okay so first up today is substance abuse toxicology overdoses are environmental stuff so this will include a lot more drug overdoses why do our antidotes and they'll get in like some hazmat stuff and some radiation stuff a little bit further into this so the first thing you want to do just to kind of get our brains on the same page here is we do some film blanks here and this is just gonna be some rapid identification of the antidotes we like to go into each of these little more detail during the lectures but it's just kind of get our brains on the same page and get us kind of thinking and clear the cobwebs out this morning so the first one we look at is a sedum in a fin and feel free to type words in the chatbox here if you want but I'll roll up the answers you go through it so they're a reversal agent for acetaminophen and there's a user about a two second delay between me and use so I will pause for just a second and see if me wants to type it in there make yourself look good and positive if you get the right answer but the right answer is mucomyst and the generic name is acetylcysteine so there are several talking teaching points throughout the full 2-day presentation that kind of come up here and there and this is the first one I mention of one of them because I know some of you are attending these different sections so on this sea in exam anytime there's a drug name you'll get both the brand name and the generic name yep exactly I'm telling you right now the ena the bcn they know that most of us know brand names best so their job is not to trick us about drug names they will put the brand name there but then they also have to respect all the manufacturers and so by doing that they give you the generic name so you can see you can see mucomyst parentheses acetylcysteine if you saw lopressor you see parentheses in the top row law or vice versa so no do not go learn new drug names for this test you will recognize wanted to Finnegan parentheses promethazine again partly good reason I do these classes making your life easier on how to study do not go make drug cards if you attend the full program during the course of the full 20 hour 18 hour program there's only like four drug dosages you even need to know because things are variable in our day to day practice so that's my first little side a teaching pointer test hint for you all right some overdoses on benzos what do we want to give them so benzos would be like our xanax our ativan medically we may give them like some versed during a procedure like a procedure sedation or conscious sedation so benzos the antidote is remains a common orphan as Anil interesting thing about those names if they've got the Z in there so most times you look at a multiple-choice test question you can usually throw out at least one answer that totally doesn't work sometimes too and if you can narrow that down to at least two drugs that have a Z in their name you've got a 50/50 chance right there so romantic on or Funes know for the benzos now carbon monoxide does not really have an antidote but it has something we need to treat them with in ORS we can't really reverse this we just need to support and help to get it out of their body and that's - and some patients maybe go into a hyperbaric chamber as well and we'll talk more about that how the hyperbaric helps to offload it quicker so cyanide now this is one you need to delve a little bit deeper into the knowledge bin alright so the easy answer is the cyanide kit which there will be a picture of it with it later in the lecture as we delve into it more but you need to know the three components in there because the kid actually has three separate drugs in it and you know if the exam doesn't ask you to three names they just ask for a cyanide kit hey he's easy question but they could ask you a question in a higher-level knowledge test and ask for the three components or to pick out which one he's following is in the cyanide kit I'll leave this up here for a second don't worry if you don't get this all it will come back up in a little bit but we got amyl nitrite and that wasn't when is inhaled sodium nitrite and that one's given IV you do not need to remember the timeframes there's also very few numbers in this exam do not worry any numbers during this lecture that you need to know highlight abstracts bold circle whatever I'll tell you and these IV and many times are not on the exam and then sodium thiosulfate but you do want to know which route which one goes that makes for a good test question because the a mole nitrite is the only one that's inhaled the other two so I'm gonna go to the next one if you didn't give these don't worry they will show back up again in a little bit when we get to the cyanide section all right we've got a couple more so we got iron so this is to be a pediatric scenario and this one is gonna be DES for all our deaf rocks I mean again look this one's got the letters F V in there so it's kind of a clue then maybe it's related to the iron overdose all right there's just two names for the same drug salicylates so that your aspirin and a little memory tip for this is remember that the three letters for aspirin a sa what does it stand for acetyl sila salic acid remember that last part acid and aspirin overdose causes a profound metabolic acidosis so the treat one the treatment for this is a bunch of bicarb and we're actually two bicarb fluids and few other things but you gotta at least do the bicarb to get them out of that acidotic state which really messes everything up if you attend the section that has the blood gas lecture and we'll talk more about why acidosis in any condition is bad for your body and can make you critically ill so bicarb for this and also for the tricyclics there's one on antidote here but that this also puts you in a very bad metabolic acidosis so these are the two common ones you Theodore's if they even reverse the question said pick an overdose which bicarb is an appropriate first-line treatment these have come to top your list you'd be looking for okay where's the aspirin where's the tricyclics these are very common that we have to administer that first because they're so acidotic only they're there for one second make sure you got all that and then we'll go into these plus a few more more in depth and talk about them one of the things with the class I try and do is not just give you bullets and things like that I mean I do give me bullets and high points and frequent points that you need to know for the tests and things are asked about a lot there's also to understand concepts because if you can understand concepts then you can answer the exam question however they write it where they write it very simply like just a little fact level question or they make it more like a sin they're like a comprehensive level question where they're really trying to get you to connect dots so I do spend more time going with some the background stuff to understand these things so we're talking off for a couple minutes and this is something easily available you can buy an entire case of it at Sam's or Costco I think and of course I can be intentional and someone wants to kill themselves or unintentional so a little feedback time here what would be an example or scenario were someone might unintentionally over to us on Town Hall in order they weren't meaning to do it but lo and behold they showed the hospital they're sicker than dirt you get a Town Hall level and it's toxic or it's way too high what person can be doing that what could be their story elderly good yeah all right I would say I would say with the elderly though whenever you think that overdose think about kidneys more than liver tunnels never excreted but there is some overlap there but that's a good thought kids absolutely you know if Town Hall chewables taste great and that's how usually iron overdose happens too because vitamins taste good I don't give me another one how about you guys us of using drugs you know I hear I'm your opiate addict you know they may not realize that their purpose that their lortab has talent oil in it of course they're taking it for the narcotic effect but they're actually killing or live off at the same time so think about that and your that's one reason why I started usually your medical screening for a lot of your mental health patients that come in or your other overdose or your other people want to get treatment for abuse and things like that because they may have an unknowingly high tylenol level when Donnell's toxic is gonna kill you by basically putting in liver failure so at the end stage of this when they're super talked they can actually look just like you're in stage cirrhotic alcoholic jaundiced from the bilirubin confused pneumonia a lot of bruising a lot of petechiae from you from the platelets and the the clotting cascade alterations they can be hypoglycemic because your liver stores glycogen as a backup energy and if you've got liver disease or damage you're not storing that backup reserve source like you normally do so they could just like in stage later liver failure in patient they could have the ascites table their their belly their soft tissues full of fluid that's because they're albumin which liver normally makes is not making and if you don't have albumin fluid just leaks out of the vascular space and we'll talk about ascites a little bit later too now this is one of the numbers you need to know from this section from the toxicology section you need to know about a four-hour town hall level because it is written in stone and is evidence-based everywhere you go and that's one of things that this exam is it can only ask you stuff it's the most part universal across all emergency medicine the reason that for our level is significant and so scientific is because of this nomogram you don't you know any numbers off of here you just need to look and appreciate that between zero and four hours there is no predictable data as far as what's the you know if they come in at our one and their levels 500 there's nothing correlated to say that that level is going to stay elevated at hour four alright so some patients come in have a super high level hour one about hour for it actually be below the line okay the first four hours of town absorption is not predictable so if you and that's one thing about an exam like this a board exam there may be multiple good answers but there's only one right in there's there may be multiple right answers there's only one best right answer oh my gosh that's like nursing school flashback right because it has for a multiple choice exam it has to be that okay so when's the best time to measure Town Hall level anytime after four hours you could measure Nate when they arrive and some providers some your attendings will do that and they may make a decision to treat before flower that's fine and if they want to that's fine but let's face it that may not be the useful number the one at four hours starts be useful if it's under this line they don't need a tree it's above this line they do need a treat alright so that's all you know about tunnel numbers in this exam as the flower level is the most useful time I mean let's face it if they don't need if I don't need to go in there to fight with a patient for 30 minutes gonna drink that yucky old mucomyst and they're just being a pain in the rear you know it's it's time-dependent its resource dependent you know it ties you up from something else do I really need to spend that time they're not going to toxic at four hours so four hours isn't abrini know for the exam for this so of course we give charcoal and we can use charcoal for anything with the exception of one and we'll get there a little bit that's always a possible consideration but the most specific here would be the mucomyst and Thecla the full generic name is in that capital in there which just means it's an isomer of that original molecule but the root word is still the same acetylcysteine or mucus smells like rotten eggs right and we prefer that via the PIO or the GI route now if some of you guys are using a seeded oat which is a brand name only because it's only one out there that's the IV form now that will not be on the CN exam because it's not a standard of practice across all of the US yet it seemed merging as a standard of practice but as right now it's not as of right now by default the universal answer we're all going to use at least is the new cleanest okay so if you do if you are familiar if you see the dote I want you to remember more for this exam than you can nest all right benzos so these are our sedatives anxiety medicine and sleep medicines of course if one xanax makes you chill out what's a hundred gonna do make you super chill the main concern here is the respiratory depression and of course when you don't breathe enough then you got respiratory acidosis and again you got allows acidotic changes go with it so how do we treat this it's we folks in the airway first focus on the airway first and they can present just depends how toxic they are they could just present a little tired a little sleepy they could present obtunded and unresponsive so it really depends the link with that dysrhythmia isn't hypotension that ties into the acid out the respiratory acidosis again we're going to talk at acid-base disorders you'll see when your acidotic your cardiac output is actually less and your blood vessels don't respond the same to keeping a good blood pressure so even though this is really a respiratory problem eventually gets so acidotic you start to have the cardio and the circulatory effects as well too so your first treatment