Archive for the 'Clinical' Category

09
Feb
11

Pill Popping On The Job. (How to reclaim the 24hr shift.)

By Jeramedic 2 Comments
Categories: Clinical and Uncategorized
Tags: , , , , , , , , , , , , , , , , ,

We work hard for our money. At least that’s what it feels like the morning after a nasty 24hr shift. We have all been there. Going home and sleeping till 3pm, 0r getting of at 7am and trying to go about your day like a cranky zombie. Some of us have become so accustomed to it (myself being one)  that we plan our days off to include recovery sleep.

Now there are some exceptions to the the 24hr shift hangover: You are either at a station that runs less the three calls a shift, or you work during the daytime for only 8-12 hrs. But even that does not immune you from feeling fatigued at work.

Sleep deprivation and long shift hours is a big deal in health and safety, especially in the EMS world. And even though research shows us time after time that sleep deprivation significantly decreases mental focus and performance (something we need when taking care of critically ill patients, and operating heavy equipment like vehicles and rescue tools) whilst increasing ones risk for heart disease and other illnesses,  there is still a split opinion about 24hr shifts. Case in point: While one agency is taking safety and shift work very seriously, another is disciplining a Firefighter for refusing to work 72hrs straight.

Now this is not a post about being over worked. I don’t think there need to be much discussion about that. It sucks, and its dangerous. We have all at one time or another responded to a call at 3am in a mental state near postictal, only to fully wake up as you are immobilizing someone on the side of the highway. Rather, this is a post about the last months self experimentation on sustaining energy while on shift, and reducing the hungover zombie symptoms the day after.

After some research and self experimenting, I came up with the following nutritional supplement and sleep protocol for my days at work.

I work ten 24hrs shifts a month, from 7am-7am, and the protocol’s hourly breakdown looks like this:

  • 7am: One cup of coffee, and one multivitamin with breakfast.
  • At lunch, 2000 mcg of vitamin B-12, and two High Stress Adrenal tablets.
  • Somewhere from 4pm-7pm 1000 mg of vitamin C, and a 20-30min nap.

Thats it… The kicker for me was when after doing the above during a 48hr shift, with an average call load for that station during the day, and waking up three times both nights, I felt better after that 48hr shift then I did after most 24hrs I had done in the past.

7am Coffee. I usually get to the station  15-20min early so I can get my gear ready and do the equipment check out before I’m officially on at 0700. Although coffee is not a must have part of my day, I do enjoy it. And the social bonding that comes with  coffee around the kitchen table with the off going crews is equally if not more energizing.

Multivitamin. I think any brand of multivitamin is fine. The idea behind taking one is the inherently poor diets that too many EMS providers have, especially while on shift. It is also a way of getting the other B complex vitamins to complement the 2000 mcg of B-12.

2000 mcg of Vitamin B-12. Vtamin B12  is known as the “energy vitamin,” and it is essential for many critical functions in your body, including energy production, supporting your immune system, and helping to regulate the formation of red blood cells. Vitamin B12 is also a cofactor in the production of Melatonin, which will help you to fall asleep faster. It also enhances the phase-response of circadian melatonin rhythm.

High Stress Adrenal. High Stress Adrenal is a 100% Food supplement that supports optimal adrenal health.  The adrenal glands play a role in energy, stress, mood, immune support, and pain management.  This product contains many of the substances produced by, or naturally in, those glands including peptides, hormone precursors, and enzymes.  Additionally, it includes l-tyrosine, food B vitamins, food vitamin C, and herbs to support healthy adrenal function. Even if you don’t get a huge adrenalin rush every time the tones go off, that doesn’t mean your adrenal glands aren’t working overtime to keep you focused and alert on calls, and awake at 4am.

1000 mg of Vitamin C. Vitamin C functions as an antioxidant and may also be useful in lowering serum uric acid. Some sources claim that Vitamin C “supports” or is “important” for immune system function. Seeing as Vitamin C deficiency is detrimental to immune function, resulting in reduced resistance to some pathogens. You can see where some people would assume benefit.  But, routine supplementation is not indicated in the general population. For that reason I do not take it daily.

Napping. I touched on the subject of sleep in a previous post. And nothing beats good restful sleep when it comes to energy. Well, I mean nothing beats REM cycles when its comes to energy.  REM is the business when it comes to sleep. It’s so important, that when deprived of sleep, subjects will fall into REM cycles within seconds of closing their eyes. Have you ever had the experience of nodding off for 30 seconds to a minute, and having a dream that last for hours, or waking up and thinking you time traveled?  Thats REM. The problem with REM cycles, is that they come in cycles. Over a normal Monophasc night’s sleep of 8hrs, you drift in and out of REM. Which on a good night will add up to about only 2hrs of REM. Thats 2hrs of awesome regenerative brain time, and 6hrs of  being unconscious.

