Alright, so we're going to continue on page one in the shock packet. Anaphylactic shock. Now when we stop and think about the signs and symptoms we have for anaphylaxis, we have strong urticaria also called hives which are red and warm.
Alright, heart rate goes up, they have difficulty in breathing, you may see it listed as DIB or SOB. shortness of breath, difficulty breathing, increased heart rate, in severe anaphylaxis blood pressure will eventually go down. You may also see angioedema or facial swelling and you may also see severe abdominal cramping.
With nausea, vomiting, and diarrhea. Now, let's talk about how an allergen gets into the body. I have to have an exposure to begin with. So I have to have this allergen, and how can I get an allergen? it into my body.
What are some methods? I can ingest it, so I eat it. What's a bee do to you?
They inject it when they sting you. Alright, what else? You can inhale it and you can absorb it through the skin, through the eyes, etc.
Alright, so that's how this allergy gets into the body. Now, In true anaphylaxis, the person has been exposed to this allergen previously. So if you stop and think about it, to be anaphylaxis, I would have to have been stung by a bee previously.
The immune system recognizes that as a foreign invader, and it decides that if that substance ever enters the body again, I'm going to attack it. And how I'm going to attack it... is through the release of histamine. And they create an exaggerated immune response. That exaggerated immune response is immunoglobin E.
Immunoglobin E is what triggers the T cells and the histamine release. The histamine is a very potent vasodilator and bronchoconstrictor. So if it asks you what part of the immune system triggers the release of histamine, it's immunoglobulin A. Those of y'all that have taken the registry before, they probably asked you something about in severe anaphylaxis, you suspect which of the following triggered an inflammatory response.
And it says IgA, IgB, IgH, and IgE. And you're going, I have no idea what they're talking about. as this young lady is nodding her head in agreement, so I assume I'm correct.
Okay. Immunoglobulin E causes the exaggerated immune response of histamine. Now, the reason why histamine is beneficial to the body, if I over-vasodilate, I'm going to make my vessels bigger, which is going to carry blood to the liver and kidneys quicker to detoxify. excrete that allergen out of the body. Too much of a good thing is a bad thing though.
Alright, for those of y'all that drink alcohol, six pack of beer in a day may not be that big a deal. A case of beer in an hour will screw you up. Too much of a good thing becomes a bad thing. A little vasodilation, not that big a deal.
It's going to help flush that allergen to liver and kidneys and help me excrete it. Over vasodilation from an exaggerated... immune response becomes life-threatening.
So if I over vasodilate, all the red warm blood is going to go towards the skin and towards the extremities, which is why my blood pressure goes down, but they remain red warm. And blood, when it loses pressure, is going to start to leak out of the capillaries. And when it starts to leak out of the capillaries, it pulls beneath the skin, and now you have red warm blood pulling beneath the skin, which is where my eudicaria hives come from.
Unicarrier hives itch. If I scratch, I am scratching that allergen off the skin to help break the absorption. The majority of blood is water and plasma. As the pressure drops...
The water and plasma is going to leak out, and it's going to accumulate in the areas with the least amount of fat. Because fat will absorb the water, areas with no fat won't. So if you stop and think about it, how much fat do you have in your eyelids?
None. So the fluid accumulation is going to occur in your eyelids. Well, if I swallow your eyes shut, you can't absorb that allergen through your eyes anymore.
How much fat do you have in your lips, your tongue, and your mouth? in your throat compared to your gut and your butt. Not a whole lot.
So that fluid accumulation is going to occur in those soft tissue areas. It's going to cause your throat to swell, your lips to swell. Well, if I swell your lips, your tongue, and your throat, you can no longer ingest that antibiotic or that seafood that's causing the alert distraction, correct? And if I swell your upper airway and give you stridor and I bronchoconstrict your lower airway, I'm going to...
create difficulty in breathing and wheezing, which is good from the body standpoint because it's preventing you from inhaling any more of this what? Allergy. And if I become red and swollen and itch at the injection site, you're trying to get that allergen out of that stink, which helps with the injection. So this release to histamine is good from a standpoint it breaks the chain reaction of the allergen.
However, it's bad because the side effects of it create a life-threatening situation involving airway and perfusion. So I have to decide what is the best treatment for this person. And that's going to break down to mild, moderate, and severe.
Mild, moderate, and severe reactions is going to determine how I treat this patient. So, if I have an allergic reaction, let's say that I have rash only. This is for mild. Rash only, BP greater than 90, and no airway involvement.
Now, when I say no airway involvement, I mean no upper airway and no lower airway. Remember, above the glottic opening, your oral and nasal pharynx, that's your upper airway. Strider is the upper airway complaint. Swollen tongue, swollen lips, those are upper airway complaints.
Lower airway complaints would be... wheezing. So this has no airway involvement.
In other words, no facial swelling, tongue swelling, throat swelling, lip swelling, and no wheezing. It's a rash only. If it's rash only, then I can give dipahydramine, also called Benadryl, at 12.5 to 50 milligrams, and you can give that IV push, you could give it PO, you could give it IM, I guess, in a cardiac arrest. You could give it IO if you had to, but basically we just need to get the drill on it.
