Altitude Illnesses

Altitude is measured by feet (or meters) above sea level. The important thing to remember is that the partial pressure of oxygen decreases with the increase in altitude. In other words, the higher up you are, the less oxygen is available for breathing. This could be a bummer. The signs and symptoms associated with altitude sickness are directly and indirectly related to hypoxia. Because we are all different, we all respond differently to altitude and therefore each patient can present with unique sequelae. Some people are just more susceptible to altitude illness.

rescue_operation_wallpaper_landscape_nature_wallpaper_1600_1200_1180The Alphabet

HVR: Hypoxic Ventilatory Response

HVR is the result of a decrease in blood oxygen saturation and ventilation after a few hours at altitude. Altered fluid homeostasis also occurs – which means that fluid is redistributed from the intravascular to the intracellular and extracellular spaces – and the result can be peripheral and/or pulmonary, and/or cerebral edema.

HACE: High Altitude Cerebral Edema

HAPE: High Altitude Pulmonary Edema

HAFE: High Altitude Flatus Expulsion

AMS: Acute Mountain Sickness

AMS is a continuum of signs and symptoms that can range from loss of appetite and headache to coma and death. AMS is generally described as mild, moderate or severe.

Mild AMS: Patients may experience headache relieved by rest and medication, nausea, loss of appetite and insomnia. Nothing is visible on physical exam. Advise the patient to stop the ascent until the symptoms disappear. The goal is to hydrate, hydrate, hydrate and eat – in spite of the anorexia

Moderate AMS: These patients may complain of headache not relieved by rest or medication, nausea and vomiting, shortness of breath, fatigue and weakness at rest, loss of appetite, and insomnia. Most of the symptoms are caused by hypoxia, so supplemental oxygen is a must. Patients should descend 1000 – 2000 feet.  Ski patrol teams and ambulances operating in the mountains encounter these patients with relative frequency.

Hydration is also a key to treatment. If vomiting continues, prochlorperazine (Compazine®) can be administered as an antiemetic. Acetazolamide (Diamox®) may also be helpful. Watch these patients for worsening of symptoms.

Severe AMS: These patients exhibit all of the signs and symptoms of moderate AMS and: sometimes ataxia, dyspnea at rest, tachycardia, and as HAPE (high altitude pulmonary edema) begins patients may begin with a persistent dry cough followed by rales upon auscultation. Late in severe AMS some patients experience blood tinged sputum. Hypoxia worsens with tachycardia. AMS occurs late in AMS (altered mental status occurs late in acute mountain sickness. HACE (high altitude cerebral edema) may also occur. Proper care is Oxygenation and descent, with administration of dexamethazone (Decadron®) for HACE, acetazolamide (Diamox®) and nifedipine (Adalat®) for HAPE.

Acetazolamide (Diamox®) – What is it and what does it do?
It is a diuretic that indirectly causes enhanced ventilatory acclimation and decreases cerebral spinal fluid production. It is indicated for patients with moderate or severe AMS and for rescuers making rapid ascents to reach these patients. Since it is a diuretic, it causes polyuria and possibly dehydration if adequate fluid intake is not maintained.

Dexamethazone (Decadron®) – What is it and what does it do?
It is a steroid with anti-inflammatory effects. While it is effective at treating AMS and HACE, the symptoms can rebound once the medication is stopped.

So, now we have HAPE, HACE and just what is HAFE? High altitude flatus expulsion. Supposedly, intralumenal bowel gas expands with decreased barometric pressure causing flatus. If necessary, simethicone (Phazyme®, Gas-X®) can be used to treat it.

Summary

Understanding how to treat patients with AMS is important, but understanding how to protect the rescuer and how not to become a patient is also a priority. Be a rescuer…don’t become a victim.

References:

Burke, TG. Altitude illness. Prehospital Emergency Medicine Secrets. Hanley and Belfus, Philadelphia, 1998.

Fogerty, WW. (ed): Wilderness Medical Society Practice Guidelines for Wilderness and Environmental Emergencies. Merrillville, IN. ICS Books, 1995.

Hackett, PH, Roach, RC: High altitude medicine. In Auerbach, PS (ed): Wilderness Medicine: Management of Wilderness and Environmental Emergencies, 3rd ed. St. Louis, Mosby, 1995, pp 1-37.

Hackett PH, Rennioe D: The incidence, importance and prophylaxis of acute mountain sickness. Lancet 2(7996):1149-1155, 1976.

Johnson, TS, Rock, PB: Acute mountain sickness. N ENgl J Med 319:841-845, 1988.

