EMS Protocol of the Week - Poisoning (Adult and Pediatric)

Previously combined with the protocol for overdoses, the prehospital approach to various types of poisoning is now given its own space to shine in the 2022 edition. First and foremost in terms of importance, as in all prehospital encounters, is for crews to ensure scene safety so as not to put themselves at further risk. From there, special considerations are given regarding decontamination of different potential exposures, from ingestion, to inhalation, to animal envenomation. Read through the attachment for specifics, as it serves as a good refresher of initial steps in management. Otherwise, this protocol contains the other basic tenets that you would expect – support ABCs, and transport to an appropriate facility (including Venomous Bite Centers as needed – check last week’s email to see where they are in the city!). 

www.nycremsco.org and the protocol binder for more!

Dave

Hypertriglyceridemia Induced Pancreatitis

Hypertriglyceridemia induced pancreatitis is relatively uncommon (about 8% of patients with pancreatitis). This is likely to become more of an increasing problem in the future due to growing rates of obesity.

Basic Pathophysiology:

·      Insulin promotes storage of triglycerides into adipose  if resistance or not enough insulin  lipolysis, releasing free fatty acids in circulation.

·      Many people have high triglyceride levels and don’t develop pancreatitis from it, so likely the toxicity causing pancreatitis comes from free fatty acids

·      It is difficult to measure free fatty acid levels, but we can easily measure triglyceride levels.

Risk Factors:

·      DM, Obesity

·      Hereditary hyperlipoproteinemia

·      Pregnancy

·      Hypothyroidism

·      Medications

Interesting Clinical Signs:

·      Xanthoma Tuberosum

o    Nontender, pink-yellow papules or nodules that occur on extensor surfaces, such as the elbows and knees, and on trauma-prone areas

·      Lipemia

o   White, milky, opaque serum on blood draw

Diagnosis:

·      Requires at least two:

o   Clinically significant history/physical (epigastric abdominal pain), CT demonstrating inflammation, or lipase >3 times upper limit of normal

o   Triglyceride level >1,000 (higher the level the more significant/ higher likelihood to be causing pancreatitis)

o   Must exclude other causes – gallstones, meds, etc.

Treatment:

·      *****Fluids*****

o   BE CAREFUL!!!! Overloading these patients is one of the worst things you can do for them. Don’t exceed >3-4 liters in the first

o   Lactated ringers (has been found to reduce inflammation compared to NS)

·      Vasopressors

o   Use early to prevent fluid overload

·      Pain control

o   Opioids can promote Ileus, try to avoid this class of medications as best as possible

o   Great time to use acetaminophen with pain-dose ketamine infusions (0.1-0.3mg/kg/hr)

·      Insulin

o   Appropriate dose is variable ranging from 0.1-0.3 U/kg/hr (dosage can vary based on history of diabetes or insulin resistance)

o   Monitor for hypokalemia, hypoglycemia

o   Likely to be best treatment

·      Plasmapheresis

o   Unclear if there is a large benefit to this

o   Invasive, requires large bore access catheter

o   Expensive, resource intensive, and not widely available

o   Heparin used during process can cause bleeding

·      Antibiotics

o   Generally, should be avoided with these exceptions:

§  Unclear diagnosis and have clinical suspicion for infection

§  Concern for coexisting ascending cholangitis

Complications:

            ARDS

            Infection

            Abdominal compartment syndrome

·      Increased intra-abdominal pressures

o   Pancreatic/peri-pancreatic inflammation

o   Ascites

o   Ileus (opioids)

o   Aggressive fluid resuscitation

o   Abdominal wall compliance (pain)

o   Pancreatic perfusion, worsens with intraabdominal hypertension  increases risk for pancreatic necrosis

Quick Tips:

·      Do not give too much fluid

·      Control pain with modalities other than opioids if possible

·      Insulin therapy is very effective, and plasmapheresis has not been shown to be more advantageous

·      Look for alternative causes before focusing solely on hypertriglyceride induced pancreatitis (consider ultrasound imaging and review patient medications)

References:

https://www.pancreapedia.org/reviews/management-of-abdominal-compartment-syndrome-in-acute-pancreatitis

https://emcrit.org/ibcc/hypertag/

https://wikem.org/wiki/Acute_pancreatitis

https://rebelem.com/acute-pancreatitis/

Happiness

Today, I’ll be reflecting on happiness. 