What Benadryl does is it blocks the further uptake of histamine. So imagine hitting the pause button. So all I'm going to do is hit the pause button on this allergic reaction. It's not going to get worse and it's going to give the immune system time to settle down and reset.
It's like hitting the pause button. I'm going to hold them where they're at. So I'm going to give them Benadryl. It's going to pause them at a rack. and then slowly over time allow that immune system to reset a moderate reaction on the other hand has a blood pressure greater than 90 and it has airway involvement all right the airway is involved Now, once again, this could be stridor, it could be tongue swelling, it could be facial swelling, it could be wheezing, anything that has to do with upper or lower airway becomes more life-threatening, correct?
Now, my goal in a moderate reaction is to reverse the effects of histamine. Remember, Benadryl paused it, but Benadryl does not cause vasoconstriction and bronchodilation. Histamine had vasoconstriction.
vasodilation and bronchoconstriction, I need to make the opposite of that occur. Well, the alpha effects of epi will make me vasodistrict, and the beta-2 effects of epi will make me broncho. So if I have airway involvement and the pressure is above 90, I'm going to give epi 1 to 1,000, 0.3 milligrams, preferably IM. Now, if the blood pressure is above 90, the muscle is still getting blood, so an intramuscular injection will work. Now, that's going to take care of vasodilation and bronchoconstriction.
However, the histamine can still continue to be released, and this reaction can still come back. So I give the epi for immediate life threat. And then to prevent the allergic reaction from coming back, I need to give what?
Benadryl. So I'm still going to give Benadryl, but ethies first. Because Benadryl doesn't have basal constriction or... bronchodilation effects. Now what happens in a moderate reaction, let's say they were wheezing and they had a little bit of facial swelling.
They ate soup and they didn't realize that there was actually some sort of seafood in there. Alright, they just said oh yeah I'm at a restaurant give me the soup of the day and it turned out to have some sort of shellfish in there. So I give them ethy and I give them Benadryl and they still have a little bit of facial swelling and a little bit of wheezing. What can I do now? I can target treat the signs and symptoms.
So I could give Solumetrol. For the facial swelling, and I can give a butyrol for the wheezing. So once I get that epi and vitadryl on board, I can target treat residual signs and symptoms. I can follow it up with an amyloid, or I can follow it up with steroids.
on what they still have. Does that make sense? So after I get the epi and menadryl on board, then I'm going to target treat the specific signs and symptoms still present.
That's in the modern. In severe allergic reaction, the blood pressure is less than 90. What's the problem if the blood pressure is less than 90? Do I have muscular circulation? If I give Epi-IM, it's not going to be picked up and be as effective.
In a critical, life-threatening situation, I need vasoconstriction and bronchodilation as fast as possible. What drug can I administer to make those two things happen? However, the biggest side effect of epi is tachycardia when I give it to somebody that's still alive.
So what I need to do is I need to go ahead and give this epi, and it's going to be 1 to 10,000. Instead of 1-1000, it's still 0.3 milligrams, but I'm going to give it slow IV push. By giving it slow over one to two minutes, I'd lessen the tachycardic side effects. If you slam it, you could potentially put that person into V-tach or V-fit.
So I want to push it slow over one to two minutes to lessen the tachycardic side effects. But I've got to get it on board because this person's... completely shut down, and their pressure's too low to pick up a drug intramuscular. What happens if you're trying to get an IV and you can't?
Go ahead and give them the IM. Just understand that they need that epi-IV push. If you can't get an IV, give it to them IM.
All right? Yes? You could.
You could if they're almost dead. You could. Any drug you give IV, you pretty much give IO. All right?
So I've taken care of the life threat. I followed it up with Benadryl. And then I'm still going to target treat the signs and symptoms. I'm still going to give a butyrol, steroids.
If the pressure's still low, I'm going to try a fluid challenge. If despite epi, steroids, Benadryl, and fluid challenges, their pressure's still extremely low, I may end up having to give them a processor. Because remember, this is a distributive basogenic type shock, and if the epi doesn't constrict them back, I may have to move to a... I have seen a couple of times in my career I've also heard of it once or twice on preparatory stuff for the registry where epi drips are used for severe anaphylaxis all right and if you stop and think about it basically we're slowly dripping that epi in to try and keep that vasoconstriction and bronchodilation and keep that person's pressure up and their lungs open and so some places as well we'll do an epi drip for severe anaphylaxis.
All right, and usually what they'll do is they'll sit there and do two to 10 mics a minute, and I'll go over drug caps after lunch. I'll teach you drug caps, all right? But that, but those. Those are some of the things that may appear.
Alright, that is anaphylaxis. Anaphylaxis, they have been exposed to the allergen previously, usually several times. Anaphylactoid, on the other hand, is the first exposure that causes severe anaphylaxis.
In the back of the ambulance, I don't care if it's anaphylactoid or anaphylaxis. When it comes to treating, I don't care which one it is, it's either mild, moderate, or severe. Up until a few years ago, I didn't know what anaphylactoid was, nor did I care, until it started showing up on some of these preparatory things. So I went and researched it. Basically, the first time that allergen enters the...
body that have a massive severe alert scratch without having the typical immune builds up the response you get stung by bee and your body goes man if that venom ever comes back i'm going going to kick its butt and then you get stung by a bee and then you have a little bit worse reaction then you get stung by a bee a third time and now it's more severe. Typically allergic reactions occur after several events where the allergen has been introduced in the body. Antiflactoid though it's the very first time.
