival and does not have relief from their symptoms check that they took it right way and that it is not expired.  Potency may also be an issue.

9.  Potent (good) nitroglycerin usually will cause a mild tingling / burning sensation under the tongue if it is in the tablet form. Nitroglycerin spray or tablet usually causes a mild headache.

10.  Beside nitroglycerin the treatment for the AMI patient should include:

     a. Early notification and transport to a PCI (angioplasty) center.

     b. Position of comfort.  (To help relieve anxiety)

     c. O2 therapy.  Even though it may not be clinically correct, NYS protocol calls for high concentration O2. See my early post: EMS Myth -There's no such thing as too much oxygen. What we should be saying: - Can Oxygen Hurt??? For more info.

    d. Aspirin.  See my early post on Pharmacology for more info.

Hope this help.  If you have any questions or comments please reply to this post.

Frank

Air Ambulances Offer a Lifeline, and Then a Sky-High Bill

Please see the NY Times article below.  As advocates for our patients, we should include the financial burden the medical care we render or order places on patients, when making our decisions about patient care and transport methods. Air Methods, which is profiled in this article, is one of the two providers of air transport in the Hudson Valley.  Air Methods (Stock Symbol: AIRM) is a for profit, publicly traded company. The other provider of air transport in the Hudson Valley is Hackensack University Health Network, a large nonprofit health system. See the picture above, with their management team posing in front of their helicopter. 

Private insurance companies often balk at the cost of air transport, leaving the patient responsible for a large bill that was often not necessary nor requested by the patient. We have witnessed helicopters being used for patients who are then not even admitted to the hospital or released after observation. Air transport, is of course at times, appropriate.  Just consider the financial impact on your patient the next time you choose to fly a stable patient just because of mechanism of injury.  Often, these patients can be transported by ground, faster and at a much lower financial cost.

To read the NY Times are article please click on the link below.

http://www.nytimes.com/2015/05/06/business/rescued-by-an-air-ambulance-but-stunned-at-the-sky-high-bill.html?ref=health&_r=1