Larson EB, Roach, RC, SChoene RB, Hornbein, TF: Acute mountain sickness and acetazolamide. JAMA 248:328-332, 1982.

Tilton B (ed): Wilderness Medicine Handbook, 2nd ed. Pitkin, CO, Wilderness Medical Institute, 1997.

10 Common Wilderness Survival Mistakes

Drinking Urine.

Urine contains dissolved solids (urea, uric acid, creatinine and ammonia), inorganic substances (sodium, chloride, calcium, potassium, phosphates and sulfates) and bacteria (often from the surrounding skin). Urea is a natural diuretic and water is required to dissolve and excrete it from the body. As dehydration increases so does the amount of urea that needs to be processed. In other words, drinking urine dehydrates you more quickly than drinking nothing at all.

Trying to snare a deer.

Imagine a 150- to 200-pound animal with its neck or leg stuck in a snare. Not only will you be causing it a lot of unnecessary pain, you’re left with a problem: How are you going to kill it? Unless you have a firearm, you’ll likely get hurt trying to put the animal down. In a survival setting, it is much safer and more efficient to focus on small game like rabbits, squirrels and rats.

Eating a raw bug.

Although bugs, like grasshoppers, can be a great food source, they are known to carry parasites and should be cooked before consumption. In addition to killing the parasites, cooking a bug usually makes it more palatable. Better to have a stew made from slugs, maggots, grubs or cockroaches than to eat them raw.

Eating food when you don’t have water.

You can live weeks without food and only days without water. Your body needs water to digest food, so eating when you don’t have water will only accelerate dehydration. In a long-term survival situation, of course, food will become necessary, so it is important to establish your camp near a location that provides both water and food.

Wearing a wet base layer.

The layer of clothing closest to your skin–which should usually be made out of a material like Polypropylene–should always be dry. Polypropylene wicks moisture away from the body, making it a great base layer. Wearing it when wet, however, is a mistake, as it will have a major impact on how quickly your body loses heat (you lose body heat 26 times faster when you are wet then when dry). For best use, keep the base layer dry. If it gets wet, change it or take it off, wring out the moisture, and put it back on.

Choosing fire over shelter.

Building a fire takes time and even if you get one going, you’ll be up all night adding fuel to the flames. Fire is the third line of personal protection (it comes after clothing and shelter) and shouldn’t be considered until a shelter that protects you from wind and moisture has been established. It is okay, however, to use a small fire to warm you during the shelter-building process.

Traveling when you don’t know where you are.

If you don’t know where you are, how will you know where to go? Travel should only be considered if your location doesn’t meet your needs, rescue doesn’t appear imminent and you have the navigational skills to get from one point to another (know where you are and where you are going).

Drinking alcohol to stay warm.

Although a sip of whiskey may make you feel warmer, it actually promotes hypothermia. Alcohol causes blood vessels to dilate, which increases blood flow to the surface of the skin and allows the outside cold to pilfer heat from the body core (brain and vital organs). Instead of alcohol, drink water and wear appropriate clothing!

Believing the sun rises in the east and sets in the west, relative to your position.

The sun’s path changes daily, reaching its northern and summer extremes on June 21 (summer solstice) and December 21 (winter solstice). The sun passes directly over the equator during the equinoxes (March 21 and September 23). Unless you are on the same latitude as the sun’s path, it will not rise or fall directly east or west of your location. In fact, it can be off by a large percentage, making navigation by sun next to impossible.

Taking your hat of when you are hot.

You lose 50 to 75 percent of your body heat through your head. Heat is calories and calories provide the body with the energy needed for daily tasks. It is better to slow down or remove a middle layer of clothing (between your coat and T-shirt) than to work up a sweat and waste precious calories.

The Attitude of Survival

A wilderness emergency could possibly happen to anyone, anywhere. When confronted with an unexpected survival situation man has the potential to overcome many challenges, beat incredible odds, and come out a survivor. But just what is survival anyway? Survival is the art of surviving beyond any event. To survive means to remain alive; to live. Survival is taking any given circumstance, accepting it, and trying to improve it, while sustaining your life until you can get out of the situation. And most importantly, survival is a state of mind.

Survival depends a great deal on a person’s ability to withstand stress in emergency situations. Your brain is without doubt your best survival tool. It is your most valuable asset in a survival situation. It isn’t always the physically strong who are the most effective or better at handling fear in emergency situations. Survival more often depends on the individual’s reactions to stress than upon the danger, terrain, or nature of the emergency. To adapt is to live. Mental skills are much more important than physical skills in survival situations. A person’s psychological reactions to the stress of survival can often make them unable to utilize their available resources. You most likely won’t use your physical skills if you don’t have a positive mental attitude.