So in the test question if it says your patient's undergone desensitizing treatment or patient carries an EpiPen or every time the patient's done about B that have an allergic reaction that's anaphylaxis okay if it says first time ate seafood first time took an antibiotic that would be an anaphylactoid so the only time you're going to pick anaphylactoid is if it says first exposure in in that sentence if it doesn't say first exposure first time ever then we're going to pick anaphylaxis treatment forms the same it's just one of those words that shows up on the registry and confuses like I've seen on the registry where it says you have a patient in severe anaphylactoid reaction patient has striders shortness of breath low blood pressure and uterine and people are like well what's anaphylactoid all it meant was this person is having severe allergic reaction but it was the first time they've ever been exposed to this allergen doesn't make a difference to me treatments feel the way Some of y'all remember seeing something about anaphylactoid, and you were like, I have no idea what that even means. And that's all it is. It just means first exposure. All right? Treatment's the same.
Subcategory, it's a vasogenic or distributive. All right? If they ask you what causes the uticaria and low blood pressure and anaphylaxis, what law? Anybody know what law that is? What's my pipe law?
What's the... the vasodilation pipe wall. Paswelli's law.
Paswelli's law says the bigger the pipe, the lower the pressure, the lower the pressure, the more volume moves through and it's going to leak out. So every once in a while you'll see them come back to the law. The Paswelli's law is the pipe law.
questions on the anaphylaxis? I also have local, moderate, severe right there in the middle of the page. I have immunoglobulin E because those are some of the common things that students struggle with.
Let's look at psychogenic shock, alright? Psychogenic shock, aka panic attacks, alright? We run on a psychogenic shock or panic attack. What signs and symptoms are we looking for? What do we think that person is going to complain of?
Difficulty breathing, tingling in hands, so we're called on shortness of breath or chest pain. We get there and they've got numbness and tingling in fingers, lips, tongue, etc. Alright, usually they're anxious, they're upset about something, they're tachycardic, they're tachypneic, which is increased respirations, and you will hear the word hyper, that's right, hyperoxemia and hypo-cardia.
All that means is their pulse ox is high and their CO2 is what? But instead of giving you a pulse ox number or a CO2 number, they say you have a hyperoxemic patient with hypocarbia. And you're like, what? And then you're like, and then it blows your mind.
All it's telling you is, you've got a panic attack. High pulse ox, low CO2. That's all these two big words see, but you see something more than four letters, and it kills you.
So we have to get used to that type of thing. Now, let's talk about what happens in a psychogenic shock. First of all, it is, majority of the time, some sort of mental-emotional response.
Alright? They got upset about something. Boyfriend left them, girlfriend left them, mom took the cell phone. They saw a fight. They got scared.
Whatever. Alright? So they had some sort of mental emotional response. That mental emotional response stimulated the sympathetic nervous system, which caused the release of epi, which is why they start getting the tachycardia and the kidney because they're scared. Now, if we look at this from a blood gas standpoint, we can kind of understand how some of these things are happening.
So I'm going to erase this, and we'll come back to it in a minute. So first of all, we've got to look at our blood gases. 7.35 to 7.35.
This way is an acid, this way is alkalosis or a base. Alright? Pulse ox should be 96 to 100%. That corresponds with the PaO2, if I was to do no arterial blood gas, of 80 to 100. Entitle CO2, which you may see it called Capno, Capnography, Entitle CO2, or PET CO2, on the test, they'll use any of those things interchangeable. It basically means Capno.
All right? is 35 to 45. Now a PaCO2 is the actual blood gas. These two numbers should be within 5 to 10. So if I had capnography of 40, if I was to actually do an arterial blood gas and pull it out, I would expect the PaCO2 to be somewhere between 35 and 45. It should be within 5 to 10. 10 points of whatever that end tile is.
So it's pretty good. So if you got somebody with an end tile of 20, they're probably between 15 and 25 if we actually pulled their blood, which obviously we can't do it back to the ambulance, but it gives us an insight as to what's actually going on from a perfusion standpoint. And then my bicarb. It's 22 to 26 mill equivalents if we were to actually pull the blood. Now, obviously we can't really pull any of these things, but we can pull pulse ox and carbon dioxide.
oxide, correct? So let's stop and look at this. Normal heart rate is 60 to 100. Normal respirations is 12 to 20. Normal pulse ox, we already talked about, was 96 to 100. And the end tidal was 35 to 45. Now, what happens if instead of breathing 20 times a minute, I increase to 30 to 40 times a minute? That means you are inhaling two to three times faster than normal, correct?
Every time you inhale, what gas are you inhaling? Oxygen. So I am actually inhaling two to three times more oxygen than the body needs. Well, the pulse ox is not going to go above 100%.
However, the PaO2, the actual amount of oxygen dissolved in the blood, man, this could go 300, 400, it can just keep going up. The pulse ox is going to stop at 100 because it doesn't know how to read more than that. The actual oxygen, because they've tripled their inhalation, that number keeps climbing, which is why they're high oxygen. Now, if you stop and think about it, every time I inhale, I have to turn around and what? So there's...
tripling their exhalation as a result of that this number usually gets cut down and will go into the teens to 20s because they are breathe excelling all their carbon dioxide which is why they become hypo carbia now where did carbon dioxide come from carbon dioxide does not come from the lungs Okay? The lungs is where we take carbon dioxide from the... Liquid state, put it into a gaseous state to where we can breathe it off.
