(Transcript is automatically generated)

Erik: [00:00:00] I've had to intubate intoxicated patients with really high alcohol levels. Mm-hmm. I've had to intubate Xanax overdoses just temporarily just to be able to protect their airway, 

Matt: which is why when people are under the influence of things, they cause accidents. Because all of those senses are dulled. 

Erik: Yes.

Matt: Because they're parasympathetic sy. It's, they've taken alcohol. Which is a depressant. Exactly. And so their reaction times are slower.

Narrator: You are listening to EMS with your hosts, Erik Axene and Matt Ball.

Erik: I think I may have had one and a half beers in the last five years. That's total of five.

Matt: Real, like you don't like a beer on a cold day, on a hot day, on a real hot day. Like after you. 

Erik: That's what water's for. 

Matt: Well, no, but I'm not saying I do it, but on a hot day, like I, there is something, I'm not a big beer guy either.

Well, like Devvin, our film guy, uh, he 

Erik: huge big beer guy. 

Matt: I say, why am I telling Devvin our film guy to you? Like you don't know. Who [00:01:00] I had to define was 

Erik: No, we could tell our friends. 

Matt: In the organization. Yeah. I'm not a big beer guy, but like. 

Erik: I got a funny story to tell you. 

Matt: All right, go ahead. Because 

Erik: I, I asked Devvin this very same thing I said, 'cause I love mowing the lawn on a hot Texas summer day. Mowing the lawn. 

Matt: Yes, I remember you doing that in your sweats. 

Erik: Thirsty sweat like crazy. 

Matt: See me and you are, everybody thought I was crazy on the hot. I loved working out in the bay when it was 105.

Erik: Me too.

Matt: They're like, you're a psycho. I'm like, no dude. I wanna be dripping in sweat. 

Erik: Me too. Mountain biking. I love it. In the heat. 

Matt: Yes. 

Erik: Most people stay home when it's a hundred and hell. I'm out there 

Matt: on my motorcycle people are like, it's too hot to ride. Like. Well then don't buy a motorcycle. Wimp. You live in Texas. 

Erik: Ah, I'm, I'm with you. Yeah, I'm with you. I don't agree with most of what you say, but I do agree with that.

Fair? No, but I was talking to Devin about this and I said, Devin, there's nothing like a cold Topo Chico, a sparkling water, like right out of the fridge after a hot, you're really hot. 

Matt: Oh, you're such a good human in. Devin goes, uh, yeah, there is. 

Erik: A beer, 

Matt: a cold Michelob Ultra or something. 

Erik: He made such a big deal about how refreshing it was, [00:02:00] and there's part of me that wants to like beer.

Yeah. So I thought, you know what? That's what I'll try. I'm gonna get really hot and I'm gonna go slam a beer. 

Matt: Oh, don't slam. I didn't say slam it. 

Erik: Well, that was the impression I got from him. Okay. So I thought, well, I'm just gonna because I'm super thirsty. Right? 

Matt: Yeah, yeah, yeah. 

Erik: So. Uh, the beer that I had was really high alcohol content is called the velvet Hammer.

Matt: Oh, well you were drinking like, okay. Yeah, 

Erik: yeah. So 

Matt: the velvet hammer. 

Erik: And so I, uh, and I don't normally drink beer at all, right? Yeah, yeah, yeah. So. I came in hot dehydrated probably, and I drank that beer. 

Matt: Did you follow it with a shot of Lagavulin or something? 

Erik: No. No, but I, but I, I, it was not refreshing. Yeah.

It was not refreshing. It only in, in enraged my wife when I came in and said, I'm feeling a little lightheaded here. Uh, anyway, so, uh, 

Matt: no. I like to have it like Corona. My wife and I like Corona. If we're gonna drink a beer like a Corona, that's probably what we would [00:03:00] pick. But yeah, Corona on a hot day, just one, like one.

I'm not talking about. It's, I'd rather have a, that's what a beer tastes best, I guess. 

Erik: Dr. Pepper or a, or a, a cold water or a Topo Chico or, yeah. To me that's refreshing. 

Matt: Well, that's good. Well, yeah, I would, yeah, I don't know. There's something about a beer, 

Erik: there is something about refreshing, about a beer.

Matt: You feel like a man after you've been mowing all day and you're all hot and sweaty and you drink a. Beer. 

Erik: I did not feel like a man that day. Day 

Matt: makes you feel like a man. 

Erik: That velvet hammer did not feel like a man. 

Matt: Well, I don't know if you'd feel like a man drinking a velvet hammer that just, 

Erik: well, you know, actually there's another, uh, I had, uh, broken my arm teaching my son how to skateboard.

Matt: I remember this story 

Erik: and the fire department brought me a bunch of funny gifts. 