Enter the realm of Polyohasic sleep. Dr. Claudio Stampi says that in crises and other extreme conditions, people may not be able to achieve the recommended eight hours of sleep per day. Systematic napping may be considered necessary in such situations. Dr. Claudio Stampi, as a result of his interest in long-distance solo boat racing, has studied the systematic timing of short naps as a means of ensuring optimal performance in situations where extreme sleep deprivation is inevitable, but he does not advocate ultrashort napping as a lifestyle. Scientific American Frontiers has reported on Stampi’s 49-day experiment where a young man napped for a total of three hours per day. It purportedly shows that all stages of sleep were included. Stampi has written about his research in his book Why We Nap: Evolution, Chronobiology, and Functions of Polyphasic and Ultrashort Sleep In 1989 he published results of a field study in the journal Work & Stress, concluding that “polyphasic sleep strategies improve prolonged sustained performance” under continuous work situations. And having tried it myself, I’d say he’s right.

So there you go, Folks.  an alternative to SVT in a can. Everyone is different,  and maybe my strategy is not for you.  Either way, I hope you find rest on your next shift. The point is that with a little planing, you can be more alert and focused on shift, and feel better when you clock out.

Already have some tactic in use? Please feel free to share.

***** Disclaimer. I am not a doctor, nor do I play one on TV. These are the results of my own trials on myself. I am not prescribing or recommending anything to anyone,and I do not  claim to be an expert or authority on what you should to with your body. Talk to your doctor before taking any dietary supplement, or starting a diet, exercise, or lifestyle routine. *******

03
Jul
10

Shock Pt 2: Cardiogenic Shock

By Jeramedic 2 Comments
Categories: Clinical
Tags: , , , , , , , , , , , , , , , ,

In Pt 1, I reviewed anatomy, physiology, and the basic pathophysiology of shock. If you have not read that already, I recommend you do so first. With that, lets talk about a form of  shock: Cardiogenic Shock.

In a nut shell, cardiogenic shock is an inability of the heart to pump enough blood to supply the tissues with oxygen. And is defined as insufficient forward cardiac output.  Cardiogenic shock is usually the result of a significant bradycardia (heart rate that is too slow) or heart block, or a significant tachycardia (heart rate that is too fast) resulting in low cardiac output and hypoperfusion. Cardiogenic shock can also be caused by severe left ventricular failure secondary to acute myocardial infarction, congestive heart failure, chronic untreated hypertension, cardiomyopathy, or long term habitual use of stimulant drugs like cocaine.

The heart can be divided into two halves,. the left, and the right. The left side is responsible for receiving oxygenated blood from the lungs ( via the left atrium) and pumping it to the rest of the body (via the left ventricle). If the left sides ability to pump blood  is compromised, then back pressure will build up in the system. Because the left ventricle is responsible for pumping blood to the systemic circulation, SVR, or systemic vesicular resistance plays a large part in the process. If the stroke volume and cardiac out put is not enough to overcome the SVR, (as in untreated hypertension) or the ventricle is weakened (as in a myocardial infarction or cardiomyopathy) then pressure will back up into the left ventricle. The hearts pumping ability can also be diminished by a cardiac tamponade, or a tension pneumo/hemothorax.



If the heart is not pumping blood into the systemic circulation effectively, then the body becomes hypoperfused. As the pressure builds in the left ventricle, the myocardium (heart muscle) will stretch to accommodate the larger volume of blood. The muscle can stretch, but only to a point before it weakens and fails, causing even less efficient contractions. The pressure will then spread to the left atrium. The left atrial pressure rises and is subsequently transmitted to the pulmonary veins and capillaries. When pulmonary capillary pressure is too high, it forces blood plasma across the alveoli-capillary membrane and to the lungs, causing pulmonary edema (fluid in the lungs).


The hypoperfusion is compounded by the fact that most cardiogenc shock due to left ventricular failure is accompanied by pulmonary edema, which dramatically reduces the ability of oxygen and carbon dioxide to diffuse across the alveoli-capillary membrane. Also, since left ventricular failure is often caused by an AMI (acute myocardial infarction) be awhere that your patient experiencing cardiogenic shock, may also be having an AMI.

Right ventricular failure by it self, will not likely result in hypoperfusen in the same way as left ventricular failure. But, right sided failure is interestingly often caused by left ventricular failure. Right sided failure can also be caused be chronic obstructive lung diseases like COPD. As the back pressure spreads to the right side of the heart, peripheral edema in the dependent parts of the body, and JVD (Jugular vein detention) often occur. These are both key signs to look for during your assessment.