Carbon dioxide is not produced in the lungs. Carbon dioxide is produced from the carbonic acid. The carbonic acid is produced at the cellular level.
Alright, so here's how this works. I got my cell, I put oxygen and sugar into it, and that creates ATP, adenotriphosphate, my energy. That energy produces exhaust, which is a carbonic acid.
The body's natural production, if everything is homeostasis or normal, this acid will break down to water and a carbon dioxide level of 35 to 45. That is perfect exhaust. So let's relate this to our car. All right? You've got your car. With the exception of a cold day, you don't...
typically see any exhaust coming out of your car, correct? Which tells me that it's running good on fuel, the spark plugs are good, plenty of oil, and the car's working the way it's supposed to, right? What happens if you're driving down 35 and you got one of those old hoopties? 1980 Grand Marquis and it is thick black smoke blowing out everywhere.
You know that car has a problem, right? Could be a motor problem, could be a gasoline problem, could be an oil problem, but we know because of all the exhaust coming out. out something ain't right so our body's designed to give us a certain amount of exhaust but not too much not too little so a change in the exhaust signals a change in the body could be good or bad just like when you see that car going down the road blowing black out you know something ain't right about that car i ain't got to be a mechanic to go that ain't right now i don't know necessarily what's wrong with it but i know it's not functioning so what ends up happening is if I increase oxygen to the cells they burn hotter correct oxygen makes it more efficient so when I double and triple the amount of oxygen going to the cell it makes it more efficient and the acid byproduct is actually going to go down which is going to drive that co2 down if acid goes down co2 goes down so not only am i producing less acid but I'm also doing what with the acid blowing it off, which is why this acid gets in the teens and 20s. Now, this, from the drop of the acid, will make this person over here alkalotic from a respiratory standpoint because they're blowing off all their acid.
So how do I create more acid in the body? I could have them hold their breath. The problem with that is, if they're having a medical problem and you have them hold their breath, you're going to make it worse. How do I create more acid in the body? I can't just go, mmm, make more stomach acid.
I can't dump acid. So go back to the signs and symptoms you told me about panic attacks, and you tell me which one of those would create more acid. Which one would create more acid? Thank you. Huh?
Thank you. No. Carpal-pedal spasms.
If I vasoconstrict... My peripheral tissue lets no longer go into the fingers and toes because of angioconstriction. Oxygen, no more blood. If I'm not getting adequate blood to the fingers and toes, those fingers and toes are going to go from...
Aerobic to, and if I vasoconstrict and I decrease the amount of oxygen to the cell through vasoconstriction, I increase the amount of what? Acid, which will... will increase the amount of CO2.
So the more severe the panic attack, the more severe the carpal-pedial spasms, because they're trying to create peripheral carbon dioxide or peripheral acid. As you start to calm them down, what happens to carpal-pedial spasms? goes away and then when they get upset again it comes back it's all about trying to create acid to counterbalance this why do they get chest pain then if i vasoconstrict your chest and i make it harder to inhale and harder to exhale you're going to take in less oxygen and exhale less carbon dioxide ...side to let those numbers what? Balance out.
Why do they get numbness and tingling around their lips and mouth then? Same thing. If I make your mouth open and numb, try to take a breath with open and numb mouth. You're not going to inhale very good, and you're not going to what?
Exhale very good. That's why they dispatch us on... 19 year old female having a heart attack and you're like, what? And you get there and she's going, hi, hi, hi, hi, hi. Having an eye attack, carpal-pedial spasms, chest pain, third one to faint.
That's all because they have become respiratory alkalosis and their body's trying to create acid to move them back to that normal pH level. Because they are hyperoxemia and hypocardia. Now. The majority of the time on a panic attack, it is a panic attack, and we can calm them down. If they have just received some sort of horrible news, all right, the El Pollo Campo North the station to several years back middle tonight we go there young panic lady probably late 20s she is having one of the worst panic attacks I've ever seen she is on the floor flailing and flopping around in our south side of the city it's not uncommon to run quite a few panic attacks on medic too.
Get to talking to her coworkers. She was in the country illegally. She had been smuggled in and the cartel, if she didn't send so many back a week, they had her daughter for ransom.
Well, her dad had been sick, she hadn't worked in a couple of weeks. And so the cartel called and said, you didn't send us our money, say goodbye to your daughter. And then they executed her daughter on the phone. phone. Don't know if they truly killed her or not.
They could have just did that and then, you know, now she's basically in their slave trade ring. Who knows? But obviously as a mom, knowing all those things that happened from the country you're from, she wasn't.
calm down. So if it's something where you're like, oh my god that's horrible, we're probably going to have to look at sedating them and transporting them. That is in 27 years that's the only one I can think that we actually ended up having to transport and medicare. Every once in a while, I'll just transport them because it's easier than spending 30 minutes on a team coaching them. And you know they're not going to calm down.
But that's the only one I can recall we've ever medicated. Calm them down, coach them, slow them down. But before you go down that panic attack, you need to rule out overdoses. You need to rule out head injuries.