even though we're going to talk about their magic on a minute your first treatment is always airway that's a standard all your assessments a is always first so if they come in and they're APNIC they're not breathin the first in this you start bagging them alright oral airway may be so much sedated just a nasal airway okay and on this exam you always go from the less invasive and the stay for things to the more invasive things another disclaimer I'm but I'm right by the big air force base here and the planes flight about 500 feet just before you land so if I have to pause for a minute it's because when the loud lightnings is flying overhead and they are pretty loud alright so rs5 first if necessary charcoal possibly and of course that there's an airway issue you got to care for that charcoal cuz of course charcoal is P o or ng we'd like to have that area security that than being a weight with our only airway protection or if we had to intubate them first if we do decide actually reverse it alright room as a con or flumazenil again you got that letter Z in there to kind of clue you in that it's for the benzo overdoses and there's the precautionary statement that it may cause seizures now this is more of a sacred cow than a truth I mean science says it can happen but does it usually happen no the reason this could happen is because if you give them as a con you're just you will suddenly bind up all the Pens those out their body and their brain will basically just stripped away from the sedating properties and the brain kind of wakes up and is hyper excitable potentially so that's where that risk for seizures comes in if they sees what we get for seizures we give benzos okay when when the concerns about if they do cease and have your benzos back to them is we may have to give more because we've got this antagonist or a mask on and it is bound them all up so you may have to give higher dosage so we really don't like to use from a zircon that much do the airway first eventually detox out personally my career I've only given her mask on twice and it was not from an overdose the patient did it was actually from an overdose we did where we gave too much versed or they didn't wake up as quick from the conscious sedation and because that person just had the one-time benzo you know they didn't they weren't taking xanax four times a day for twenty years their brain wasn't that hyper excitable when we basically welcome so the risk for seizures is the risk procedure is more with the chronic abuser actually but romance con is your test answer for what specific antidote now carbon monoxide will be from something that was burning and so if you hear about a carbon dioxide exposure you always have to think back okay what was the cause where did this come from what was on fire what was combusting whatever and again it could be accidental like a you know Fire Department brings in a family from a structure fire or it could be someone you know trying to kill themselves you know lock themselves in the garage or the car running that old-school way of trying to kill yourself I'm gonna go to sleep and ever wake up so it could be accidental or intentional but you can't smell it taste it or notice it's really there so sometimes the accidental ones they don't really know that's what they're being exposed when they present to the ER with a bunch of headaches and nausea things like that and like oh by the way you didn't clean your chimney out before you started the fireplace this winter you've been exposing yourself you know for several days and of course if it is from a fire like a structure fire we got thing about burn injuries also and we'll talk about those but headache is the most common symptom but that's very nonspecific right many things have a headache right your most specific symptom is the cherry red skin or mucous membranes so we're talking about looking inside their cheek maybe pulling down their lower lip looking down inside the gum line look at the roof of the mouth maybe pull down their lower eyelid look down inside their [ __ ] I will sack they're very cherry red very bright red so I've highlighted this because this is a unique finding for this so it makes for a good test question however if you wait for these cherry red skin to show up it's usually in stage and super toxic okay so your patients probably critically ill there we're gonna diagnose this of course we can do mini tests for this but the most specific useful test is look at that carboxyhemoglobin on your blood gas panel and whatever the number is it has a half I have a four to five hours which means half of the drug will metabolize out in four hours another half in another four hours another half and and if you look at pharmacology and biology it takes about seven half-lives to completely eliminate someone some someone something so to completely get us out your system it's about 20 24 to 28 hours did you go for four hours times seven now they're synonyms should go away somewhere after the second half-life but they still got a high level for some time we may also look at other tests as well to think of the scenario sometimes I get exposed as carbon dioxide and they pass out and they don't die right away but they're laying there like motionless for a long time as those levels are building and building and we got the risk for rhabdo with that so we might do things like checking their urine for myoglobin okay if their urine has enough myoglobin in it to see it here's a little test word for you we see that you're in his tea color like iced tea kind of that brownish color and if this was an inhalational injury like a structure fire we may have to worry about things about ARDS pulmonary edema things like that all right our treatment for this so we really can't reverse carbon oxide what we do is we give them high flow oxygen and so we hope is with every ventilation they take as a off gas that frees up a hemoglobin carrier that that 100% can jump on and try and occupy that carrier site so you're trying to super saturate them as what you're doing alright it really just takes time though for this to wear off sometimes listen them to the hyperbaric or the dive chamber if we put them in a higher pressure atmosphere that helps with some of the offloading so that's usually not routinely done because if you do that there's a critical care transport you're gonna be tying up some resources in the dives you can have to have a nurse and a tech in there with them pressurized you got what about transport crews and you're also tying up a community resource so we typically don't use the hyperbaric except for very select circumstances regardless in the ER we will still to start with a hundred percent oxygen first so I still go to your test answer under education so kind of each exam concept of each blueprint category closes out with something about reassessment patient education things we do kind of after the fact or promoting health because those are part of our nursing domain also so some stuff we can be teaching our community members about is you know where do you get carbon dioxide from well anything that burns so we should have smoke detectors and if you've actually got like any gas appliances those kind of things then you also want a carbon monoxide detector which is a little different than a smoke detector or if you have a fireplace so those are giving off you know direct gas all the time when you're running them and the symptoms the headache was most common and the charrids skin or mucous membranes was the in stage most specific are you cyanide so this is a very lethal poison the reason it's so toxic is because of what it does the cyanide molecule goes to your mitochondria and turns them off your mitochondria the the energy power plant for your cell as soon as you turn the mitochondria off they immediately go into anaerobic metabolism and our metabolism gives off lactic acid lactic acid is like a speed brake once lactic acid starting to form your ATP production becomes very inefficient and it shuts down almost immediately so if SIA is exposed by inhalation cuz you can breathe it as a few more vapor a cyanide gas it's going to turn off your lung cells within a matter of minutes and what are your lungs supposed to do this was exchange oxygen for co2 if you turn that off they're gonna become hypoxic very quickly you can only go with that option for about maybe two or three minutes you won't be dead yet but you'll you'll be unconscious and then Prime about four or six minutes you'll be dead so very fast inhalation wise we can also get it by the GI tract you can actually swallow cyanide in a capsule form if you wanted to kill yourself intentionally you can also get it to it naturally it's one of your pitted fruits it's either cherries apricots or peaches but the pits of some these hard pitted fruits they've got some trace cyanide in them but you actually have to consume so much of that that it's not really a practical way to do it but it doesn't actually occur though and the last way we can get it is actually through our IV if I've store my patient on nipride the vasopressor nipride breaks down to a cyanide type metabolite that's why in your hospital if someone's knee I see you on I pride your policy your hospital policy probably says that you going to change the entire nipride IV and tubing out every 24 hours well before it starts to break down all right so this patient if their toxic dose I know they're probably looking critical in extremis a total resuscitation scenario okay and we're just gonna focus on dealing with that so there's no specific there's no most common symptom or whatever but there is a very specific one which is if they're breathing off bitter almonds the smell of bitter almonds that's strong is suggestive that it's a cyanide and I would say too if you smell that you're probably too close to patients so put some distance between you and the patient there so it just depends how toxic they are we can measure a cyanide level although it's not like practical to do if you think it's a sign of exposure they're probably critically appearing and you're focusing on resuscitating him anyways okay a more common thing we might do is just get a lab two camps that we do that on a lot of patients these days because remember the cyanide is turning off the mitochondria and the mitochondria are the the releasing that lactic acid because they're going into the anaerobic metabolism so usually do lactate some more often we do actual cyanide serum levels and please don't be doing emails to now for Malcolm asking his patients especially as inhalational because they are probably off gassing this stuff and you don't want to expose yourself so if you know that bitter almonds get away keep some distance so here's the cyanide kit and this is a look inside it and it actually has those three products in there so here's your chance to write the words down again if you want I've bolded put in red the ammonites Reich is the one that's different the other two are both Ivy so snakes are a good test question when they say which one do you administer by the airway route and they put a bunch of names for you you like okay Allen I try it's the only one that goes or you see maybe if you didn't know this you're like Oh airway I thought we you know give meds buy IV for resuscitation or overdose no so this is kind of unique so it makes for a good test question now how can you remember this one is airway because these words all sound big and doctor words and hard to remember amyl nitrite has an A you can remember a for airway you can also number the in for nasally which is a way to do it so let's look at how this is actually done so the amyl nitrite is actually these two ampules and what you do is you break them open like the old Finnegan ampule or the epi ampule and you basically shake that liquid out of the ampule you don't draw it out to shake it out into the inside of the non-rebreather if they're still breathing on their own or into the face piece of the bag valve mask or we're going to put it down the ET tube the reason we're doing this is because it is a vapor okay as you we know more and more about different airborne particle sizes these days talk about coronavirus we know we got droplets we have secretions we got aerosols we got VAP these are all different particles this medicine has to be delivered as a vapor so we are not going to put this in a nebulizer and do that that makes a hold that changes the molecule changes the delivery so they got this non rebreather on them they got this liquid inside there about two MLS of liquid and it's kind of dripping and all and that's fine but as the oxygen goes through the non-rebreather the patient breathes it in they're picking up the fumes or the vapor from it and breathing it into their lungs okay and again if we're bagging them we just shake this liquid out into the face piece and then continue bagging them with our bag valve mask the other to go IV you do not hear about times or speed or anything just know both the sodium products are given IV and do the bandwidth we will you just skip the videos on the bandwidth because the bandwidth because they're kind of clunky don't worry it's just stuff too reinforced learning is nothing exam critical now this is the cyano kit a little different product this is not a standard test answer yet this is also like the new cleanest this is an evolving treatment that some places are using so I just want to show you what it is you don't get confused but look at the name it's not this it's not the same as cyanide kit it's a cyano kit very specifically spelled differently okay this is just one