Hey all,
This week's EMS protocol is on pediatric respiratory distress/failure. The thought of a pediatric patient experiencing respiratory distress is enough to cause me to go into respiratory distress... but let's discuss how our pre-hospital colleagues initiate care for these patients.
Remember that respiratory distress and respiratory failure fall on a spectrum:
Respiratory distress is characterized by:
- Increased respiratory effort/WOB
- ABSENCE of central cyanosis symptoms: anxiety, nasal flaring, increased respiratory rate, accessory muscle use (ie retractions), lethargy, etc.)
Respiratory failure is characterized by:
- Presence of central cyanosis symptoms: agitation, lethargy, severe dyspnea, labored breathing, head bobbing, grunting, severe retractions, severe bradypnea, etc.
- Hypoxia and/or hypercapnia
The prehospital approach to these kiddos corresponds to a progression of care based on the level of training present. CFRs start with ABCs and monitoring vital signs. If needed, these providers can implement airway adjuncts and administer supplemental O2 at appropriate levels for either respiratory distress or failure. At this level of training, CFRs can then address potential overdose. BLS crews will pick up from here and can additionally request ALS backup and transport the patient. If the on-scene team is ALS trained, they can perform advanced airway management if unable to continually bag ventilate the patient. From here, ALS providers will start cardiac monitoring and establish IV/IO access as necessary while en route. They can even assess and treat for a tension pneumothorax (which may develop after resuscitation has begun!).
If a known cause is identified/suspected such as aspirated foreign body or anaphylaxis, treatment via those protocols will be used. If persistence of respiratory distress/failure, then providers will default back to this protocol.
There is not a lot to be aware of from an OLMC (shameless plug for our e-mailed survey 😊) standpoint other than awareness of the level of care the on-scene providers are able to provide - this will give the receiving team a better idea of what to expect when the patient is rolled in and instill the appropriate level of fear.
See the attached protocol and check out https://nycremsco.org/ for more!Best,
Zachary KimPGY-2 Emergency Medicine
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Decision Making Capacity
In the 1914 case of Schloendorff versus the Society of New York Hospital, Justice Cardozo wrote, “every human being of adult years and sound mind has a right to determine what shall be done with his own body.” Determining a "sound mind," or decision making capacity is something that we do often in the emergency department. This makes many providers uncomfortable because it gives patients the ability to refuse our recommendations. This POTD is going to go over what defines capacity and how we can assess it.
Capacity refers to the ability of a person to utilize information about their illness and proposed treatments to make a choice that aligns with their values. Determining capacity is often a clinical judgment typically made by a physician, whereas competence is a legal state determined by a judge. Assessing for capacity allows us to act in our patient’s best interest while respecting their autonomy.
You can assess for capacity by determining if the patient has the ability to: 1. Communicate 2. Understand the information 3. Understand the situation 4. Manipulate the information presented and make a logical decision.
These points can be ascertained by asking the patient to recount their story, your recommendations, state what they do or don't want, and back their decision up with logic.
It is important to note that capacity is defined around a specific medical decision; you should assess capacity with each new intervention or treatment proposed. In addition, capacity can be transient and exist along a continuum. So before you call up psych to help determine if your patient can refuse dialysis, go through these 4 points and see if you can determine decision making capacity yourself.
Thanks for reading!
Ariella
References:
https://www.emrap.org/episode/november2014/decisionmaking
https://www.uptodate.com/contents/assessment-of-decision-making-capacity-in-adults
Ariella Cohen
M.D. Emergency Medicine
Maimonides Medical Center
Medical Abortions & Misoprostol Toxicity
Medical abortions can be done until 11 weeks of pregnancy and are 98% successful in terminating a pregnancy. They are popular because they are relatively safe and easy to administer. As of 2021, patients can get these medications via mail or pharmacy.
Contraindications for medical abortions include ectopic pregnancies, pregnancy > 11 weeks, adrenal insufficiency, renal failure, liver failure, cardiac disease, and coagulopathy.
Medical abortions are typically performed using Mifepristone and Misoprostol. Mifepristone blocks progesterone, preventing the pregnancy from progressing. Misoprostol, a synthetic prostaglandin E1, induces uterine cramping to help expel the pregnancy (think: misoprostol, like prostaglandin). Misoprostol should be taken 24-48 hours after mifepristone and patients should expect to have some bleeding but it should not exceed 2 pads/hr for 2 consecutive hours (think: rule of 2s). Patients are encouraged to take a repeat pregnancy test at 4 weeks or get an US to confirm termination after taking these medications.
Mifepristone dose: 200 mg PO
Misoprostol dose: 800 mcg x1-2 buccally or transvaginally.
If given buccally, the patient will place two 200 mcg pills in each cheek and let them dissolve.
Given the stigma and laws prohibiting safe abortions, many people are now seeking alternative means for abortions, such as medications they find on the internet. Some medications marketed as misoprostol are not regulated and contain other dangerous substances.
Misoprostol toxicity is very rare, however, due to more limited access to these medications people are at increased risk for harmful side effects. Normal doses of misoprostol in safe abortions are 200-1000 mcg depending on the route. This may cause a slight fever, chills, cramping, nausea, vomiting, or diarrhea, but symptoms typically improve quickly. Toxic doses are in the 3-8 mg range; these patients may have severe GI issues, high fever, chills, severe myalgias with rhabdo, bradycardia, hypoxia, AMS, and hypotension. Doses as high as 12 mg may result in multisystem organ failure and death. Symptoms develop very quickly after ingestion as it is completely absorbed from the stomach in 90 mins. Treatment involves removing any tablets from the vaginal canal, rectum, maybe stomach, and supportive care/symptomatic management until symptoms resolve (usually 12 hours).
Thanks for reading!
Ariella
Resources:
https://www.who.int/news-room/fact-sheets/detail/abortion
https://www.emrap.org/episode/emrap2022july1/postabortion
https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-022-01889-6
Graber, D. J., & Meier, K. H. (1991). Acute misoprostol toxicity. Annals of emergency medicine, 20(5), 549-551.
Henriques, A., Lourenço, A. V., Ribeirinho, A., Ferreira, H., & Graça, L. M. (2007). Maternal death related to misoprostol overdose. Obstetrics & Gynecology, 109(2), 489-490.