The patient in cardiogenic shock may present tachycardic or bradycardic. Will likely be short of breath with possible chest pain. Possible JVD (right side failure). Lung sounds may be clear, diminished, wheezes, crackles, rales or absent depending on the severity of pulmonary edema. White or pink frothy sputum may be present. The patient will likely have fast labored respirations. Level of consciousness may be diminished due to hypoxia. Skins may be cyanotic and or diaphoretic. Spo2 reading will be low. Blood pressure will likely be normal or hypertensive (in exacerbated congestive heart failure) or  low in decompensating shock.

Treatment is aimed at airway and cardiac support. The patient should be placed in a position of comfort. If pulmonary edema is present, the patient well likely prefer to be sitting upright in a high fowler’s position, with their legs hanging off the gurney. Although the patient may present in a state of shock, treatment should also consist of treating the underlying cause (AMI, CHF) which if managed effectively, can relieve the hypoperfusion.

When available, a 12 lead EKG should always be obtained. Support the airway and breathing with High flow O2 via non rebreather mask, you may need to assist ventilations via BVM (bag valve mask), CPAP, or intubation. Nitroglycerin (if blood pressure is acceptable) will reduce cardiac work load and oxygen demand through vasodilatation, and relieve pulmonary hypertension and edema. Morphine may also be useful. Furosemide 40-80mg IV will relieve pulmonary edema through diuresis. IV fluid administration should be minimal so as not to exacerbate the pulmonary edema.

Cardiac support with Dopamine at 2-10mcg/kg/minute, or Dobutamine at 2-20 mcd/kg/minute will increase the force of cardiac contractions, increasing systemic perfusion and reducing pulmonary hypertension.  If the patient is bradycardic, than 0.5mg of Atropine IV, or trans-cutaneous pacing to increase the heart rate to a perfusing level is appropriate. Always be cautious of AMI in a badycardic patient, because bradycardia can be a protection response of an ischemic heart. Tachycardias (depending on the type, and severity) can be treated with 6-12mg of Adenosine, and other antiarrhythmics like Amiodarone and Lidocaine. Also Synchronized cardioversion if available, and in some systoms a Beta blocker may be indicated.

The patient may have additional cardiac compromise such as AMI which will require appropriate treatment, and transport destination.

*** Always treat your patients according to your local protocols and scope of practice. And use medical control as needed. ***

In part 3 we’ll leave medical, and deal with trauma, burns, and Hypovolemic Shock.

30
Jun
10

Shock Pt 1: Anatomy, Physiology, and Pathophysiology Review

By Jeramedic 8 Comments
Categories: Clinical
Tags: , , , , , , , , , ,

This is the first in a series of posts, that will go over the five types of shock. Covering the basics of pathophysiology, presenting signs and symptoms, and the course of treatment. Before we can understand the various types of shock, we must first have a foundation on which to build.  What follows is a review of  anatomy, physiology, and the general pathophysiology of shock.

Shock is a serious life threatening medical emergency, and can be caused by several conditions.No mater what the cause , the end result will be Hypoperfusion of the cells (Shock) and if uncorrected, death. The cells of the body require a constant supply of Oxygen and other nutrients, as well as a content removal of Carbon dioxide, and other waist products in order to functions efficiently and maintain Homeostasis. For normal perfusion to occur, three systems must be intact: The pump (the heart) The pipes (the blood vessels) and The fluid ( the blood ).

The pump is what “pushes” the oxygenated blood from the lungs, and circulates it to the cells, tissues and organs of the body, where oxygen and other nutrients are exchanged for carbon dioxide and other waist products, which are then carried back to the lungs and other organ systems (such as the liver and kidneys) to be removed. If the pump is too slow, as in Bradycardia, or pumps too fast or inefficiently as in Supra-ventricular tachycardia or other arrhythmias, or if the pump is not strong enough to circulate the blood effectively, hypoperfusion may occur.

The pipes are what carries the blood to the cells and tissues of the body. If there is a obstruction in the pipe as in a Thrombus or Embolism. Blood flow and thus perfusion beyond the point of occlusion will decrease.  If the integrity of the pipe is lost either through Trauma, a ruptured Aneurysm or increased vascular permeability resulting in a decrease of circulating volume, there will be less blood available to transport nutrients and waist. Also, excessive vasodilatation can lower blood pressure resulting in hypoperfusion.

The fluid is what holds and transports the nutrients and waist products. The blood contains erythrocytes (Red blood cells) which have a protein called Hemoglobin. Oxygen molecules attach them selfs to the hemoglobin so that they may be carried throughout the body. In the lungs deoxygenated blood travels through the capillaries surrounding the alveoli. Through the proses of diffusion, oxygen which is at a higher concentration in the alveoli, crosses the alveoli-capillary membrane into the blood where there is a lesser concentration of oxygen. At the same time, carbon dioxide which is at a higher concentration in the blood, crosses the capillary-alveoli membrane into the alveoli, where it is removed during exhalation. The oxygen molecules bind to the hemoglobin and is transported throughout the body. The blood enters capillaries within the tissue where again through diffusion oxygen is exchanged from the blood to the tissue, and carbon dioxide form the tissue to the blood. The blood, now deoxygnated returns the the lungs where the process repeats it self.