dose she'd give it one time and you're done you don't have to do this three-step process like the cyanide kit you do this is just a one dose IV thing but it is not the standards on the exam yeah and it won't be for you know at least next year so I mean most places still are using a cyanide kit and again by default even if you had this product you still have a cyanide kit accessible that is the default that we all have so if you are using this just don't focus on this for the exam answer make sure you know these ones the three pieces there in the cyanide kit alright iron overdose so this is usually a pediatric situation I mean no one wants to go oh let me just take all these iron pills and kill myself although it would be a pretty definitive way to go but kids usually have have it happened to them because you know vitamins taste good and unfortunately we don't teach them these things aren't candy they can get a hold of me as an overdose on them the concern of the iron is the damage it does to the gastrointestinal tract your GI tract is very vascular and things that damage the lining can promote hemorrhaging which in and of by itself is not the problem but the problem of GI hemorrhage is a lot of times it goes unnoticed for some time let's face it your stool doesn't automatically turn bright red immediately let's go take some time you don't drop your Hema gram your hemoglobin your Metacritic you don't drop that for possibly several hours so it's not an immediate thing it's more of a slower insidious and this kid could have been taking extra these over the last couple days kind of sneaking in some here sneaking some there so it can kind of build up gradually now depending how toxic they are of course they may look mildly sick or severely sick I mean if it's already been going on for some time they can come in in extremity and be resuscitating basically unresponsive cuz their hemoglobin so low or the parent caregiver may say yeah he's having some blood in his stool it's probably been going on for a period of time the phases of toxicity for this it's got a unique progression you do not need to know the numbers just understand the progression it's a very distinct progression this is straight out of the the enpc class and any time he and PC references something that's what you want to go by is your default because the ene and the bcn are pretty much buddy-buddy and they'll follow the T and CC and the MPC guidelines every chance they get so a MPC teaches us about these four phases phase one is the missed diagnosis phase this is the phase where the keiki get brought in there have some belly pain no one knows what's going on the parent doesn't other vitamins are all missing maybe ever having some blood in their stool okay now belly pain nausea blown this tool does not always go ding-ding-ding iron overdose because you can have some bad gastroenteritis is basically diarrhea infectious diarrhea is they can cause the same thing and that's the more common thing you'd think of unless you had some compelling reason otherwise to think oh well there's the empty bottle of vitamins we better check the iron so phase 1 can get missed and we just okay it's a bad GI bug we give the kid some fluids some nausea and diarrhea medicines in the ER we look at their Hema gram and remember it doesn't drop right away so it's probably normal or borderline low and you know if you'd read Hema grandma after your IV fluids and I'd be a little diluted also so there's nothing screaming saying hey this is an iron overdose we treat the kid they get feeling better they perk up send him home phase 2 is that back at home face or the kind of recovery phase a little bit and the parents I'm home they're watching the kid you know the kids still feeling kind of uni you know he's crummy hey but he got some fluids got some meds the ER so we kind of got him you know somewhat stabilized at home and he's kind of convalescing but he's not well yeah phase 3 now they suddenly get sick again because now the hemoglobin has dropped now that we you know the true damage was from the iron being in their GI tract that's what's really causing problem now before with I was just maybe a bad infection er slunk that there to come back to the ER at this point alright now this is where you and that's why with these like repeat visits the ER whenever you get a repeat visit you kind of to think what what was the first presentation what do we do what do we not look at what's positive change here this is where the provider needs to say hmm we thought it was his bad barrel infectious diarrhea the kids not getting guys actually getting worse and now the hemoglobin is down what am I missing that's where a good clinician they'll say give me the iron panel all right whatever you do at your shop is fine with you just do a serum iron or you do the entire iron panel the exams not going to ask you to differentiate that it just depends on your provider but you're gonna basically do some iron studies and see that it's low alright this kids quickly ill and we're gonna treat them we'll come back to the treatment a minute phase 4 is basically the recovery phase after the treatment after you've saved their life if they've been admitted they've been entreated they've been detoxified whatever these kids go on to more often than not have some chronic GI problems from some of the damages happening a GI tract some strictures adhesions things like that okay so just a quick review here phase one is misdiagnosis sometimes it's a bad infectious diarrhea give him some meds fluids they go home phase two kind of recovery time they're feeling better looking a little better because he treated them but they're still having that occult or unknown iron damage go on in Phase three Nelly's to come to it now it actually caused enough problems that they actually get profoundly ill or critically sick and then phase four is there long term complications so once we pick up on the that's what's happening there's an iron overdose and again just you don't need this number on the exam you only need the towel for hours there's some variability here the blood loss is going our main concern so as soon as we're thinking I if you have enough clues to think iron or dose don't even wait for the hemoglobin to come back low go ahead and get your type and cross now against eight and definitely if it's fall death those three phases where the kid was already there before they got treated but they're worse than a critically ill interesting oak could be iron going to get the type and cross because we needed that's what they need is that blood replace an ASAP so deferoxamine or desk for all is the antidote of choice here and again that letter Fe is in both of those words so it kind of helps remember that this is the only or dose however I want you to put a star here Circle it highlight it because it's good for test question because its exclusive this is the only overdose scenario the charcoal is actually contraindicated what does contraindicated mean doesn't it doesn't just mean you waste your time it actually means you'd be a pretty yourself libel if you did it because you eventually cause more problems and it literally does not do a thing okay charcoal is designed to absorb something bind to it and then help eliminate it and it will not do that with iron the way the iron molecule is attached to the hemoglobin carrier it you can't absorb it you can't buffer it you can't nullify it you've got to cut it you actually have to cut that bond that's what the word chelate means if something is a key later are you doing chelation therapy that's actually a substance that cuts the bond from whatever you're trying to get rid of so dead Fox in the industrial our chelation agents or ki laters and basically when they cut the iron off the hemoglobin the iron is then excreted back to the GI tract in its active form so this kids I shouldn't have detectable iron levels in their stool because it's not metabolize it's in its in its raw active form because all you do is cut it off the hemoglobin so this makes for a good exam question and it's the only one that requires a key later and it's long once you do not do the charcoal because they ain't gonna do a thing to them and it can actually cause more damage in their gut it's already damaged the salicylates was the aspirin and the shorthand for that is a sa and this is comically an elder there's a couple so we know tylenol is liver all right aspirin and you'll see the other ones when they come up aspirin tricyclics digoxin and lithium the are all kidney excreted okay so the so anything is renal excreted can be high-risk in the elderly because a lot of elderly walk around with some mild degree of renal insufficiency which means medicines and substances don't metabolize as fast or effectively so calmly this will be a senior who even taking normal doses of aspirin I'm not talking a baby astronaut you can take two aspirin every six hours according to the bottle okay that's maximum dose and some seniors do that for their chronic arthritis and things like that not the ideal medicine but some do so even at normal dosage and a senior or a me with any renal issues or any that's a little dehydrated because your kidneys need water to work it can build to a toxic level so elders are more at risk for this and you know you know all the risks with that aspirin it's why the surgeons how you stopped it before surgery because it increases the chance for bleeding it can promote ulcer formation so you got GI bleeding also you might see this person with some bruising on their skin from their platelets being altered from the effects the aspirin and it is going to affect our acid-base balance and this is one of the ones that can give you a very bad metabolic acidosis which is why the bicarb from the treatments so you might see all these other all this other evidence of this the aspirin fact in the body the the bruising of the skin the petechiae the upset stomach the belly pain there's an ulcer being aggravated there from it why would they be to kipnuk can you connect those dots yet same as I already told you one of the things it does cause why would they be breathing at a faster rate see if anybody wants to guess that they're breathing exactly so if they're if they're at acidotic they're compensating by trying to hyperventilate just like our DKA patients may be doing to kick me as well too or people who are septic might be breathing a faster rate okay so well the kidney is not a problem we're gonna see it as a compensation I've only seen a couple aspirin overdoses that were toxic they didn't die but every one of them they were already sitting up try potting breathing like 3040 times a minute because they were so sick now tinnitus is a very specific finding and this is pretty unique for aspirin for so definitely highlight this one for the exam tinnitus is ringing in the ear ringing in the ears and literally it's like a ringing so if someone presents the triage and they give you their list of all these other complaints that none really make sense now I'm also there's ringing in the ears your thought should be um can I see your med list let's look what medicines prescription and non-prescription you're using cuz that's gotta be something you have to if they say me in the ears you have to at least address it at least look at their med list there's always we need an aspirin level but if they got some aspirin on there or they're taking aspirin like compound or it's yoga I you see this lot of times like younger males doing construction it's just a stereotype I perceive they're taking a lot of those goodies powders or those stand back or what's the other one BC powders all those headache powders it's more coke on the southeast and those have a high dose of aspirin in them and they may not have been thinking oh I'm actually overdosing myself when I take you know six of these a day so look at that Med list first and again just FYI it is about a six-hour level you want to get to be the most useful but it's not the same degree of certainty as the town hall for our level is so still tunnels off I'm gonna need to look at this if I was remembering a specific number so if that aspirin level is up then I might be looking at things like their PT in their INR because I know aspirin affects that I might be going back and asking already have any blood in your stools when I triskele GI bleeding definitely look at the Hema gram you know if they're not already hyperventilating but let's say they're obtunded let's say they're so critically sick it's like a resuscitation we have to control that airway we put them on the vent we need to remember oh we're treating aspirin overdose my starting vent rate does not need be twelve or fourteen it probably needs to be like twenty or more okay so we need to start hyperventilating them on the ventilator by car is going to be the first line probably the first thing you'll do I'm trying to reverse that acidotic state you don't need what about dosage you're gonna give a bunch of fluids also by the way cuz you get those kiddies going to filter this stuff out and they're critically ill they might wind up on dialysis they get why dialysis because this is renal excreted and if they're that super toxic and critically ill we may need to take we may need to take over the work of their for them I've never seen it get to that point although the couple handful I have seen again like two or three bicarb fluids and just respiratory support basically then you have to intubate them just you know kind of watch them your tricyclic are fortunately not used much anymore they are used for antidepressant i