You need to rule out diabetes. You need to rule out renal failure. Because remember, people will hyperventilate to blow off toxins and acids.
So that hyperventilation may not be from anxiety. That hyperventilation could be because they have a brain stem injury in their chemoreceptors. If you think about Shane Stokes.
It could be that hyperventilation is because they're a renal failure patient. They haven't gone to dialysis. They haven't taken out the trash. so now they're blowing off all the trash.
A Tylenol or aspirin overdose because the aspirin increases the acid in the stomach, how do I get rid of acid? Breathe it off, pee it off, sweat it off. An aspirin overdose will hyperventilate to eliminate the acid. Remember the name for aspirin?
Acetosilic acid. So they essentially put acid in their body. So a acesilic overdose will hyperventilate and how do I take take care of metabolic acidosis so what's the antidote for an aspirin overdose then? Bicarb.
That's a registry question by the way. You have a patient 32 year old female hyperventilating anxious with the empty bottle of aspirin. That's a cilid overdose. They're hyperventilating not because of panic and it says in there like depressed and all that so you start thinking about anxiety but that empty bottle of aspirin they're hyperventilating from the cilid overdose. Tylenol because it destroys your liver and your liver can't take out the toxins and clean the blood, they will end up hyperventilating to eliminate the trash as well from a Tylenol overdose.
However, that's usually six to eight hours down the road. So we need to make sure that before we go down to the mental, the mental emotional phase, we've ruled out overdoses, metabolic causes, trauma, etc. All right, which if we do a good set of vitals, we get a good history, we'll be able to tell relatively quickly. All right.
So Which brings us to blood gases since we kind of already opened the door with panic attacks Depending on how many questions you have you are probably going to see Anywhere from 6 to 10 acid-base balance questions on your registry. Now, you're probably only going to see one or two that actually have the blood gases written down. But they're going to ask you scenarios, and you are going to have to figure out what they are.
Are they respiratory acidosis, respiratory alkalosis, metabolic acidosis, metabolic alkalosis? They're going to ask you scenarios, so let's do this. 16 year old female, respirations are 6 and shallow with pinpoint pupils.
Alright, and it says respiratory acidosis, respiratory alkalosis, metabolic acidosis, or metabolic alkalosis. Alright, first of all, if I got slow respiration, spin-point pupils, I overdosed on what? An opiate. An opiate does not affect stomach acid or your liver. It affects your what?
breathing well if I'm only breathing in six times a minute I'm only taking in half as much oxygen correct which means all of my cells are going to go from aerobic to anaerobic which are going to increase the amount of acid Make sense? And then if I'm only breathing in six times a minute, which is going to make me hypoxic, I'm only exhaling six times a minute, which is going to make my acid go up and make my CO2 go up, which would make me... hypercarbon and high co2 comes from high acid and this is a respiratory breathing problem therefore it is respiratory acidosis They will give you scenarios and not necessarily blood gases. Every once in a while, some students will report one or two blood gases, but they typically will have a few scenarios where they're having to pick the type of acidosis or alkalosis.
Alright? What if I said this? Let's just change it.
16-year-old female, gunshot wound to the left thigh. with gross, meaning a lot, hemorrhage. What is she in? Not metabolic. Let me ask you this.
If I'm shot, what am I losing? Blood is red, blood is warm, blood has oxygen and sugar. So anytime I'm losing blood, I'm essentially losing oxygen. And if I'm losing oxygen, I cannot have respiration.
And here's what you need to remember. There's breathing and ventilation. Breathing is bringing air into the upper airway.
Ventilation is rising and falling of the chest and moving oxygen into the blood and carbon dioxide out. that's ventilation respiration actually occurs at the cellular level where I take the oxygen and I convert it to energy and get carbon dioxide as a byproduct that is respiration so when I am shot I'm not delivering oxygen to the cells so the cellular respiration goes from aerobic to anaerobic because the cells are now hypoxic from blood loss So think of it like this, when I lose blood, I'm losing oxygen, it makes the body hypoxic, and the cells can't respirate. Now, after 20 minutes, there's enough acid built up that the body can't...
handle it and now it starts to affect the liver and the kidneys so after 20 minutes it becomes metabolic but the first 20 minutes of trauma the first 20 minutes of a cardiac arrest first 20 minutes it is typically respiratory acidosis. Once all that acid builds up and becomes stagnant, now it starts to affect the liver and the kidneys and becomes metabolic after those 20 minutes. The only time that we're going to see a patient in cardiac arrest start out as metabolic acidosis is if they were metabolic acidosis before they went into cardiac arrest, which would be like my dialysis patient. Today is Friday. You have a Monday, Wednesday, Friday dialysis patient.
They didn't go to dialysis this morning, and they didn't go on Wednesday. They essentially haven't taken out the trash and acid since Monday. So that person is going to start out metabolic acidosis.
Does that make sense? Because they had all that trash built in. ...on the other hand, versus me, knock on wood, I don't smoke, I don't have any breathing problems, what's my pulse ox right now?
I'm relatively healthy, especially for an old fat guy. I'm probably 98, 99, 100 percent, correct? If my heart stopped right now...