If there is a decrease in circulating volume as with blood loss and or dehydration, there will be less blood to transport nutrients and waist products. Also conditions effecting the red blood cell and its hemoglobin such as anemia and carbon monoxide poisoning can decrease the amount of oxygen that can be transported to the tissues, resulting in hypoperfusion. As you can see, a malfunction in any one of the systems can result in shock.

During hypoferfusion the cells become ischemic and switch from a Aerobic metabolism ( with oxygen ) to a Anaerobic metabolism ( without oxygen ). The primary energy source for the cell is glucose. In a Aerobic metabolism glucose is broken down ( Glycolysis ) which produces pyruvic acid which is further broken down into carbon dioxide, water, and energy (ATP). However during hypoperfusion the cell switches to an Anaerobic metabolism (without oxygen) where only the first stage of glycolysis is possible. This produces very little energy and with out oxygen pyruvic acid can not be broken down, and instead is converted into lactic acid which accumulates in the cell, lowering the cellular pH. The acidosis reduces the ability of hemoglobin to transport oxygen which compounds the problem. The lower intracellular pH causes the membranes of the lysosomes and other organelles to rupture releasing enzymes that damage the Sodium-Potassium pump which causes an influx of sodium and fluid, which causes cellular edema, which causes the cell to rupture releasing the lysosomal enzymes, lactic acid, hydrogen and other cellular contents into the interstitial and intravenous space causing further acidosis.

The body has various ways of compensating during shock. However if the cause of the shock is not corrected the compensatory mechanisms will become overwhelmed and fail, causing death. A decrease in blood pressure is detected by the Baroreceptors which activates systems to reestablish normal blood pressure. The sympathetic nervous system stimulates the adrenal glands to secrete epinephrine and nor-epinephrine which causes an increase in heart rate and contractile strength, as well as  vasoconstiction all of which increase blood pressure.

In the kidneys, the detection of low blood pressure stimulates the Renin-Angiotensin-Aldosterone system. The enzyme renin is released by the kidneys. Renin acts on a plasma protein called angiotensin, which is converted into angiotensin I. Angiotensin I is converted into angiotensin II in the lungs by angiotensin converting enzyme (ACE). Angiotensin II is a potent vasoconstrictor which increases peripheral vascular resistants which increases blood pressure. Angiotensin II also stimulates the sympathetic response, and stimulates the pituitary glands  secretion of antidiuretic hormone (ADH) which causes the kidneys to retain electrolytes and fluid. The hormone Aldosterone which is secreted by the adrenal cortex also stimulates the kidneys to reabsorb sodium potassium and water, increases the intravascular volume. As the blood pressure slowly decreases, so does the intravascular osmotic pressure, which causes fluid to shift from the interstitial space and the intracellular space, into the intravascular space to increase the circulating volume.

Respirations increase both in rate and depth. This increases the amount of oxygen available, and attempts to eliminate the build up of toxins from the anaerobic metabolism. If there is blood loss due to hemorrhage, the damaged blood vessels constrict slowing the amount of blood flow and the clotting and coagulation cascade begins. If the conditions causing shock are too serious, or progress too rapidly, the body will be unable to keep up with the demands and move into a state of decompensation.

The heart rate and respirations will increase dramatically. The skin will be very pale cool and diaphoretic. Peripheral pulses will be weak or absent. Urine out put will low or almost none. Level of conciseness will decease from agitated to unresponsive, and the body moves into irreversible shock. At this point the blood pressure is so low the heart and brain become hypoperfused. The hypoxic heart will tire quickly, possibly becoming arrhythmical before failing. The Vasomotor, cardiac, and respiratory centers of the brain will become ischemic and die causing the cessation of compensatory efforts. The blood will begin to pool and coagulate in the capillaries. Because of the loss of vasomotor control from the brain and the low blood pH, capillaries become permeable and the pre and post capillary sphincters relax causing wash out sending microemboli and toxins into the tissues and systemic circulation, and the body dies. Once the body moves into the late stages of decompensation and irreversible shock, resuscitation and survivability are extremely low.

Now that we have all that taken care of, we can move in to the various types of shock, and what to do about them. Remember that for a patient experiencing shock, the best treatment is always safe and efficient transport to an appropriate facility.

In part two, the basic pathophysiology, signs and symptoms, and treatment of  Cardiogenic Shock. <—- Read Here

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