depressants there's only a couple still out there elavil or amitriptyline there's one of your few that you may actually come across they just there's too much the potential actually gets sick off them and there's some interactions with other medicines that's whether it really not favor anymore if someone's still taking a tricyclic is probably because it's the only thing that actually still works for them so we just don't see it much but they are so bound at a high level it's hard to get rid of them they cause many effects on the body there's a lot of cardiovascular stuff so I bolded this here this next sentence about the properties here I bowled it so we have a little conversation about using doctor words on the exam they're going to use the more professional words okay when we do a little bit later on we'll talk about meiosis and the dry assist time at whether people is constricted or dialect dilated they were use these more professional terms so whenever we say something is an anticholinergic how do we remember what that would look like or how that patient presents what is an anticholinergic so atropine is your prototype anticholinergic medication so if you just think okay what would actually pain you if I gave them a milligram of atropine okay it would speed their heart rate up it would dry them up or those two the common things you think of so that's your anticholinergic syndrome okay high heart rate and drawing up secretions all right so that's one thing to try seconds will do they'll act like you just gave us matric mean try cigarettes also calls alpha blocking effects so let's slow down and think about where are my alpha cells and what do they do your alpha cells are on your blood vessels all right and when you stimulate the alpha cell when you cause a response you caused it activate you caused it to go to work it's gonna tighten the blood vessel alright so they have a good blood pressure you need to have some intact communication to your alpha cells tricyclics act like an alpha blocker so if alpha stimulation gives you blood pressure alpha blockade will drop your blood pressure can you may think of your blood one of your blood pressure medicines it's usually by mouth or by transdermal that might be a clue there works by reducing your blood pressure because it's an alpha blocker and I'm sure you've used it to keep in this business more than six or nine months blood pressure medicine is an alpha blocker sometimes you've probably even given it as a patients being discharged cuz their blood pressure was up too much at the time of discharge yeah ii see if you maybe want such big s pill or patch so that is your clonidine or cat oppress is an alpha blocker so if you ever say anything about what is alpha blockage or stimulation cause think of clonidine as an alpha blocker and if a person took too much to drop their blood pressure so i'm trying to get you to be familiar by putting you in common places you actually are familiar with them so a bad tricyclic overdose high heart rate low blood pressure very cardiotoxic as far as the dysrhythmias go as far as the heart it can really be anything eventually that initial tachycardia from that anticholinergic type response that atropine like response and then eventually get the blocks pauses PVCs and eventually you lose your heartbeat also because you're so asked to Datuk with this and again I keep referring to being a static is bad for your cardiac and your vasculature again you lose your cardiac output this is just a little memory tool to help remind you about TCAs and I bolded the letter C's here because you're gonna remember the three the letter the word 3 has letter T and T CAS has a T so the 3 just linking those two T's they're the three C's T CAT see the 3 C's if your places patient shows up with unexplained cardiac dysrhythmias convulsions me seizures or unresponsive in a coma a clinician is supposed to think about tricyclics and possibly start managing that all right unexplained cardiac convulsions or coma the three C's this is also a time for me to tell you as part of your studying for this exam that it's as simple as going online and there's a whole bunch of medical mnemonics out there like this there could be those little study aids or those little memory tools for you if you look in the back of the book I sent you there's a few in there also just some common ones that I've used in my career there's many more out there so this is just a little pause me to remind you to tell you there's some other study helps free to to remember certain things certain syndromes and we'll talk about and we do the organophosphates will cover the models and the sled jump is a very common one that most people will use as part of our clinical care or prepping for exams so bicarb absolutely get them how that metabolic state and we just treat the symptoms all right there's no antidote for this the charcoal is not gonna work and less there's still something to absorb we're still gonna try it and that's fine but you'll be treating with vasopressors you're gonna do something for rate control you'll be treating the seizures possibly to cardiac convulsions coma so still use like benzos for the seizures if they had to ask you which drug you'd want to give first of course make sure your patients perfusing if they're if they're so hypo tends to have a blood pressure of course you'll start a presser first if they got a blood pressure maybe it's a little low their heart rates a little high the first drug definitely the bicarb prevent them from getting worse okay all right let's talk about some stimulants so I did I did mention to you here on the slide amphetamines methamphetamine we're actually a time I all stimulants here about the next three or four separate products of course math would fit in this category as well as things like cocaine they all have a stimulant type effect so the patients could all present the same whether it be something recreational like the meth or they're overusing saline prescription like adderall or Ritalin and they're overusing it they're all going that hyperdynamic that stimulant type state where that sympathetic system is being over driven okay whether it be chemically manufactured or actually prescription weight-loss meds the bariatric clinics the weight loss clinics they still prescribe data packs and that can be misused as well too because it does have a stimulant like effect so both recreational and non-recreational exposures and just lunching side note here for you so what we see is when people can't when they're like meth addicted and they can't get it and will be the perfect environment really can't get it more not really perfect but the most limited like in jail and this is an actual article and she's been seeing other jails too that there's actually some meth like effect in some scabs and sores and his patients they've seen him on camera actually eating these meth sore so these scabs how gross is that right that will not be the exam that's just kind of little side interesting thing there to get your interest nail what is that what's up with that yeah but Google down your own about meth heads eating scabs so the stimulant response again is that sympathetic system your sympathetic system is your fight or flight system alright that's predominately your epi in your new rep you're being released at a higher level when you can cause a sympathetic stimulation from any stimulant so of course the heart rate will be up the temperature could be up so here's your pupil work all right any any sympathetic any stimulant response you get dilated pupils then fancy term is mad rias's and it's so easy to remember why because there's a D in madrasahs and there's a D and dilated and of course when you're stimulated sympathetic system fight or fight you're running away from the bear or running away from the snake those eyes are big you're scared okay so sympathetic response dilated mydriasis pupils that word formication that's actually that actually is why the meth people they are always touching and scratching themselves as the meth is excreted some to their sweat it sends like a an extra sensory signal it feels like there's something on you like a bug is walking on yours a fly just landed on you and they're always touching themselves that leads to the abrasions the skin breakdown that leads to the sores that never heal up you're always messing with them that medical ward is formication so that was mostly with the math now the cocaine is still a stimulant response but the unique thing for the exam about cocaine is the treatment is specific there's a do and there's a do not for it and that is answered by looking at why a cocaine exposure causes what it does okay it doesn't stimulate the heart directly it doesn't stimulate the blood vessels directly cocaine works in the brain and it tells the brain to dump out more these catecholamines your sympathetic transmitters so the impulse for your heart rate or this person's heart rate with the cocaine like palpitation layer is coming from the brain not from the heart itself it's dumping out more this now side note the reason people enjoy doing cocaine is not because of the sympathetic not because their heart rate goes up not having palpitations not because they're getting paranoid but is that what it does initially is it causes your dopamine which is your mood transmitter that's when your happy mood transmitters it causes the level doping to surge multiple times its normal level and that's what feels great about cocaine you feel so great that initial rush and then that wears off and now you go to the ER because your heart's racing and pounding out of your chest from the other sympathetic stimulation and that's usually how this person will present palpitations skipping beats maybe even chest pain or tightness from that over stimulation the heart soars their mental state could really be anything you know they they could still be a little bit high and worked out they could be sedated or just you know sluggish to respond anything but the cardiac is what we're worried about out okay and again the pupils again it's a stimulant effect so we're still gonna have the madrier cyst those dilated those big sympathetic fight-or-flight scared pupils the treatment that the the test question is important here is what do we not do because they're most common presentation or are most common concern emergently is that heart rate control because they can be tacking away at 150 or more or with the palpitations and if you follow your ACLs algorithm part of your heart rate control is to give a beta-blocker and for cocaine overdose this your test point do not give a beta blocker so you need to break the rules alright and let's look at the reason why first you're not given that your listener because it's not it's not a heart problem all right we treat the heart for cocaine by treating the brain we slow the brain down if I give them the beta blocker their heart rate will come under control do you will be blocking the beta cells of the heart and your beta cells play a role in your rate so you're blocking the the rate control the heart the heart will slow down but what is still dumping out of their brain all those Caddick they're circulating they're still comment they you've just taken the heart away and these katakana he's like we can't go to heart they just give it a bunch of lopressor those beta spells are blocked where do we go we're lost well the Catalonians also like to go to those alpha cells on the blood vessels and they're going to over stimulate them so you can actually get a rebound or a reflex massive hypertension and Stroke the patient out so beta blockers for cocaine overdose no no no no potential risk is a hypertensive stroke because the catecholamines can't go nowhere except to the blood vessels so that's good for the test because it's an unique one where this this I'm not gonna say the only time we don't treat it with beta blockers but definitely if he knows cocaine overdose and all arrows you know it's a young twentysomething guy he's kind of high palpitations high heart rates maybe he even admits to using it do not give the lopressor first you have the benzo slow it down in the brain it's a brain problem be for benzos for the brain and no nitro because her chest pain will blow away when you slow the brain down with the benzos all right then our hallucinogens so these are kind of all lumped together they all have a very similar effect there's you know I put GHB an X here there's a couple others out there also you're basically looking for some alteration in the mind process some perception thing so hallucinogens that doesn't mean they'll start like hallucinating like freaking out but it changes that mental state is what it does now by themselves most of these are actually used safely and not a big deal and don't cause problems the key is when it's mixed with alcohol which happens a lot of times that's when this sedation effect is multiple times multiple fold and they can actually come in like Anna respiratory rest so it's combined with alcohol these become the problem there's many of these you know college parties underground clubs these get together they do actually see and all that and they know no one brings alcohol in there they don't serve it and they can't bring it they're checking bags the door because that's gonna big why would you want to pass out the point of dying that's not where you're going that even that Club to have a good time alright so by themselves are usually fine that being said anytime we think there is possible hallucinogenic you know they can with a rest for a problem their predominant