One definitely must be in the proper frame of mind to survive an unplanned survival situation. Attitude or psychological state is most certainly number one. It is undoubtedly the most important ingredient of survival. With the proper attitude almost anything is possible. To make it through the worst a strong will or determination to live is needed. A powerful desire to continue living is a must. The mind has the power to will the body to extraordinary feats. Records have shown that will alone has often been the major factor for surviving wilderness emergencies. Without the will to live survival is impossible. Survival is possible in most situations but it demands a lot of a person. Humans can be very brave and resourceful when in emergency situations. The mind is a very powerful force. It has control of the body, its actions, and its reasoning. What affects you mentally affects you physically. If you think that you can’t survive, then you won’t try to survive. A commitment or goal to live, refusal to give up, and positive mental attitude greatly increase chances for survival.

A positive attitude has a very strong influence on the mentality and motivation necessary for setting a goal to live. Set goals give motivation and attitude necessary to survive pressures. When placed in an unexpected survival situation you will be forced to rely upon your own resources; improvising needs and solving problems for yourself. If you want to survive then you must ultimately decide to take care of yourself and to not count on others to help you. You must continually strive towards a goal of survival. Picture your goal in your mind and visualize yourself reaching it. A person with a stubborn strong will power can conquer many obstacles. Never give up your goal to live, because without any will to live those lost in the wilderness will likely despair and die.

While in your survival situation you will be confronted with many problems that you will need to overcome. Your brain will be your best asset but it could also be your most dangerous enemy. You will have to defeat negative thoughts and imaginations, and also control and master your fears. You will need to shift mental processes and adopt that positive and optimistic “can do attitude”. You will need to be creative and use your ability to improvise to adapt to the situation. Work with nature instead of against it. You will have the crucial task of solving the problems of staying alive. Your problem solving must be based on recognizing threats to your life, knowing their priority of influence, knowing their severity of threat to your life, and taking actions that will keep you alive. It is important to consider your safety at all times. If you sum up and analyze what you need to combat it will be easier to fight known enemies than if you were fighting something unknown. Loneliness, fatigue, pain, cold/heat, hunger, thirst, and fear are your major enemies in emergency survival situations.

To keep your body alive you must react to your body’s problem indicators and defend yourself against the major enemies of survival. Always remember to keep your positive mental attitude. Don’t add any extra burden to yourself by falling into a destructive mental state like feeling self-pity or hopelessness. Remember the important aspects of your life and don’t let the image fade. Think of being lost as an opportunity to explore a new area. With the proper attitude your experience could be interesting. Enjoy the challenge. You might as well enjoy the outdoors while you’re there and grow stronger as an individual as a product of your survival experience. Your positive mental attitude will help you combat your survival enemies. Most people have more than likely experienced loneliness, fatigue, pain, cold/heat, hunger, thirst, and fear before, but have not had to combat them all at once, and to the extent that they have been a threat to their lives. Any one or a combination of them can diminish your self-confidence or reduce your desire to struggle for life. All of these feelings are perfectly normal but are more severe and dangerous in wilderness survival situations. By learning to identify them you will be able to control them instead of letting them control you.

Loneliness is a survival enemy that can hit you without warning. It will strike you when you realize you are the only person around who you can depend on while in your situation. Nowadays modern society barely gives us a chance to test our ability to adapt to silence, loss of support, and separation from others. Don’t let loneliness gnaw at your positive attitude. Fight it by keeping busy by singing, whistling, daydreaming, gathering food, or doing anything else that will take your mind off the fact that you are alone. Also while in your survival situation, boredom or lack of interest might strike you. It must be cured to maintain a healthy survival attitude. Once again keep busy to keep your mind occupied.

Make sure to avoid fatigue. Fatigue is the overuse of the muscles and the mind and is a serious threat. It can cause you to lower your defenses and become less aware and alert to danger. It causes inattention, carelessness, and loss of judgment and reasoning. Take time to refresh and rest your brain and body. Conserve your energy. Rest, sleep, and calmness are essential. Pain is natures signal that something is wrong. When in moments of excitement you may not feel any pain. Don’t let it get the best of you; it can weaken your desire to go on.

Cold and heat are other enemies of survival. Exposure to the elements can be very dangerous. Get sheltered as best you can. If cold try and find shelter and build a fire. If in really hot weather get out of the sun. In the cold you might find it easier to sleep in the day time and stay awake at night by a warm fire. In very hot weather you might also want to seek shelter and/or sleep in the daytime.