I still have a hundred percent oxygen in my blood. It's just not what? It's not circulating.
I don't have a stomach issue. I don't have an acid issue from a metabolic standpoint I have a oxygen delivery issue if I don't deliver off the cells can't have respiration. Which is why in most heart attacks when it's a heart or pump issue and I don't move the oxygen, to have all the oxygen in the world it's just not being moved. Which is why AHA went to hands-only CPR get that oxygen moving and get it circulated so most of our cardiac arrest unless we know that had some sort of liver kidney renal failure issue it's going to start out respiratory acidosis and within 20 minutes if we haven't corrected it then it becomes metabolic all right what if so gunshot wound blood loss to lose an oxygen let's say that she Respirations 32 and deep and she's lethargic.
Shallow is usually hyperventilation. Deep means what's wrong with her? If I have fast, deep, and lethargic, that's the beginning of hyperglycemia and DKA.
Is that an oxygen delivery issue, or is that a metabolic issue? So this person's metabolic acidosis with respiratory compromise trying to blow off all the acid. They gave you two signs of DKA.
If we go through this entire shock packet, which we will over the next day and a half left now, Every one of those types, phases, illnesses, injuries, etc. that is in this packet has roughly three things that separate it from everything else. The registry will always give you at least two of them. So, for example, let's just, this is kind of off topic, but this is what I mean by at least two classic signs and symptoms. JVD.
If I say a patient has JVD and I give you no other clues, a patient with JVD could be right-sided heart failure, could be complete heart failure, could be a pericardial tampon, could be a tension pneumo, could be liver failure, could be renal failure, right? That's what JVD by itself can mean. But if I said JVD and absent breath sounds, those two classic signs and symptoms now make even what? What if I said JVD and muffled heart sounds? What if I said JVD and yellow scleria?
Liver. So that is where you sit there and you have to put those signs and symptoms together. So when I say DKA, DKA usually has fast, deep respirations, lethargic, they stink, polyuria, polydipsy, polyphasia.
I gave you at least two classic signs and symptoms of DKA, it's just you weren't thinking and breaking it down. NDK is metabolic acidosis. Let's change it to a 32 in D and Tylenol overdose. What is she? Still metabolic acidosis, but they're trying to blow off the liver damage that's caused from the Tylenol.
What if I did this? 16-year-old female, upset stomach, times three days. Basically, nausea, vomiting, diarrhea, upset stomach for three days. metabolic alkalosis because nausea vomiting diarrhea and upset stomach she's throwing up all her stomach acid so expect a handful of questions whether they either actually make you know the blood gases or they give you a scenario and you have to pick let me give you a blood gas one 44 year old male, chest pain, and you have a pH of 7.34, a pulse... ...ox of 96 and the end-tidal CO2 of 40. Let me change that.
Let's make that 50. 50 and bicarb is 24. Okay? First of all, 734 is that normal acidotic grapholide. So I'm barely...
Acidotic, correct? Is my bicarb between 22 and 26? Therefore, it's not metabolic. If it's metabolic, the bicarb is going to change one way or the other.
So let's stop and think about this. I'm acidotic. My oxygen is fine, but my end tidal is what? Not low. High.
Which makes my acid low. It makes me acidotic. Let's stop and talk about what happens in chest pain. If I'm having a heart attack, despite having all the oxygen in the world, I can't what? Deliver it.
And if I can't deliver oxygen, the cells go from... aerobic to anaerobic which produce more carbon dioxide is that a cellular respiration issue there so this person with this heart attack is actually respiratory weapon acidosis I'm acidotic bicarb is normal makes it respiratory and because my end titles out of whack this person's respiratory acidosis which most of your heart attacks will because most of our heart attacks if I block the park pipe, no oxygen goes past the blockage. That's an oxygenation issue, which makes it respiratory. We have to get past the mindset that respiratory is this. Respiratory is more than just your lungs and your upper airway.
I can have all the oxygen in the world and the clearest lungs in the world, but if my heart's not pumping the blood out, that oxygen's not going to the tissue. And that tissue can't have respiration. Ventilation's here. Respiration is the movement of that oxygen and sugar into the cell and creating that acid. Alright?
So that's where this one's at, the CO2 was out of whack. Yes sir? If the CO2 was lower, would it be hypo-carbia or would it still be hypo-carbia? It could be.
So let's say I got this. Alright? So let's say that I got 20. Which may not be uncommon in severe respiratory acidosis.
Because at first they're going to try and what? They're going to try and blow it off. For example, an asthma patient.
When we talk about asthma a little bit later... an asthma patient can suck air in, but they can't get the carbon dioxide out. So depending on how much movement's in the lungs, that CO2 may be high or low depending on where they're at.
So let's just, real simple, acid, normal, or alkalotic? Bicarb out of whack? No.
So that's not metabolic then, so I'm at respiratory acidosis, correct? Do I have one of these numbers out of whack? Then it's respiratory acidosis, move on. Don't make it more difficult than that. If they give you numbers, is it acid, normal, or alkalotic, and is my bicarb out of whack?
What happens if I was to make this? Let's say that I got bicarb of 16 and end tidal of 80. Acid, normal, or alcoholic? Acid.
Bicarb out of whack? Metabolic acidosis. What's the respiratory trying to do? Compensate.