so massively sedated fixing the on the ventilator we need to think could this be a forensic case because again people don't intentionally mix alcohol with this stuff they don't intentionally do that so this usually is unintentional which means someone was trying to do something possibly like male on female sexual assault so they'd be defenseless and there's some amnestic properties with these two some have some retrograde amnesia that at the point of ingestion when you know they slipped the girl the the GHB and the drink the the rohypnol the roofies or whatever for a period of time before that it's like a mind erase so the girl mean I remember who was sitting next to her for the prior thirty minutes talking to her that slipped to the drug so think forensic think you know chain of custody possibly think about law enforcement volve whatever your evidence collection procedures are I will we spend more time on that under the OBGYN we talk about sexual assaults but just think about that all right so we had to ask the questions you know could this be a date rape sexual assault thing now the GHB the ex and all that it's an airway problem is sedation so airway is always the first thing we may just need to put a nasal trumpet and that in them we may need to you know make sure they're sitting up high make sure they're their friend that came with them it's in their coach I'm hey Stanley so stay awake Nancy stay away keep talking me things like that but if we have to will control that airway okay we don't usually like to for for them these loose engines because typically when it starts to wear off it wears off pretty quick not like it wears off like in thirty but once they start to wake up it's like five or ten minutes they're completely waking ready to go okay and sometimes if you're not assessing your intubated patient often they can review self extubated so we want to definitely watch the airway close and often so I've got and because we're on different time zones I refer to the time because we're take a break here I've referred to the times by just saying what time we are after the hour I usually type to a break message in here the chap to see what the time stamp says so it says 12 minutes after if you guys will rejoin here at 22 after 10 minutes I found in these classes is usually sufficient and if you think of a question that you didn't ask during while I was talking type it here in the chat box I'll look at it when I get back for my coffee pot and for something I need to address I sure will so we'll come back in 10 minutes okay so actually I got a little video for you here I do show this one is kind of a bit of humor just to kind of lighten up a little bit and take things not so soon not so seriously for a minute this is some paramedics hug so we got both alcohol intoxication and we got alcohol ISM one is the disease of chronic use and problems one is actually just being under the effect already impaired it is a commonly used drug it actually it's actually classified as a drug under the USP the United States Pharmacopeia the actual ethanol molecule itself is and of course we see this a lot of our overdoses you know now is it because the person gets drunk and they start feeling oh I'm so sad and sorry for myself and I take pills or the vice versa doesn't really matter which order it happens but we do see it as a concurrent ingestion a lot of our overdose patients that we deal with and the disease is when it affects not just temporarily being intoxicated but actually affects your entire life your work your finances your family relationships you know of course your physiology as well too and your health so that's the disease state and that's a chronic situation I'm assuming if we've been in this business more than a week we've seen a drunk person so we can kind of make some judgments and some assumptions what they look like but remember even with chronic alcoholism they could look like your neighbor you know and now do you really know they have a problem some people do you'll compensate and do fine you know for most of the day till they start withdrawing they got to start drinking again so it just depends really where they're at individually for us for emergency care we're gonna focus on two things this one is the acutely intoxicated patients of course we're about things like airway and aspiration and then our person might be withdrawing from chronic alcohol use we're about things like seizures with that and injuries and there's an I'll do that too when someone's under the influence there's another fancy medical term for you nystagmus that's the little twitching of the eyeball if you tell them to follow your finger all the way left or all the way right they'll get a little bouncing a little jitteriness right there at the side when they look all the way over and that's called nystagmus and that can be a sign of alcohol intoxication acutely all right and of course depending on if they have alcoholism and they've got the long-term disease a liver damage they can have all the findings of that end-stage liver as well to the ascites the jaundice the confusion the bruises from the platelets being affected by their liver all that so it just depends where they're at in the spectrum you know from an acute intoxication up to the disease process if we are worried about withdrawals in our chronic alcoholic we do want to minimize stimuli because basically they're seen as we more excitable as the alcohol starts to really the other system so they are at high risk for seizures so not the ideal person to put right in from the nurse's station with all the alarms and the phones and things like that but also not the one to put around the back hall down the hallway in the corner where no one ever goes because they are at risk for seizures the are at risk for doing silly stuff trying to climb out the stretcher getting hurt hitting their head you know and risk for aspiration or their injuries so it's kind of a balancing act you know how much can we control them prevent those seizures from happening now under the medicines were talked about let's go and clear the air about this on the seat in exam if focuses on emergencies and the emergency measures you do in the first and I use these words time and time again the first line the first acute phase the first short period of time when truly we're doing emergency care saving lives you know things like that so banana bags are not gonna be on the exam okay banana bags do not save lives at a minimum depending on how you mix your banana bag your pharmacy you're giving over at least a two hour period that's already outside of the emergency resuscitation say the life thing that time period we're gonna make a big difference immediately so those won't be on the test all right d50 it's got a it needs we need to talk about dextrose in the alcoholic because that can be something we have to give to them in an emergency period so we're gonna look at who needs d50 and how to prevent some complications and we'll jump to the warranty Korsakoff in just a second we also worry about electrolytes we know that they're probably nutritionally deficient their electrolytes are out of whack a lot of times potassium magnesium or to the common ones that they're out of whack with now again not under state an emergency first oh my gosh give them two grams of MAG stat okay but we are looking at these things these patients as we woke them up more of a paramount concern probably if they're already having seizures or starting to of course then benzos the drug of choice there but let's come back to the whole dextrose thing and talk about Wernicke's encephalopathy and korsakoff's psychosis this is something I added in with a little more detail on the slide you might need a write a few more notes in the side column there so I'll slow down as I go through this so Wernicke's encephalopathy is encephalopathy means basically brain swelling all right and this is a unique kind of swelling that if we don't prevent it and it happens it can actually cause korsakoff's psychosis which is the permanent damage to the brain where they actually have psychotic neurological deficiencies because of the brain damaged so the encephalopathy causes the psychosis all right so how and why does this happen the common trigger for this we talk about our alcoholics is giving them d50 or d-10 because not everybody has D 15 or someplace due to having to use fast d 10 drips over like 10 minutes if we're giving them a large dose of glucose that glucose molecule requires thiamine to be carried across the blood-brain barrier and a lot of our alcoholics are malnourished and if you're malnourished you're probably eating a lot of protein which is where thiamine comes from so that's the underlying problem as they probably Thiemann deficient and you give becoming their blood Sugar's low remember their livers jacked up it doesn't store the glycogen so they can drop their blood sugar and okay the blood Sugar's you know 40 that's doing some d50 if they look malnourished before you give the d50 you automatically give a hundred of time in IV it's like over a minute or two and then the d50 what you're doing is you're ensuring there's enough time in their body to carry this large glucose molecule to the brain safely because if you don't the glucose gets trapped outside the brain and the brains gonna swell in response to that okay so this is not the Fineman in the banana bag over the two to four hours this is you draw it up in a syringe 100 milligrams you give it IV and then that's gonna protect that brain you're not gonna make someone fine and toxic your B vitamins are excreted through kidneys just fine if it's low it can be a lifesaver if it's not low then you're not hurting nothing you bet you could potentially saving their life okay so anybody looks malnourished most commonly an alcoholic so it could be like a cancer patients - you're in stage HIV anybody who might be thiamine deficient that you have to give large amount of dextrose to d50 OD ten push the thiamine first and it protects the Wernicke's encephalopathy and the Korsakov psychosis now if they do start going through withdrawals the DTS the root word here is delirium that's it's not just the shapes but remember the delirium part that means there's an alteration or thought not they're drunk but this is where they have like the hallucinations you know the spiders on the wall the Devils sitting here next to me talking to me okay they're they're not connecting with reality okay it's like a psychosis all right and this is key because it tells you not only are they having the autonomic stuff the high heart rate the blood pressure that they're sweating clammy but now their central nervous system also and when you combine the two both the tremors in the autonomic system manifestations and from the CNS the confusion the disorient the delusions and all that this is like just a half a step away from having seizures and being critically unstable okay so DTS are both the physical findings as well as the mental as well - and this person should be made to know I see you rightly monitored closely lithium is prescribed for bipolar disorder some depression and like the tricyclic is not used much anymore because it's got such that narrow therapeutic range and it's easy for it to get too high or to be too low and not be effective so we don't use it much anymore um if a person so on lithium it's probably one of the few things that's still working for them so we don't see this as much as we used to symptoms are really kind of nonspecific though I did highlight the more common toxic ones I don't really have any easy memory tools now remember these because they seem kind of vacant in a sense but people don't typically overdose on lithium and the ena would not say someone who intentionally took an overdose the more common and here's another test point for you things that happen commonly are commonly asked about on the test they don't ask you about the zebras they don't ask you for the things that are so rare that never happened the most likely lithium overdose as soon as it's already on it and you'll see it on their met this no go okay I'm getting a lithium level and some vague symptoms now it's also a kidney excreted one so renal some of our treatments for this is a bunch of fluids see those kidneys going get it from filtering get this level down of course we hold the medicine so there's not an antidote for it's just basically making sure the kidney function is at a high level didge normally people taking this have afib or something that requires this kind of I know tropic support of the heart I'm sorry the cardiac output support this is usually also like the aspirin granny who's taking normal dosages little dehydrated little Reno's efficiency goes to a high level how do we predict what digitoxin see will show up with well if one digoxin slows your heart rate because remember Nursing Scalia to check that apical heart rate for a minute you might have to hold it if one pill slows it a little bit what's ten or a hundred gonna do it's gonna really slow it down in heart blocks and could possibly throw them into heart failure as well too right so look for heart rate for your symptoms most commonly and the patient may report these yellow halos meaning they might see like yellow rings Brown things in their visual fields low picture I have here is they suppose that van Gogh the artist might have been exposed to Fox Club which is the precursor drug to didge and so a lot of these yellow rings are in some of his paintings and so it's thought that maybe he was actually having these visual symptoms from walking about