Hunger and thirst are enemies that can really depress your positive mental attitude. Try and find some water. Food can wait. A person can survive for weeks without food. Try and conserve your body’s energy reserves. You may be better off resting than wandering around aimlessly looking for food. Even if you find food you may have depleted more energy than the food can supply you with. If you can acquire food easily then go for it. A man with a full belly can withstand more survival pressures than a man with an empty belly. Lack of nutrition could make you more susceptible to depression. Remember your positive frame of mind and keep your goal to live fresh in your mind.

Fear is a big enemy to guard against. Fear is a completely normal reaction for anyone faced with an out of ordinary situation that threatens his important needs. People fear a lot of things. People have fear of death, getting lost, animals, suffering, ridicule, and of their own weaknesses. The thing most feared by people going into the wilderness is getting lost. There is no way to tell how someone will react to fear. Fear usually depends entirely on the individual rather than on the situation at hand. Fear could lead a person to panic or stimulate a greater effort to survive. Fear negatively influences a man’s behavior and reduces his chances for successful survival. The worst feelings that magnify fear are hopelessness and helplessness. Don’t let the idea of a complete disaster cross your mind. There is no benefit in trying to avoid fear by denying the existence of a dangerous survival situation. You need to accept that fear is a natural reaction to a hazardous situation and try to make the best of your predicament.

Do your very best to control your fears. Be realistic. Don’t let your imagination make mountains out of mole hills. Expect fear and learn to recognize it. Live with fear and understand how it can alter your effectiveness in survival situations. Don’t be ashamed of any fears you may have. Control fear, don’t let it control you. Fears can be lessened by keeping the body busy and free from thirst, hunger, pain, discomfort, and any other enemies to survival. Learning basic outdoor and first aid skills may help you prevent or ease fears by increasing your confidence in yourself. If fear creeps up on you make sure to think of positive things. Maintain your positive mental attitude.

A more dangerous enemy than fear is panic. Panic is an uncontrolled urge to run or hurry from the situation. Panic is triggered by the mind and imagination under stress. It results from fear of the unknown, lack of confidence, not knowing what to do next, and a vivid imagination. Fear can build up to panic and cause a person to make a bad situation worse. In a panic a person’s rational thinking disappears and can produce a situation that results in tragedy. A panic state could lead to exhaustion, injury, or death. A positive mental attitude is still the best remedy. To combat fear and panic keep your cool, relax, see the brighter side of things, and stay in control. Keep up your positive self-talk and remember your goal of survival.

Keeping a positive mental outlook is for certain the most important aspect of survival. While in a survival situation you will practice self-reliance. You will only be able to depend on yourself and your abilities. You will have to overcome many challenges that you are not accustomed to. Modern society is conditioned to instant relief from discomforts such as darkness, hunger, pain, thirst, boredom, cold, and heat. Adapt yourself and tolerate it, it’s only temporary. When you first realize that you’re in a survival situation stop and regain your composure. Control your fears. Recognize dangers to your life. Relax and think; don’t make any hasty judgments. Observe the resources around you. Analyze your situation and plan a course of action only after considering all of the aspects of your predicament. Be sure to keep cool and collected. It is important to make the right decision at all times. Set your goal of survival and always keep it fresh in your mind. Never give up. Prepare for the worst but hope for the best.

 

OTC Overdose

otc

Over-the-counter (OTC) drug abuse is on the rise. Since 2000 there has been a fourfold increase in abuse of cold medicine. Nonsteroidal anti-inflammatory drugs (NSAIDS) are the third most commonly intentionally overdosed medicine. Acetaminophen overdose is responsible for the greatest number of drug overdose hospital admissions in developed countries. Hundreds of different nonprescription medicines are available. This article discusses assessment and treatment considerations for overdoses of four of the most commonly abused OTC drugs.

RISK FACTORS

Nonprescription medications are easy to obtain. Thus, they are appealing to youth: Adolescents are the most common over-the-counter drug abusers, and they often combine OTC drugs with street drugs and alcohol. Teen OTC drug abuse often occurs in fads, as groups of teens discover the effects of the drugs together.

Not all overdoses are intentional. Some are accidental, and many patients are at risk of greater adverse effects from regular doses of OTC drugs. For example, alcohol consumption creates a synergistic effect with many medications, especially NSAIDs. Patients over 60 additionally risk gastrointestinal bleeding from even regular doses of NSAIDs. GI bleeding can also develop from NSAID overdose when a patient is on blood thinners or has a history of ulcers.