Expect a handful of those. Those of you all that have taken those tests before, you remember seeing some of the things like this. Am I pretty accurate? And you're probably going to see one to three where they actually give you a blood gas, and then a handful of scenarios where they give you a scenario, and then you've got to pick the type of it. I see some feedback.
Yes, sir? Will they always do it? Uh.
Not, not typically. Not, not for what we're trying to achieve today and not on the basis of register. If I was to sit there, like for example, you could technically, like let's say I didn't give you a buy card, but I gave you this right here.
here let's say that I gave you a 44 and I didn't give you anything this person's most likely metabolic I don't really have enough information but they are acidotic these two numbers are with the range it's most likely metabolic but I really need that by card to be the kind of this back I've not heard of them doing that. Alright? So does that make it a little bit more clear on our acid-base balance? If you struggle on acid-base balance, take what we just did, write the blood gas levels a few times on a piece of paper. You remember 90% of what you write.
You only remember about 5-10% of what you read. So if you start and you're scared to death about blood gases for whatever reason, put it on your cheat sheet. You need to write that cheat sheet a hundred times before you take the registry.
It takes roughly a hundred times of writing something to get it cemented in memory. So if you're scared about blood cast, it's whatever it is, take out a sheet of paper and go, okay, here we go. Start writing your dry erase book.
And then at two minutes stop and do that four or five, six times a day. We're talking, that's going to take 20 minutes of your day. That's it. Start practicing.
in that to where you're A, putting it in your memory, B, you can be efficient at that dry erase board. And if you do vapor lock 100 questions into it, it's right there in front of you. All right? But you're going to have to put in that effort. I mean, that's all there.
I'll tell you everything you need to put on there, minimum, but you're going to have to put in that effort. And if you stop and think about it, you know, if you spend, it takes you two minutes, and you do that five times a day, that's ten minutes. Ten minutes to have a 30-year pension and career. 10 minutes a day and that's where y'all are at.
Everybody in this room is here to try and get that next step in their career and either get that next job or keep their current job or change departments or make more money for their family, where they're at, whatever. And now it's a matter of putting in the time and effort, all right? So I know we started with panic attacks.
This is where we're at for the blood gases and how it. that's going to come into play on the register. All right, any questions on that? All right, we're going to skip cardiogenic shock because I'll cover that in cardiac.
We are going to do sepsis real quick. Now... Anytime I put something bad in the blood, alright, anytime I get something bad in the blood, the body's response is to get that bad stuff out of the blood as soon as possible. And how we get it out of the blood is we get...
it through the liver and kidneys as quickly as possible. So what are the blood vessels going to do anytime something bad gets put in them? Dialate.
Okay, so dilate to get that blood to the liver and kidneys. So if I have an infection, is an infection good or bad? Back.
So the infection in the blood is going to cause vasodilation. That vasodilation is going to cause the blood pressure to go down, heart rate to go up. If heart rate goes up, I need more oxygen and to eliminate more CO2, so respirations have to go up. Because of the vasodilation and the drop in the blood pressure, all the red warm blood moves closer to the skin, which is going to drive the temperature up.
I am also going to have a response of leukocytes, or white blood cells, and T cells, which are going to fight the infection. And the byproduct of fighting is heat, which will also increase the temp. I need more energy, so I have alpha and beta cells in the pancreas. The alpha cells are going to release glucagon.
Glucagon triggers the release of storage glycogen from the... liver so the alpha cells in the pancreas are going to tell the liver dude it's an emergency it's fight-or-flight we got this massive infection give me a bunch of manpower and we need energy so it's going to dump all the stored sugar from the liver the beta cells in the pancreas are going to release insulin to try and help convert all that excess sugar, which is why in early sepsis, BP goes down from vasodilation, temperature goes up from the inflammatory response, and the sugar increases to help fight the infection. This is early sepsis.
Now, do not confuse this with early phase of shock. I'm talking so many developers... Now, to develop sepsis, you usually have an infection somewhere else in the body, most commonly the urinary tract because all your blood goes through there, but you have an infection somewhere else in your body. And that infection is not killed or treated appropriately and it leaves that organ... or target tissue and it ends up in the bloodstream called septicemia and it ends up poisoning the blood with this infection.
In the early stages of when that infection left the UTI for example and starts getting in the blood you're going to have the inflammatory response, which is going to cause the blood pressure to go up, or blood pressure down, temp up, and the sugar up from the alpha and beta cells in the pancreas. Over time, this person cannot... fight this infection. So over time, their body can no longer fight it, so blood pressure will return to normal.
Tempt will actually go down a lot of times, 97 or less, and the sugar will be low. That's late sepsis. So think of it like this.
In the early stages when I can fight the septic shock, my tempt's fighting it, my sugar's fighting it. I'm giving it all I can. Now I'm just tired and give up. And so what you'll see is you'll see the temperature lower than normal.
Because they've burned through all their sugar reserves, their sugar will become low. Where this creates a problem for paramedics. There's no doubt in my mind that if I told you all right now you had a 62-year-old female, weak with a temperature of 102, blood pressure of 90 over 50, and a blood sugar of 250, you may not realize the sugar part. fact she's been sick and has a fever you're going to default to what?