the low level elevated didge serum level from the foxglove you don't know if that's urban legend or not but just kind of something interesting help you remember maybe the yellow halos and the answer though is digibind we don't usually use this because if you give did your mind you will take away all the patients did and this person normally needed it for their heart output you can throw them in a massive CHF and pulmonary you basically tailor all their heart output basically because you're gonna bind it all up completely so we're gonna focus on symptom control and you only use the digital mind it was like truly a life and death scenario because you have be prepared to put them on some other type of inotropic support now I've only seen a few digital toxic people and we just been able to treat symptoms never use the digibind myself and all these 20 plus years but it is your antidote of choice if you have to all right and then we've got some others I'm just to connect some dots here some people fill in the blanks for you all right so coumadin so we're gonna give the reversal for that any guessers on that little self-test here so that'll be our vitamin K D prepare to know that for the test that's a common standard one dilantin so we don't have an antidote for dilantin we just treat their symptoms and easily to remember how this might present remember what you have to do when you have someone on a diet and IV let's say there are application and their levels low and we give them a loading dose in the ER if we're doing an IV they have to have the cardiac monitor on that's the same thing if their level is two because if it's your give them too much of it too fast or make them toxic so look for your cardiac rhythm changes with that lanten as far as symptoms go but we just treat the symptoms holder dilantin it'll filter out of it calcium channel blockers so if you block all the calcium channels no calcium can get across we treat this by basically giving a large extra dose of calcium we're trying to give you more than you need trying to force those ion channels opening in okay so you got two choices calcium chloride or gluconate I'm gonna tell you a little something about which one you do for which so if you look at calcium chloride there's a letter C and you remember that calcium chloride is more concentrated than gluconate it has to go through a central line and this is the one you use on your code or crisis or crashing or critical patient so I mean all these letter C's here to remind you calcium chloride is like really the emergency drug life and death central line gluconate all your members letter g that's for your good patient this will be a slower infusion there to be stable you can do it through a peripheral line they're not crashing okay calcium gluconate less rapid and it's not as caustic or it's not as it doesn't burn the vessels like chloride does so that's how I remember which one for its patient concentrated code crisis crashing versus your good patients ethylene glycol this is when you get to right in there I added it a few classes ago so so this is basically your antifreeze and your alcoholics may turn to this so when they can't get regular ethanol and so if they're toxic from this we treat this with an alcohol drip so we put them on the same thing they really want in an IV your body prefers the ethanol over the ethylene glycol and it just lets go of it so basically you're making them drunk on regular alcohol albeit via IV and then we just weaned or titrate them off of that in the ICU of course you look for withdrawal precautions or C wash skills or whatever you're using it's your facility to watch that because we have to get them off that we can't send them out drunk so you do have to wean them off the alcohol drug beta blockers and or calcium channel blockers to degree but for the most part of the question will be about the beta-blockers so if you overdose on metoprolol you're gonna block all the beta receptors on the heart and that heart rates gonna go down okay we need to take control that heart rate and the way we do that is with glucagon okay Luca gone it's like a secret agent it knows the backdoor secret access code to get to the heart rate Control Center because you can give you can give all the EPI and stuff you want but those beta cells are blocked they're not going to respond to it but the glucagon knows how to sneak in the backdoor and it has I know trophic properties rate control properties and your this will be a drip and you'll be titrating the glucagon drip to the heart rate you want so it's basically a chemical pacemaker and oral sulfone areas you can write this one in we got a blank space because I want to know this for the test - this is your metformin or glucophage those oral anti-diabetic medicines and to answer why the antidote is what it is we need to look at what does this do you know simple answer - drops your blood sugar but it's not just that drops your blood sugar but it's how it does it so how does metformin ague glucophage work they basically they go to your pancreas when you're a type-2 diabetic they go to your pancreas and tell your pancreas hey dude get up go to work make every little bit of insulin you got it's trying to wring it out like a like a wash rag or a washcloth trying you all the water out drink it all the insulin out so when you overdose on this the insulin production goes through the roof it's basically like your body is on an internal insulin drip what do you think their blood sugar is gonna be super low and you can't catch it you it's almost like you can't give the glucose fast enough it keeps dropping it's in the tank and you've got him on a d-10 drip probably or d5 or d-10 at least and still low sandesh tan or octreotide is our answer for this you're gonna give this by an IV infusion and what it does is it blocks the pancreas from receiving the signals the metformin so hopefully a painter slows down its insulin production okay because otherwise it's it keeps just just dumping out and this profound massive hypoglycemic so it's an aesthetics the pancreas from this insulin demand that the Met form is putting on it you know if you tend on the GI lecture you'll see sanest and is also the treatment for varices are bleeding varices so that's two uses for saying a statin and then heparin so i Coonan was vitamin K now this is a little joke so CV and think of the humor this what in a joking way what is the antidote for heparin overdose what do you actually do when the heparin is being toxic to him you don't give something but what do you do in other words you only get heparin toxic a certain way first thing you do you know stop the heparin drip okay that's the that's the comedy part okay so that doesn't reverse it but it does stop it because you don't get heparin toxic any other way all right but as far as a medicine to reverse it so let's say you had a patient in there's a patient that trauma ICU and they're on a heparin drip let's say the medivizor they're in a heparin drip for a PE or something okay suddenly there's some need to have to take them to surgery all right you can't go to surgery with your PT TV being too high so they stop the heparin 30 minutes later it's still too high and the surge is like we need to go right now to surgery that's we okay proteins so they actually need to reverse it right now because yes you would stop the drip first but to reverse it protein sulfate all right we'll come back to that I'm moving to our environmental emergencies so are our temperatures are hot and are cold so we've got different degrees of hypothermia and we're talking core temperatures you do not need to memorize these numbers the only one you need is 86 and there's a reason for that one one reason don't you know all of them it's because there's a little overlap actually and sometimes actually more symptoms and sometimes as you know in the real world that temperature may vary from five minutes to ten minutes okay but at 86 degrees it's a physiological rule there's things that do not work the same below 86 so we have to warm all our hypothermic patients to a minimum of 86 that is a medicine biology standard so you need to know that one for the exam as with any other history we're gonna ask questions about the exposure the length of time the circumstances things like that we talked about paradoxical undressing with some of these that means the opposite pair Doc's means you don't know why are you doing the opposite which you should do so when you're cold you should put clothes on but sometimes people get hypothermic then she takes their clothes off it's thought this has to do is both some central nervous system dysfunction as well as the peripheral nerves sending out a very painful stimulus as the nerves actually start to die off and freeze so whatever the cause the fact is some hypothermic patients could show up just in their boxers or actually naked in the snowbank you know when the wilderness medics get to them or whatever so it's kind of a unique thing that can occur with that now they're not dead - they're warm and dead and again below that 86 certain medicines don't work the same the physics of the body doesn't respond the same we still do these designing treatment for a normal thermic patients as a hypothermic patient it's just we can't presume that things are actually having an effect until we get to 86 degrees so we don't change any of our dosages or therapies any of our ALS stuff fluids but you don't change any of that below 86 we just have to keep doing it till they're at least 86 before we consider you know termination of efforts because things are not gonna work the same below there so same airway stuff of course warm warm fluids and such as far as the treatment again we're going from less invasive to more invasive here so and we just add on as we go so we always start with all hypothermic patients with the warm room the blankets the things like that I did put a body a body contact here but obviously I'm not talking about your department but that is something like in a wilderness and wilderness medicine teaches this that yeah if you got two people out camping in the woods or someone hypothermic you know in there and carry them out you gonna put them in a sleeping bag with another person strip down try and get some that radiant heat transfer from the warm person to the cold person trying to equalize that out or in the tent or whatever so that passeth and that's the key here this is all passive external sources of rewarming now if there's still not really respondent and teachers not coming up we're gonna add something else to it okay now most places we do give our IV fluids warmed first round that's fine but if for some reason we didn't initially give the more influence now we're going to because it's more of an invasive process and it might get fairly dramatic with in putting the peritoneal trocar in let me check my sound right quick this one so they've just lost it they might put that peritoneal trocar in and actually instill some warm saline and then busy irritating the perineum I'm some okay we're good so basically a warmed peritoneal lavage as possible and then we might even get more dramatic if they still feel it or spawn by going super invasive like in the Oh are where they actually take them up there open their chests and pour warm sterile saline in try and actually to irrigate the whole floor actually well to or bypass possibly so again they asked for the exam you know what's the first thing you do you always think what's the less invasive what's less complicating what's safer you do and then you just add on from there as a patient hopefully starts to respond or if they're not responding you add on frostbite so this is more the superficial tissues your skin your soft tissue has water in the cells and when water freezes it expands damaging the cell wall now if it's just frostbite it's just surface freezing and not core temperature you know the nice thing is your skin Slough Soph and it regenerates as a unique property of your skin cells that we can regenerate them so it's usually not a big problem as long as we address it early the area's most commonly involved areas that are further from the core or have less circulation and so there's little rhyme we use in medicine fingers nose penis toes cheeks and it's just reminding those small areas are more prone this is also on the areas that when we're doing the wound repair and we're doing like lidocaine with epi we don't want to give the EPI part okay if you put epi in these small areas at these at vasoconstrictor we have the risk of causing tissue tissue ischemia or shutting down the blood flow is it so small with circulation in addition to the actual freezing we get the slowing of the blood flow so these patients are at risk for blood clots to form in these extremities so there's a medicine that is associated with your frostbite patient and this is from TN CC we might be considering putting them on some aspirin trying to prevent some blood clot formation in these very profoundly cold extremities and because the slowed circulation there so aspirin may be a medicine associated with frostbite treatment there's really no other medicine we use with it's just warming but that would be a medication you might see as part of an order set or associated with it now trench foot is a specific problem we're typically in our homeless folks where they get the frostbite at night when the temperature goes down and in the daytime the feet coming in these distal areas these toes they thaw out and they Reaper fuse and the next night they freeze again and then they Reaper fuse and you get