Rounds 9/17/2015

State updateToxicology Update: synthetic

Cannabinoids , Marijuana, and powdered caffeine

Epinephrine and Cardiac ArrestsMarijuana and Synthetic

Cannabinoids

Welcome back

• VA and transports….don’t• Patient preferences and destinations …TBD

Toxicology Update

• Powdered caffeine: unregulated and marketed as a dietary supplement . Two young men died this past year from overdoses. One teaspoon is equivalent to 28 cups of coffee.

Synthetic Cannabinoids

• Marijuana…active ingredient is THC. There are now many synthetic cannabinoids [SC] available . They first appeared in 2008 and they have proliferated. Sold as liquid for e cigarettes , dissolved in energy drinks , sold as “legal alternatives to marijuana” , they are dangerous. Over 26 synthetic cannabinoids are considered schedule 1 drugs [highly illegal] . There have been over 20 deaths in the past 18 months in the US. 90% of these deaths came after smoking the drug.

Cannabinoids continued

• There are other effects beside deaths…delirium, seizures , psychosis , hallucinations and coma. Thee are no available antidotes.

• These drugs are not detected by our toxic screens!

• Names of these drugs include Crazy Clown, 10X, ABD-Pinaca, AB-Chiminaca , etc.

• Over the past 6 months there have been 1200 ED visits and 17 deaths in 12 states [southeast] .

Marijuana

• It is estimated that 160 million people used marijuana at least once last year. This is 4% of the world’s population!

• The active component of marijuana is THC. The content of THC has tripled over the past 50 years.

• There is clear evidence that marijuana use may be addictive. 1% of cannabis users become dependent on it and will withdraw when they are abstinent. Over 2/3 of users stop its use. It is not terribly addictive.

More marijuana [please? ]

• Three side effects will be noted. Cannabis use increases the likelihood of psychosis by 1.5-2 fold. You are one and one half to twice as likely to become psychotic if you smoke marijuana.

• Marijuana use decreases testosterone levels and lowers sperm counts . It will decrease fertility in men.

Cannabinoid Hyperemesis Syndrome

• This is a condition of recurrent episodes of vomiting and colicky abdominal pain occurring in patients who use marijuana regularly.

• The clue to this syndrome is that the patients get relief from hot showers. The vomiting is resistant to medications [Zofran, etc], but hot showers or the use of capsaicin [red hot chili peppers] topically applied will relieve the vomiting and abdominal pain .

Cardiac Arrest Update

• In November we should have the 2015 AHA Guidelines. • Therapeutic Hypothermia is question with 2 new papers

from Europe and Australia shedding doubt on its utility• We must increase the rate of Bystander CPR. We need to

get our schools to make CPR training mandatory and we need to get the public to understand how time sensitive life is. In a large study from Denmark [ 29,000 patients] over a 10 year span . Bystander CPR tripled their success for CPR. No surprise….

Epinephrine and Cardiac Arrests

• There has been a lot of question about the utility of epinephrine in cardiac arrests. Three recent papers should help guide our efforts. Our resuscitation rates are 40 %. This is markedly better than most communities. Epinephrine is a part of our protocol and we should continue to use it given our success. But what does the recent literature and scientific data reveal ?

Two recent papers from the AHA database using the GWTG on adults and children

• BMJ 5/2014 Donnino, Michael et al . They studied 120,000 in patient PEA and Asystole cardiac arrests to examine the question of timing in administering epinephrine. What they found was that if given at 1 minute 12 % survival was seen and if given at 7 minutes there was only a 7% survival. Neurologically the patients who got the drug early did much better neurologically. There was a 10-20 % decrease in survival for every 3 minutes in administration of epi. YOU MUST GIVE IT EARLY.

Pediatric nonshockable arrests and Epinephrine

• In JAMA August 2015, 1 month ago by Lars Anderson [really !] et al . They had 1558 patients and again the time to epinephrine was critical. If the time to epi was >5 minutes the survival to discharge was 21 %. If the epi was given in <5 minutes the survival to discharge was 33%. There was a stepwise decrease in survival, neurological outcome for delays in administration of epinephrine just as was seen in adults. GIVE IT EARLY

Capnometry

• CO2 is an odorless, colorless gas . It is created as a byproduct of metabolism.

• A normal End Tidal CO2 is 35-45 mm.• Levels >45 reflect hypoventilation, the patient

is not breathing well. They are retaining CO2• Levels <35 are a result of hyperventilation

Capnometry

• There are 2 configurations of capnometry : sidestream [a sample is diverted to the side] and mainstream [a sample is measured at the end and not diverted] . The mainstream is used for intubated patients. The sidestream may be used in any patient.

Capnometry

• Two recent cases are useful to look at the multitude of ways that capnometry has changed our practice

ETCO2 versus Oximetry• ETCO2 reflects ventilation. CO@ rapidly diffuses across

cell membranes and if the airway is compromised [not breathing, obstructed etc] the ETCO2 will rapidly rise within seconds

• The oximetry will often remain artificially high for minutes in these situations.

• Hold your breath for 2 minutes and watch as your ETCO2 will rise quickly. The O2 sat will hardly change

• This is the critical reason why ETCO2 must be followed in patients receiving benzodiazepines or narcotics. Imagine that this patient is placed on oxygen at the same time . The O2 sat will not go down for a long time after the ETCO2 has risen [to reflect that the patient has ceased breathing]

ETCO2 vs Capnometry Cont’d

• In one study of intubated prehospital patients an abnormal CO2 was documented BEFORE changes in the O2 sat level in 70 % of patients with hypoventilation.

• If the ET tube is dislodged the capnography waveform will be markedly altered.

• In one study of paramedic intubation the groups that used ETCO2 continuously had 0% misplaced tubes. In those medics who did not use capnography 23 % had misplaced the tube.

Cardiac Arrest and Capnography

• Capnography indirectly measures cardiac output . It is a very good tool for measuring the effectiveness of CPR. A capnography that remains less than 10 during a resuscitation indicates futility . There has not been any meaningful cardiac output. A sudden rise in ETCO2 will frequently precede ROSC.

• So there are 2 good reasons to use Capnography in arrests. It indicates that the tube is correctly placed and has not been dislodged and it is the only effective tool for measuring the effectiveness of our efforts with CPR.

Capnometry continued

• The next few slides are all demonstrating waveforms and their possible uses for diagnosis. The waveforms are taken from a monograph from Zoll.

USE OF ETCO2

In addition to cardiac arrest patients and patients who are sedated other patients who must have

ETCO2 include :Altered mental status , both to be certain they are not retaining CO2 and to monitor their ventilation

statusSerious Head injury

All respiratory problems: asthma, COPD,CHF, etc

Institute of Medicine Report on Cardiac Arrest

• The Institute of Medicine released a report this past summer which describes cardiac arrest as the biggest public health issue in the US. They noted the tremendous variation in resuscitation rates in the US . They asked all of us to try to commit our communities to try to increase resuscitation rates. We need to do all of the things we are trying to do. Every student should be trained in CPR[preferably hands only] . They recommend community wide programs to increase the number of lay rescuers, programs to increase AED use and availability. They want all programs to know their rates and to try t increase them. Its all the things we are trying to do. Dispatch is a key component . The report is over 400 pages long.

CVA Recognition

• CVA was only recognized in 50 % of the patients in a recent study from NYC a total of 310 CVA patients]. The use of the CVA scale was the single best predictor of success in recognition . It was most commonly missed in patients without motor findings and in patients with severe strokes.

• In patients who had a CVA scale performed the sensitivity was 84 % .

Cases

• The good x 3, the bad x 5 and the ugly x 4.