As with many medical problems, the very young and very old suffer the worst consequences. Nearly half (46%) of all antihistamine overdoses involve children under 6.

CASE #1: SEVERE PAIN

A nervous mother calls you for her son, who recently broke his leg. Your 16-year-old patient is lying on the couch, complaining of severe right upper quadrant pain that has been worsening for the past two days. His mother tells you he has been vomiting frequently for “a while.” A physical exam reveals abdominal tenderness and no signs of problems with the broken leg. The patient’s heart rate is 112, blood pressure 94/60 and respiratory rate 28. The boy tells you he has been taking acetaminophen for his leg pain. A bottle of 500-mg pills on the coffee table is nearly empty. Based upon your exam and history findings, you suspect an accidental acetaminophen overdose.

Acetaminophen (Paracetamol)is a non-narcotic pain medication used by millions of people each year. It is the most common adult analgesic and most common pediatric medication. Adults can safely ingest up to 4 grams of acetaminophen a day; pediatrics can ingest 90 mg/kg. Consumption of 150 mg/kg per day or more is toxic and considered an overdose. Acetaminophen overdose is the leading cause of acute liver failure in North America.

After ingestion, acetaminophen is quickly absorbed through the stomach directly into the bloodstream. Once there it can only be metabolized into waste by the liver. The kidneys can only excrete acetaminophen after it is metabolized in the liver. Acetaminophen overdose saturates the liver’s normal metabolic pathways and prevents effective function. As a result, a toxic metabolite forms, which binds with proteins in the liver, resulting in cellular death, which eventually leads to liver necrosis.

Patients with acetaminophen toxicity go through four phases. Phase 1 occurs during the first 24 hours following ingestion. During this time the patient may be asymptomatic, but may also have loss of appetite, malaise, diaphoresis, pallor and complain of nausea and vomiting.

Phase 2 occurs 18-72 hours after ingestion. During this time, patients often complain of right upper quadrant pain with tenderness upon palpation. Nausea, vomiting and appetite loss worsen. Patients may also present with tachycardia and hypotension.

Acetaminophen toxicity fatalities triggered by cerebral edema, sepsis or multi-organ failure usually occur during phase 3. Fortunately, fewer than 4% of overdoses are fatal. Patients in phase 3 develop jaundice and severe tenderness around the liver, often have difficulty clotting blood and can develop internal bleeding. Lab testing may reveal evidence of hepatic encephalopathy, renal failure, hypoglycemia and acidosis.

Patients who survive the first four days and three phases enter phase 4. Over several weeks symptoms slowly subside. Organ failure is managed while the body heals. Just less than half of severe acetaminophen overdoses require liver transplants during phase 4. Fortunately, most patients’ symptoms are completely resolved in roughly three weeks.

CASE #2: AMS

You receive a midmorning call for a child with an altered mental state. The patient’s mother tells you her 8-year-old son stayed home from school because his allergies were making him sick. Although he’s been taking Benadryl, he seems to be getting worse. The boy began complaining of blurred vision 15 minutes ago. He is confused and resists help. His skin is very hot and dry to the touch, and you notice a half-empty box of Benadryl on the floor nearby. You start supplemental oxygen and obtain vitals: pulse 142, BP 86/62, respirations 28 and shallow. The child has accidentally overdosed on his antihistamine.

Histamines are released into the bloodstream after exposure to an allergen. Antihistamines counter their effects by blocking histamine receptors in the body. Antihistamines can be either sedative or nonsedative. They normally reduce bronchospasm, vasodilation and edema caused by histamine release. The maximum safe antihistamine dose differs from brand to brand. Overdoses are identified through symptom recognition. Brand-dependent differences in dose sizes often cause accidental overdoses.

Normally antihistamines have a 10-hour half-life. However, in cases of toxicity, half-life doubles, keeping the drug in the system longer. Antihistamine overdose symptoms develop 30-120 minutes after ingestion.

The mnemonic Dry as a bone, red as a beet, hot as a hare, mad as a hatter, and blind as a bat is a tool to remember the symptoms of antihistamine overdose. Mucous membranes dry up, and the skin becomes hot, dry and flushed. Vasodilation leads to hypotension and tachycardia. Pupils dilate, and vision becomes blurred. Mental status changes include hallucinations, agitation, disorientation, lethargy and, in rare cases, coma. Seizures are uncommon and, when they do occur, short in duration. Sedative antihistamine overdoses also present with delirium and sedation. Antihistamine overdose patients frequently have dangerous ECG abnormalities. Tachycardias are common, as well as lengthened QT intervals. Nonsedative antihistamine overdoses can cause torsade de pointes.