There is endless literature, philosophy, and psychology devoted to this one word. I spent a couple of hours this morning reading reading about happiness. A few themes emerged, and I wanted to take a moment to share them with you along with some of my takeaways.

(1) “Experienced” versus “Remembered” happiness

Experienced happiness: the happiness you experience in the moment. Experienced happiness can entail going out to dinner with a friend, enjoying a lovely glass of wine, going to a concert. The moment-to-moment bliss can be nourishing. On the flip side, binge-watching Love is Blind on my couch gives me great joy in the moment, but the next day, I look back and I feel sad like I wasted an opportunity to do more. In general, this term captures the “carpe diem” or “YOLO” mindset. However, being happy in a moment can be different than being happy for a longer timeframe.

Remembered happiness: when you reflect back on a period of time and feel satisfaction. For example: residency. Each moment is challenging and often not “fun.” But you may look back on the breadth of the experience and feel a deeper satisfaction that could not be captured in one single moment. The multitude of experiences culminated into happiness. People often use remembered happiness to measure life satisfaction. 

My takeaway: Framing it in these two categories actually really helped me. Being intentional with each type is important. Moments of experienced happiness will help me withstand the journey of the remembered happiness, so it’s important to prioritize simple pleasures that bring me joy. If I overemphasize experienced happiness, then I might lose sight of my larger ambitions and lack purpose. However, if I only prioritize remembered happiness, I might look back on my life with regret that I didn’t enjoy the process along the way. I think the moments in life when we have jolting reminders of our transience push us to embrace experienced happiness even more. 

(2) The Hedonic Treadmill

This theory is also termed “hedonic adaptation,” and it talks about how people typically live at a “happiness set point.” As positive events occur – like getting a great new job, achieving a longstanding goal – expectations correspondingly rise. Thus, there’s no net gain in happiness. The same theory actually holds true with negative events. Over time, you’ll eventually return to your happiness set point regardless of the stressor. 

My takeaway: I am 100% guilty of this. I remember there were so many times in medical school when I thought, “When I match into residency, I’ll be so much happier.” But with each accomplishment also came a new set of dreams. At times, I’ve forgotten to celebrate my achievements in pursuit of the next goal. I think pushing past the negative life events to maintain the happiness set point shows a level of resilience that is innate to us as humans. But the lack of celebration with the positive seems like a missed opportunity to potentially redefine my set point. However, even more importantly, I think this concept made me realize the emphasis I’ve placed on external sources of happiness rather than internal.

(3) The World Happiness Report

The UN publishes a report each year ranking each country on a scale of national happiness. These results are based on respondents rating their happiness. The survey uses a Cantril ladder – “it asks respondents to think of a ladder, with the best possible life for them being a 10, and the worst possible life being a 0. They are then asked to rate their own current lives on that 0 to 10 scale.”

Finland has been ranked the happiest country in the world four times in a row, followed by Denmark, Switzerland, Iceland, and Norway. USA falls at #19 of 146 countries in 2021, relatively lower than other developed, wealthy nations. One theme noted by analysts is that the top ten countries have “solid social support systems [and] good public services.” These countries also tend to have higher taxes. 

The NY Times article that I’ve linked below tells the story of a Finnish town named Kauniainen, also known as the happiest city in the world. On the surface, is a gloomy weathered town, with stoic residents. However, they cite an Adult Education Center as one of the integral components to the city’s contentment. I remember reading this article when it was published three years ago, and I never forgot it. The simplicity, strong sense of community, and investment in social systems really stuck out to me. 

My takeaway: One of my conclusions is that it helps to have a strong sense of belonging. For my in-laws, they derive a lot of happiness in their church group. For my husband, he finds camaraderie in his cross-fit group. And I realized for me, a lot of my happiness is the strong sense of community that we have at Maimo. I feel happy, grateful, and fuzzy-hearted when I reflect on that. 

References:

https://hbr.org/2018/11/what-kind-of-happiness-do-people-value-most 

https://en.wikipedia.org/wiki/Hedonic_treadmill 

https://www.nytimes.com/2018/03/14/world/europe/worlds-happiest-countries.html 

https://www.nytimes.com/2018/12/24/world/europe/finland-happiness-social-services.html

https://worldhappiness.report/faq/