this cycle of freezing and thawing and that causes cracks in the skin and those cracks in the skin can promote bacterial or fungal growth so trench flu is an infection on top of a recurrent frostbite problem so it's actually two problems infection and frostbite now obviously this very dramatic example here and you see probably on his right foot he's gonna lose mm two or three of those toes or so maybe some the ones on the left are salvageable it just depends base definitely need some wound debridement and you go to you know the wound care therapist or whatever if he's admitted things like that maybe a vascular surgeon deal with the initial ischemic digits there but trench hood is a combination of two problems as far as the degrees at least frostbites we classify them very similar similarly to burns we both consider the area as well as the depth and the area more towards the core is gonna be more damaged and less likely to be salvageable the area further away from the core less damaged probably heal up just fine there's a very subjective call they're not gonna ask you the only thing from the test for this would be which is the area more likely to have permanent damage and you just like a full thickness burn you've seen about those third and fourth degree scenarios all right first degree is gonna be mild our submersion injuries so we may actually have more of these than we know about because sometimes they don't even get to the ER because they're you know dead on scene and you know unruhe son resuscitate able is that a word I just made it one but regardless of what they submerge in the end result is always the same it's a lack of oxygen to the tissues that hypoxia now most commonly we do think of water drownings pools lakes streams rivers things like that we can also have dry drownings I don't mean the Facebook urban legend from two or three years ago about drowning in a teaspoon of water dry meaning a dry substance sand grain quicksand if you want consider like you know the Amazon jungles because the person goes deeper into this substance like in a grain silo if they fall in from the top or other up they're doing work as more and more the substances over them there's less oxygen so it's still an auction absence problem so that is actually fairly uncommon and those are usually body recovers anyways because you have to drain the entire silo to actually get the patient out to get them to the ER so a lot of those don't make it we're more likely to see water drownings or submersions right that is the more common one now that beans that will possible knowledge tech check here for you this is a serious question if if EMS brings you a drowning patient a near drowning her going to call it if that's all you know is they were found the bottom of pool what other two injuries are problems you need to check for with every one of these you're not just checking for the drowning and treating that but there's two other things that can commonly can occur with this patient when you check for give you guys a second and trauma and what trauma specifically it was if you can only check for one sign of trauma and a drowning patient you want to assess their what exactly head and you can put both together because we typically treat head and c-spine's together because one-third of any head injury will have a c-spine injury also so yes we always assess head and c-spine and we check a core temperature if so hypothermia and head and neck injuries are concurrent to be considered with drowning because that person could have been laying at the bottom of that pool for three four or five six minutes okay and remember you don't die right away from that breathing you start getting you know hypoxic you know but you're unconscious you hit your head for every moment that person's on the bottom that pool their body is completely enveloped by that pool water and it's a law of physics that heat always goes from a warm source to a cold sore and I don't care how long unless the hot tub every other pool out there does not warm the water to normal body temperature all right so even a 5 degree difference from that by the water to the body is enough to start sucking the heat out of there and of course you're laying there motionless so you're not generating any heat you're unconscious about the pool so drowning near-drowning injurious in a pool head and neck injuries and get that core temperature for sure and we'll treat what we seaweed and again with the knee returning we don't do anything different and it doesn't matter what they were in we still do the normal airway stuff we still you know we still try and ventilate them we still secure the airway etc we were suss nothing changes because it's a drowning now after the fact in their in their post acute phase if we resuscitate them they're in the ICU they do have to worry about certain things like well are they more risk for some atypical lung infections from seawater are they more at risk for like a pneumonitis or nards from some that inhalational of the water product that's down the road the initial ER resuscitation room we don't do anything different we check the core temp you check that spine we know in others we don't go in there and start doing some deep suctioning oh because it was a drowning injury you know we still try and ventilate them you know and actually if we're doing compressions you know what's our what's our relief for a foreign body airway obstruction is chest compressions now so we're doing the same we're not doing you know we're not doing blind finger sweep sand stuff like that no the surfactant no that would be on your I see orders and again this exam only only focuses on those initial things we do and the initial think these people is resuscitate them something to oxygen definitely control the airway check the temperature to check the c-spine maybe depending on em and I'm not gonna say everybody does surfactant is going to depend on your intensivist your pulmonologist over your ICU your critical care units they're gonna decide upon that so I would not expect to see on the test our heat emergencies so I'm not gonna say it's impossible but again knowing what this exam focuses on which is the emergency period of care not the admission orders the transfer orders I would not expect to see surfactant on there I would expect more to see normal airway maneuvers basic oral suctioning basic resuscitation and get him up to 86 degrees the heat emergencies so your body regulates heat by sweat is his primary heat release to evaporate it and from fluid fluid loss to the big concern of the heat emergencies is that fluid loss and in if you attend the general medical section on one of their sessions we do go into the foods lecture lights and I'll tell you there again also that's salt and water our best friends anywhere water goes salt goes okay or it helps keep the work should be actually sit down and then with sodium losses right behind that you get potassium losses so those are the two electrolytes we worry about with is the possible massive dehydration on these patients now heat cramps it's not gonna be on the test most likely because this is basically just a home first aid emergency you don't ego the ER you just get in a cool environment you get an AC drink some fluids you'll be fine so not likely to see questions about this the two that are emergencies are heat exhaustion and heat stroke so these are the ones to focus on now the nice thing about both these is we're treat them the same they both have basically the same problem for teaching purposes the only difference is the temperatures a little bit different but there's still overlap so we're not going to rely upon the temperature alone to say oh it's heat exhaustion we're gonna look at the skin okay so again for exam purposes if they say what's the best physical assessment that looked for for heat exhaustion or stroke don't worry about the temperature look at the skin heat exhaustion they're still sweating profusely like soaking wet like drenched in sweat and heat stroke their body's temperature control center is now shut down it doesn't know how to make sweat anymore it's not in control itself so their skin is hot and dry so look at the skin the treatment for both is similar they both may be cooled off however you want to do it they both need fluids okay one person is still sweating their fluids the other person can't because they're already so far down the pipeline they both need to have their electrolytes looked at because of that fluid loss and both when you look at things like rhabdo or di see just in a profound muscle insult from this high stress in the body so treat both the same cool fluids electrolytes maybe getting on my globin our CPK our ck-mb when our muscle markers for the scene exam if you don't go to any other sessions I'm gonna tell you any time you measure measure muscle breakdown the cen will let you pick either one of the three CPK ck-mb or Sarang CK they all mean the same thing one is not better than the other for exam purposes radiation so some has that stuff they're so radiation stuff so this can be an accidental like a dirty bomb or like a terrorist act or could be industrial most commonly to us we're exposed usually in our x-ray Department's non-italian we take precautions obviously but that's a potential disposer if we don't take our precautions so there's that possibility there the gamma and neutron rays are the ones that we worry about these are the ones actually go through your body and cause a cell damage and can lead to things like cells actually dying or to the cancer changes as the nucleus has changed with each one the alpha and beta particles these are not usually as much of a concern because they're very light they're very small and even just your normal clothing it could be a bear can be a protective for this but that's one reason also that to be fully decon from anything we talk about your patient has to be naked they're all their original clothes I mean hopefully ian has put some and you know maybe they got gallons or a sheet or something but they need to have all their clothes off okay because especially if these alpha beta particles they could still be on the clothes when we talk about the petroleum distillates like the gasoline exposure same thing there some some of those um gasoline molecules you smell it if they come in and still smell gasoline they not been adequately be calm alright so decon is wet and naked to be fully decon for radiation we can limit the exposure or the amount their exposure is it turned by how long they were exposed how close they were to the source and how much of a barrier was between the source and them and so we can as providers we can still do some things where someone's been exposed if they're wet naked and it was like a the gamma or neutron exposure they can be giving that stuff off that gets to be radioactive we can still care for them if we manage our exposure so if I can do a procedure intervention that's a quick one versus a long one working with that time component if I can do it from a distance possibly you know if you know not being right up in their face but maybe from an arm's length or something or the amount of shielding like late aprons and all that so we can manage the potential for us to get exposed even while caring for these patients now typically radiation it's gonna affect the GI system first your GI system has some of the most rapidly developing tissues and cells in your bodies they're more likely to be affected first so GI symptoms nausea vomiting blood the stools things like that now if they're critically ill right at the exposure it's gonna be a bad day that's a high dose exposure some people have slower exposure or time like in Oxon occupations like radiology that's where they were their monitor badges etc so well decon is important if I can do something and limit my exposure like as simple as opening an airway I'm gonna do that really quick but then I'm gonna and then make sure I got my apron on make sure we're from a distance make sure they get in decon so I can do some life-saving things if I limit my exposure petroleum distillates so the most common one here will be gasoline I'm sure most of us have smelled gasoline that distinct vapor that distinct smell it comes from that and that's similar to the vapor from other petroleum products paint thinners paint some of the lubricants kerosene things like that these all have that petroleum vapor because they're all petroleum by-product alright so the concern here is getting this gas into your lungs inhaling it and the most common mechanism for this to happen is actually accidental which is someone siphoning gas like from their car gas tank to their lawnmower you know they're they're like oh I'm not going the gas station I'm just going to get some at my car or like during times of disaster like down here in the southeast with hurricanes people didn't buy gas their generator and the power's out so they siphon the gas out of their car and they give this inhalation while they're trying to work the siphon tube to get it out most common symptom here is just this frequent intractable COFF they can't stop coughing about to the point of our pass out the problem is that petroleum gas goes deep into the lungs and it basically stays there and so taking out theirs occupying the functional lung space that you can't exchange oxygen the treatment for this is High Flow oxygen so it's the same as a carbon dioxide high flow option you're hoping that every time they breathe off a little bit of it that they're breathing in a few more option knowledge fuel is trying to replace that they're so