CASE #3: NAUSEA, VOMITING

A 23-year-old male is complaining of nausea and vomiting. He presents lying anxiously on the couch, guarding his stomach. His girlfriend says he took several bottles of ibuprofen. Your partner estimates there were 30 grams of ibuprofen in the two now-empty bottles. The exam is unremarkable except for hypotension and tachycardia. The patient is treated for ibuprofen overdose, including intubation and ICU care after developing metabolic acidosis, renal failure and adult respiratory distress syndrome.

Over 10% of all medical patients in the U.S. are on some form of nonsteroidal anti-inflammatory drugs (NSAIDs). Annually, more than 103,000 people are hospitalized and 16,500 die from NSAID complications, including overdose. Average-size adults can safely consume up to 100 mg/kg of a single NSAID in one day; toxicity begins as patients pass this threshold. Ingestion of more than 400 mg/kg often leads to life-threatening conditions.

NSAID overdoses can cause renal failure and lead to intestinal and stomach ulcers. Manifestations of overdose develop 4-48 hours after ingestion. Complaints include headache, tinnitus (ringing in the ears), deafness, nausea and abdominal pain. Physical exam may reveal diaphoresis, rashes, pulmonary edema, convulsions and hypertension, which develops as a result of water retention.

Mental status is a good measure of NSAID overdose severity. Minor overdoses cause changes such as anxiety, confusion and disorientation. Patients with major overdoses can become delirious and have decreased levels of consciousness. Expect dysrhythmias such as tachycardias and bradycardias. Patients sensitive to aspirin who overdose on NSAIDs may go into respiratory arrest. Within days of ingestion, patients can develop adult respiratory distress syndrome, metabolic acidosis and renal failure.

CASE #4: SEIZING

At Elmbrook Middle School, a 13-year-old is seizing. Upon arrival, your patient is responding to painful stimuli in care of the school nurse, who says she seized for three minutes. The girl has no history of seizures, takes no prescription medicines and has no allergies. The nurse says she had been acting strangely in class, as if she were drunk; however, she does not smell like alcohol. Physical exam reveals constricted pupils, diaphoresis and moaning upon palpation of the abdomen. While examining the patient you find a box of cold medicine capsules in her pocket. You suspect the child has overdosed on dextromethorphan, a drug in cold and cough medications.

More than 140 common cold and cough medicines contain dextromethorphan, a synthetic non-narcotic chemical commonly known as DXM. The normal recommended dose of DXM is 15-30 mg. DXM is absorbed through the stomach lining into the bloodstream, eventually raising the coughing threshold in the brain. Since DXM acts directly on the brain, it affects mental status. DXM comes in many forms: liquid, capsules, tablets, gel caps and lozenges. Capsules and tablets are the most potent and frequently abused. Abusers seek DXM because of the effects it provides, which are similar to those of PCP and ketamine. The amount ingested is dictated by the desired effects of use, which occur on four plateaus. Generally, users must take at least 100 mg for minimal effect, but many abusers often take more than 200 mg at a time.

When a patient has consumed between 1.5-2.5 mg/kg, they enter the first plateau. They experience a sensation of alertness and restlessness, and feel intense emotions and general euphoria. This patient may have loss of balance and appear intoxicated. Additionally, their pulse and core body temperature may become elevated.

Ingesting 2.5-7.5 mg/kg puts patients at the second plateau. These patients present with slurred speech, motor impairment, emotional detachment and short-term memory loss. Abusers may complain of hallucinations and strobe light vision. Some describe this plateau as being in a dreamlike state, detached from the outside world or heavily “stoned.”

Significant body toxicity begins at the third plateau, ingestion of 7.5-15 mg/kg. Patients present with an obviously altered level of consciousness and may not be able to comprehend what is said. They complain of disrupted sound and vision, have trouble recognizing people or known objects, and have abstract thoughts. Some feel emotionally detached and complain of out-of-body experiences.

Consumption of more than 15 mg/kg puts patients on the fourth plateau. Nervous system disruption denies the brain of normal sensory input and may cause temporary blindness. Rapid heart rates are common. Patients experience signs of severe overdose: lifelike hallucinations, major delusions, recall of buried memories, feelings of out-of-body separation, etc.