Sepsis. And you're gonna start an IV on her, give her some fluid, and then you're gonna take her to the hospital and recognize she needs IV antibiotics. There's no doubt in my mind that everybody in this room would probably get that correct.
But what happens is this is the one we miss. Okay? We missed that 62 year old female, blood pressure 114 over 60, temperature... 97.1, sugar is 60, and she's non-diabetic, and she's weak times two weeks.
Tim's pretty low, and you go, oh, but she's old. Old people are always cold. Sugar's pretty low, especially for a non-diabetic, and then she's been weak for several weeks. This is late sepsis.
This is more life-threatening than that one, because this one, the inflammatory response is still there, and it's more likely to respond to antibodies. We missed this one in the field. That's why all the sepsis screenings have altered low temp as well as high temp on them.
Alright, and I think it's, don't quote me on this because I get confused in my head. I have a lot of information that's useless. But I believe most of the hospitals are somewhere in the 97 or less range.
A lot of times they'll go like 100.1 or higher or 97.3,.6. 6.1, something like that. Javier? Did the D6, would that change with the experience? Like eating, like they breakfast without it?
What type of that? So in a normal person, yes. In a person that's already burned through all their stored glycogen, in the sepsis, not necessarily.
Like, for example, if, I'll just use me. I'm not a diabetic. So if I have an ache since last night, I should have woke up this morning, and my blood sugar is probably 60 to 80. All right?
If I was... was to go be a cop and eat a dozen donuts, I would expect my blood sugar right now to probably be two to three hundred. All right. So that's how we're going to affect it because she's so depleted. Breakfast may not increase her sugar because she's already dumped all that stortibacogen from the liver because her body's been under stress for several weeks and that's never recovered.
The other key to that would be, let's say that she's right here. Let's say that she has a tip of 102 and blood sugar is 260 and she's been weak for a few days and you get to asking her okay are you a diabetic and she says no and so she's not a diabetic so that blood sugar 260 isn't diabetic related we need to start asking some other questions have you ran a fever well she's febrile febrile high blood sugar that's typically early sepsis So we get to asking her, well, you know, have you been going to the bathroom more than normal? Well, I've been peeing a lot. Well, what color is it?
It's getting pretty brown. It also burns when I pee. Okay.
She had a UTI that was untreated, and now it's becoming what? Septic. Or maybe in the test question they'll use something about recently finished antibiotics for X, recently had disinfection.
All right? So just understand that a lot of times we miss that late sepsis. Late sepsis, decreased temp, decreased show. here early sepsis increased temp increased sugar all right treatment dose the same we're going to give them fluids if their pressure is extremely low they don't respond to a foot challenge then we'll look at giving a presser definitively need antibiotics to kill the infection. Alright, any questions on that?
Alright, last thing on that page is hypovolemic, which is nausea, vomiting, diarrhea, could also be blood. If hypovolemic and hemorrhagic are both listed and it's trauma, the better option is what? Hemorrhagic.
Hypovolemic does not have stage or classes. You cannot use stage one, two, three, and four. four with hypogluemic because we can't relate blood loss to nausea and vomiting loss.
Does that make sense? So class or stage one two three and four was specific to hemorrhagic. Hypogluemic just means fluid in general. Stage one two three and four was specific to hemorrhagic. Now This question comes up, we talked about it a little bit earlier on IVs.
You have a gunshot wound to the abdomen, blood pressure is 118 over 98, heart rate is 124, respirations are 24. Select best IV catheter. Earlier we were doing the foot. 16 gauge inch and a quarter, 14 gauge 2 inch, 18 gauge inch and a quarter, or 20 gauge inch and a quarter. Coswelli's Law tells me I want the best combination of short and fat.
I want the shortest catheter with the biggest diameter. We do this all the time on the fire ground, alright, when you stop and think about it. For those of y'all that aren't firemen, I apologize, but basically think of it like this. On the fire ground, we have hoses that go from here to this big.
Which one gives me the most water, a hose this big or a hose this big? The 5-inch. A hose this big gives me the most water. Which one is going to have less turbulence, which we call friction loss? A hose this big that is 25 feet long or a hose this big that's 1,000 feet long?
The shorter and fatter, the less the water spins and creates turbulence and the easier it flows through it. So the best combination of short and fat here then would be the what? 16 and a quarter. People have a tendency to stop and think, well you know that needle's longer. Well if it's longer, it's going to create more turbulence and spinning and you're not going to get as much volume out of it in the end game.
And this question gets quite a few people. We use it on our finals as well. So always pick for trauma the best IV catheter is the shortest path. If it would have been a 14-gauge inch and a quarter, then that would have been what? Then the answer.
A 2-inch, though, is going to almost double the amount of turbulence and the friction loss in it, so to speak, compared to an inch and a quarter. What's the fluid rate I should be giving this person? 25 cc's an hour which is TKO because this person has not lost enough blood to warrant giving football at this video. I know, what stage are they in? Two.
Stage two, everything goes up, they've lost a liter give or take a little bit. Stage three, pressure's down, everything else is up, they've lost a liter and a half give or take a little bit. Alright?
Good on that. Good on hypolemic and hemorrhagic. Alright, let's see here. Let's go ahead and take 10 minutes, and I'm going to try and get all of cardiac on page 3 done, maybe even page 2 before we go to lunch.