intractable cough high flow oxygen now organophosphates this is gonna be on your test talking to all you know former students some people email me back and things like that this is about 75% of people get at least one or two questions about organophosphate so this is definitely worth your time to look at this so these are the nerve agents weapons of mass destruction like your sarin gas your VX things that are terrorists might use you know to take out people very quickly the way they work is they cause a respiratory paralysis and what they actually do is at your and so this huh Crestor weren't at all your neuromuscular junctions acetylcholine is a transmitter that goes across to give you a contraction you need a seal choline to do this and the muscles we're talking about here are obviously your diaphragm and your intercostals when they get paralyzed the agent that's in the nerve agent the nerve poison the toxin it inhibits acetylcholinesterase acetylcholinesterase is a normal enzyme in your body that you need so each time you take a breath and your diaphragm contracts you have to make some your own acetylcholinesterase to erase the acetylcholine from the junction so it can repolarize for next impulse so think of the acetylcholine as a transmitter is kind of like the potassium in your heart you know if your potassium is too high you don't get a heartbeat if it's too low you don't need a heartbeat and that potassium has to depolarize with every impulse well and your muscles acetylcholine is the transmitter we're looking at and a nerve agent completely blocks the acetylcholine esterase from doing this job so with each impulse the acetylcholine builds to a higher and a higher and a higher level and now you have too much acetylcholine too much acetylcholine is the end result and you can't get the next diaphragm contraction all right they are in also known as an acetal cholinergic crisis or you just say cholinergic crisis okay too much acetylcholine is the problem it can't it can't get a race they can't get dissolve with symptoms they say this is where they're leaking fluid out of every orifice all right now they're not going to die from all these fluids what they die from is the respiratory paralysis we see all these fluids coming out their body because the same acetylcholine effect affects other receptors your Nick you don't need to notice an exam under stands why the nicotinic and muscarinic receptors are also stimulated that's why a seal choline causes fluids okay but the one that's gonna kill you is the paralysis of the diaphragm and you can also get food in your lungs with this so when you hear the question or you read or you study about the treatment is to dry them up with a churro 15 let's face it you're not gonna sweat to death the diaphoresis you're not gonna diarrhea to death you're gonna die if not be able to breathe and the fluid in your lungs so actually the fluid will drawing up which is not in these lists is Branca Rhea fluid in the lungs they can actually drown their own fluid from organophosphate and not bill to breathe okay so for the tests you want to know one of these to memory phrases you could only know both because they both work they are both similar with the exception of one finding different between either one and do not memorize the words memorize the phrase so don't memorize all seven words just memorize muddles because when you see this on the test you're gonna say okay muddles was my word and you're gonna write on your piece of paper you get a piece of paper during the test or a dry erase board you'll write down muddles and you'll go back through the question and say can I match all this patients symptoms to something from the word muddles and you may ask them to the fluids so you're like okay well what what fluid word could you be for well urination what fluid word could DB for we got several choices you got diaphoresis diarrhea what's the other one here vacations of stooling you can make all the symptoms fit the only two they don't fit a fluid is the eye so we got my osis so earlier we discussed that madrasahs with a D was dilated meiosis must be the opposite which meiosis has an O in it and so the word constricted has an oo also so mad Rises D dilated meiosis o constricted with the O and the word constriction you can also link meiosis to organophosphates okay so the eyes finding and then the CNS where has excitation that's not really a fluid symptom that's the seizures that can happen with this you know it's one reason why valium is one of our second line drugs for this so for the exam memorize one of the two phrases and that's all you need I don't walk around with these things in my mind I just remember the phrases and every time it's going to test Ivan he'll make all the symptoms match one of my key phrases I memorize muddles or sludge them all right so of course my decon is patient because it could stop some the chemical on them and the drug of choice is the atropine so they earn a cholinergic crisis they need large doses of an anticholinergic an atropine is your prototype anticholinergic out there and you have to give it lots of it you basically I looked up in one of the the Army Ranger medic manuals I trained with them some and it's they say you need a proximal grams of atropine to fully atropine eyes all the receptors on the average young adult male which is the most likely one to get exposed meaning a soldier that's a lot of atropine so it's got to be the first drug because you get find it and you gotta give give give give it second line is the 2-pam chloride and then only if they're having the seizures do you give the benzos so atropine is the go-to answer with 2-pam chloride being the second step if needed and then the benzos for the seizures so downrange this is what the guys carry so they have an atropine auto injector at least for them that auto-injector has two milligrams in it so at least they have a double dose and there's a two PM chloride and you sure your brain may say well gosh that's not enough to save a guy so the way this whole scenario works is if they think there's a gas release they call it they'll holler gas gas gas and they're supposed to immediately inject themselves the atropine and they're gonna put their suit on and they're supposed to be hauling part of the French hauling ass away all right now as they're running away from where the exposure was as they see people starting to draw up their fellow soldiers all that they're going to reach up and grab their kit off of that guy who just died he doesn't need it and they're gonna inject themselves again the kind of the cool thing with this is these guys are trained to carry these injectors in certain places on their kit or on their body so if you have to go up to a buddy you know which pocket it's in so they keep them all in the same pocket base or compartment so hopefully you make it out of the exposure zone with a minimal exposure and maybe you had to pick up a few kits along the way and self inject just to make sure you stay alive so yeah because you can't carry 50 syringes with you all right and you're your medic for your squad your platoon he doesn't carry about maybe four or five just enough in case you didn't bring yours so that's how that whole scenario works there so it's not that one injector will fix you you need to use one immediately and then start fighting more so same for us an ER I need to immediately get that crash cart open start getting the atropine and call my pharmacist I need more I need backup I need more we're running a lot cuz you're gonna go through it really quick all right some fill the blanks to kind of tie some pieces together and remind you some key points we talked about I've got two on the end that you'll have to write into I add it in also to kind of enhance some learning stuff so the first one which overdose is activated charcoal contraindicated so this is made for a great exam question because there's only one overdose we should not do this for anybody want to guess we'll put extra points for participation if you want test yourself so you can get right which overdose is charcoal contraindicated again there's a couple second delay so much okay good so someone types iron good one of our pediatric situations by the way for PTH emergency's there's only about 10 or 12 pediatric topics on this exam it is not pediatric focused but they still do ask a few things they're kind of unique so from this lecture the only one was the iron overdose like when we do respiratory we'll talk about asthma bronchiolitis under general medical to us impedes rashes if you come back for one of those sessions so just you know there are a few peds things but they're pretty straightforward what was that little memory phrase that had three letters to remember tricyclic s-- tricycles for short-handed TCA so on the C's was unexplained cardiac dysrhythmias the other two were unexplained coma and unexplained convulsions the three C's this to me when they're like mega toxic cardiac convulsions comas which is the most important time to measure a Tylenol overdose serum level so we really drove this one in we beat this one up said it's show time showed you the nomogram showed you the reason why this one is so solid written in stone so much to be able to type in number for me here right quick and the number is from where it's very good alright there were actually only two numbers we needed from this entire lecture was the for our town hall and where's the next one what's coming up in a minute it's question number five we'll get there a minute all right we had three ways you get exposed to cyanide and I'll go through them for you so you can inhale it as a I didn't tell you this so one ways you can inhale it accidentally is if you're in a structure fire also because the things in your house all everything is plastic foam vinyl all these synthetic materials give off some cyanide when they burn so if you're treating someone for carbon monoxide from a structure fire you might need to ask the questions do we think there's been a sign that exposure also because they may have been healed so these nasty toxic fumes so you can inhale it you can swallow it alright remember I said the one of the pitted fruits contains some of it but this is not likely to happen or we can get it from our nipride IV that we started for hypertension and if we don't change that tubing out corner policy it can actually break down to a sign I'd like molecule so airway cut in vascular three ways you can posit exposed this is the other number you need to know from this section and this was how dead not dead into warm and dead at what temperature 86 so again part of what I do is try make your life easier as far as you know not getting so focused on this minutiae are these specific detailed things because lot of things vary from provider to provider from shop to shop from this drug dose to the others very few things are so absolute they could be universal for exam because let's face it your Doc's in Minnesota they practice a bit different than the ones in Florida do alright so I I think that's a big use these classes to alright patient does snore your line of coke they showed up a triage oh my heart's raisin is jumping on my chest what am i used to get control that heart rate and slow it down cocaine overdose what medicine benzos right so be for brain it's a brain problem is dumping out too much stimulant so I'm gonna slow the brain down heart rate will come in line I'm not gonna give them the beta blocker alright so we just did this pick one of the two memory phrases for your organophosphate exposure the two key phrases you only need to know one of them so she put muddles and the other option is sludge them just same things just written little bit differently I think if you go a little deeper and studying where you might see dumbbells used also it's pretty much the same it's just another way to put a letter with each of those findings what cranial nerve eight findings of so she would ask for an overdose so aspirin was the Osito still look Selleck acid and it had a neuro finding it's the one I said if they could come to triage they say I'm complaining of this you want look at their medicine list and see how much ask when they're taking what was that one unique thing it was a fancy medical word tinnitus means ringing in the ear and that's cranial nerve eight and that is your this is when you got it right in by the way that nerve has to name is the same nerve but you can name it one of two you can call it the acoustic nerve or the the Stabilo ocular nerve and I got one more for you to write in name an overdose that causes meiosis so let's start with that one first what was the key letter there when we're looking letter O so what overdose or exposure has the listeners first is that constricted or dilated with the oh my OSIS that's the constricted one constriction has an O in it so we've got two choices here we got two possible exposures that cause constricted pupils that letter again organophosphates cause meiosis and then another one from that video the opiates so this is one of your opiate findings this is one of the reasons EMS can give an archaeon sometimes they're unresponsive slow breathing rate agonal breathing or not even breathing and they have constricted pupils you give the narcan so an opiate has an oo also how about that so opiates are gonna phosphates meiosis letter O for constricted so Madras this is the opposite and that's the DP annette for dilated which is that stimulant effect so anything that's a stimulant meth crack cocaine taking too much at all because the dilation is a stimulant effect all right