Medications contain varying concentrations of DXM; thus the amount required for overdose varies. For example, 4 oz. of Robitussin, or half a bottle, can cause a DXM overdose. Symptoms include blurred vision, dry mouth, delusions, nausea and vomiting, numbness in the fingers and toes, headaches, diaphoresis, abdominal tenderness, and dry, itchy skin. Other signs include extremely irregular heartbeat, hypotension, shallow respirations and a decreased level of consciousness.

Patients with critically high toxic levels of DXM may experience uncontrolled violence, severe psychosis, seizures or coma. Toxic DXM levels, especially if mixed with other drugs or alcohol, can lead to death.

Additional problems occur when cold medicines contain multiple drugs. For example, overdosing on a medicine with DXM and antihistamines could cause a synergistic decrease in respirations and lead to respiratory arrest.

ASSESSING THE OVERDOSE PATIENT

Scene size-up is very important on suspected overdose calls. Be sure the scene is safe. Overdose patients who are hallucinating or in a psychotic state can be aggressive and violent. Keep yourself and your coworkers safe. If necessary, wait for the police before entering. When approaching the scene and patient, keep in mind that in addition to the medical emergency, the patient may also be having a psychological emergency. Many suicidal patients choose a slow but potentially lethal combination of OTC drugs, alcohol and street drugs.

OTC drug overdoses can compromise critical systems. Begin by assessing the ABCs. Ensure patients have a patent and secured airway, and be prepared to suction vomit. Provide supplemental oxygen, and assist ventilations if needed. Check the adequacy of circulation and, if indicated, start an IV and begin cardiac monitoring.

A thorough and accurate history is critical to proper patient care. Information obtained in the field affects in-hospital treatment. Be a detective—spend a few extra minutes getting all the information you can from the patient, bystanders and other scene clues. Try to find out what was ingested, when and how much. Find out if the patient has vomited. If so, how often and how much? Try to determine if the overdose was accidental or intentional. Overdose patients are often unreliable historians.

Pay attention to scene clues around the patient and in the immediate area. Look for medication containers or spilled drugs and medications. Collect any medicines you find and bring them with the patient to the hospital. Interviewing witnesses may provide information critical to proper care. Often the person who called you knows exactly what happened. Separating the reporting party from the patient relieves the witness’ anxiety about revealing the truth, and they often will detail what led to the overdose.

Intentional OTC drug overdoses are a manifestation of psychological distress. Unfortunately, these patients may reject your assistance. When treating an intentional overdose, it is important to show you care by providing compassionate care. Establish a trust with the patient by listening to their answers to your questions and being honest.

A complete assessment includes a thorough SAMPLE history and physical examination. Physical signs reveal important clues to your patient’s condition. For example, pupils constrict during DXM overdoses and dilate from antihistamines. Remember to listen to lung sounds and check for any abdominal tenderness. Investigate pain using the OPQRST mnemonic. Monitor vitals frequently. Note any changes and look for trends. Hypotension may occur very quickly.

FIELD TREATMENT

The primary goal of field treatment for OTC overdoses is to protect and maintain the airway, breathing and circulation. Manage any life-threatening conditions immediately. Effective treatment starts with airway management. Deliver supplemental oxygen to all potential overdose patients. Many OTC overdose patients are prone to vomiting because medications contain multiple drugs. Watch for vomiting and be ready to suction. Place patients with decreased levels of consciousness in the left lateral recumbent position and consider inserting a nasal pharyngeal airway to improve air exchange. If necessary, ventilate with a bag-valve mask.

Monitor patients carefully. Patients who overdose on sedative-based medications often experience rapid decreases in respiratory rate and depth. Be prepared to secure the airway with intubation, a Combitube or another non-visualized airway device. Keep in mind, however, that because the patient is at high risk for vomiting, use only airway devices that isolate the trachea from the esophagus. Do not use an airway that could cause aspiration.

ACTIVATED CHARCOAL

The purpose of activated charcoal is to neutralize the toxin by absorbing it in the stomach and intestinal tract. Once absorbed, the toxin cannot enter the bloodstream. Since it is impossible for activated charcoal to absorb toxins already in the bloodstream, early administration is key. Consider administering activated charcoal, especially within one hour of ingestion. Activated charcoal can significantly decrease the effects of overdose up to four hours after ingestion when patients have taken antihistamines or NSAIDs. Give patients 1 g/kg by mouth. The dosage is the same for both adults and pediatrics. Because activated charcoal is an oral medication, it is contraindicated in patients with decreased levels of consciousness.

SYRUP OF IPECAC

You may run across families at home who still have syrup of ipecac. Administration of this, designed to induce vomiting, is unacceptable. Do not administer syrup of ipecac to any patient, and encourage anyone you encounter with the medication to dispose of it properly.

OTHER INTERVENTIONS

Initiate IV access on all overdose patients and provide a fluid bolus if patients are hypotensive. Check the blood sugar level of any patient with altered mental state or a decreased level of consciousness. Patients who have seized are often hypoglycemic.

Consider naloxone if you suspect polydrug use involving narcotics and the patient has a decreased respiratory rate. Follow local protocols to administer a benzodiazepine such as midazolam or diazepam to patients who begin to seize. Patients who are hostile or combative may require chemical sedation. Administering a sedative such as lorazepam may not only be prudent for your safety, but also for proper medical care.

Provide EKG monitoring for all overdose patients. Monitor for both tachy- and bradycardias. Patients who have taken antihistamines may have lengthened QT intervals or spontaneously go into torsade de pointes. If conscious, torsade de pointes patients often complain about palpitations.

NASOGASTRIC TUBES

If local protocols permit, consider placing a nasogastric tube. Emergency departments often perform gastric lavage on overdose patients who arrive within one hour of ingestion. This reinforces the importance of on-scene assessment and an accurate transport priority determination. While gastric lavage has no benefit when patients have ingested acetaminophen, early placement will not hurt the patient, and may help.

Any time you suspect an OTC overdose, transport to the hospital is required. Often there are antidotes available in the emergency department, and the ability to administer them depends on your ability to recognize both the kind and severity of the overdose, and provide safe and rapid transport.

During transport, monitor and support ABCs, reassess vital signs and continue to gather patient history. Advise the ED staff of any changes in the patient’s condition during transport.

PATIENT REFUSALS

Occasionally we are called to a potential overdose where the patient appears fine and refuses transport. However, OTC overdose patients need a physician evaluation, even when they appear asymptomatic. An intentional overdose is an attempt to self-harm and a threat to personal well-being. Anyone who poses a potential threat to themselves or others cannot sign a patient refusal. Patients, who have potentially overdosed on anything, including over-the-counter medications, can be placed in protective custody by the police. Utilize police assistance if necessary to ensure patients are transported to the hospital.

A Note About Our Courses

Due to Occupational Health and Safety statutes, many safety courses are mandatory for workers. Hand in glove with the statutes are the many company policies which mandate such training.

With the recent downturns in the economy many people are looking for work, many are working under more restricted means, and yet the courses are still priced for the older economy. The established training facilities have been slow to realize they are now dealing with a depressed economy and refuse to lower their prices…not this facility!!!

EFFECTIVE JULY, 2016, ALL RAEMS COURSES HAVE BEEN DISCOUNTED.

For example, Wilderness Survival Techniques, which is mandatory in many jurisdictions for solo outdoor work, has regularly been offered at $265.00. It is now, and shall remain available for $198.75…a 25% reduction. All of our courses are now similarly reduced in cost to assist you all in making it through these difficult times.

In addition to price reductions we will also further discount classes for multiple participants. In other words a group of three booking online will receive further rebates.  We will not, however, consider any reductions in the amount of enjoyment one has, the amount of fresh air provided, or the many thrilling opportunities to commune with the bugs and beasties of the wilderness.

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As always, Industry standard courses covering the majority of worksite and occupational first aid requirements will remain available for organizations and industry at a substantial saving through our exclusive discount rate program.

Contact us…or see our course listings for more information…

August 2016 Wilderness First Aid Course

P1030057$195.00 CDN

A 2 1/2 day course designed to cover remote first aid while enjoying a wilderness setting.  All class sessions are held outdoors in the Rocky Mountain Wilderness, where the validity of each theory may be shown more effectively. Some classes may be modified as they progress due to the unpredictability of nature and weather.

Hands-on practical sessions and lectures combine with an outdoor environment to effectively introduce the unique challenges of casualty care in the wilderness. This course is a must for outdoor counsellors, hikers, hunters, and anyone involved in remote areas.

Student will receive an introductory package beforehand containing a what to bring list. All participants receive reference guide ( actual classes will be visual and hands on), basic first aid items, and a familiarity with the processes involved in dealing with wilderness emergencies. Accommodations will be tent or shelter. If you wish to bring a trailer or an RV for your use please advise us.

Remote Areas Emergency Medicine and Survival will accept no responsibility or liability for any injuries or losses due to improper behaviour. A waiver will be signed by each participant. This is a wilderness area, and various wildlife should not be approached!!

Register by emailing us or use this link