Matt: I know. 

Erik: And my colleagues in the ER set me up. With the, like the, the, um, the, the OBGYN bed and all, and it was kind of a funny thing. 

Matt: Had the stirrups and everything. 

Erik: Yeah, they did. And uh, I got discharged home with some Norcos and I'd never had Norco in my life and I took one of those Norcos and I was [00:04:00] acting so funny 

Matt: mm-hmm.

Erik: That my wife thought maybe it was a head trauma. So she wanted to bring me back, which is kinda what we're talking about today. Are toxidromes. Yes. Whether you've like slammed a velvet hammer when you're mowing the lawn or. Are you taking

Matt: that just sounds weird when you say it like that. Can I tell you my story?

The first, first time I ever took opioid pain medication. 

Erik: Okay. 

Matt: Or narcotic, I should say narcotic pain medication. 

Erik: They are narcotics. 

Matt: They are narcotics. Uh, I had been kicked, uh, in my former life. As you know, I used to train horses. 

Erik: Mm-hmm. 

Matt: And I had got kicked. I was breaking a bunch of colts. Hold on. In a round pen up in Washington State, we had this little stud colt who was kind of a little jerk.

He's being a little jerk as I was trying to. You know, get him ready to get him under saddle. And so I kind of tied him up just like, okay, you're gonna go think about it. Calm down a little bit. Like you're just a little too riled up. And so like, sometimes you gotta either work 'em and I'd worked him for a while just to kind of get some of that energy out, tire 'em out, and then I was gonna go tie him up.

Well I went to go time up and then I came over to like, um, they call it sacking a horse [00:05:00] out where like you'll take a, a pad uhhuh and you just kind of flop it on 'em. Yeah. And it desensitizes 'em to having something on their back. Yeah. They call 'em sacking 'em out. Sure. So I was walking up to him with this pad and you just kind of flop it on it.

It doesn't hurt him, you're not hurting him. But as I walked up, he saw that pad and he freaked out, and both hind legs kicked at me. 

Erik: Oh, 

Matt: no. And thank God if I would've been a step closer, he would've hit me dead center in my chest. And I mean, he fired. Really hurt you. Oh. He fired hard, both hind legs. He full on kick.

And so as he goes to kick, I just kind of went like this and put my hands up and he hit this thumb and crushed this thumb. 

Erik: Broke it. 

Matt: Oh yeah. Yeah. So I am about 10 miles away from where I lived at the time. 

Erik: Yeah. 

Matt: And I had a 1993 Chevy single cab, four wheel drive, stick shift pickup truck. 

Erik: Awesome. 

Matt: And now I'm like, so I'm kind of sitting there and it's kind of bloody.

And I know, I'm like, oh, he broke my like. My thumbs broke. Like I just knew. Yeah. 

Erik: Yeah. 

Matt: And so I drive back anyway, I won't get into the story anyway, my thumbs broke. I [00:06:00] go home and I got a, a, a prescription for Vicodin. 

Erik: Yeah. 

Matt: And I get home, but the pharmacy was closed by the time we got outta the emergency room.

It was like two in the morning. We get home, I wake up at like five, six in the morning and my thumb is killing. 

Erik: I bet it is. Yeah. 

Matt: Throbbing killing me. But the pharmacy's not open yet, so my wife can't go get the pain meds yet. So I go over to my boss and I'm like, dude. I am dying. Like, do you have anything?

And he gives me like, I think he gave me like a thousand milligrams of like Advil. He's like, here take a bunch of Advil. So I pop these Advil. Well, then an hour later the pharmacy opens up. Donna goes, gets me the Vicodin, come back. And I have never taken narcotics ever in my life. And I don't remember how many I took, but I took like two bite.

Oh no. Oh yeah. Oh no. I mean, I didn't take like go crazy, but I took like 

Erik: we're talking about toxidromes today. 

Matt: Yes. I took, 

Erik: are you breathing? 

Matt: I took the max dose. Donna came in, my wife came in like an hour later and I am drooling on the couch. Oh yeah. I am so gorked outta my [00:07:00] mind. 

Erik: Mm-hmm. 

Matt: But I, my arm didn't hurt anymore.

Erik: Oh, that's good. 

Matt: So those pain meds do have their place. 

Erik: You know, it's funny, I think one of the best anti-theft devices you could purchase on a vehicle is a manual transmission. 

Matt: Oh, a hundred percent. Nowadays, for sure. 

Erik: If you have, why three? You, you might leave the keys in the ignition. Nobody's gonna steal it because nobody knows how to drive it.

Matt: Yes. And the person that would steal it or would know how to drive it wouldn't steal it. 

Erik: That's exactly right. 

Matt: Yeah, exactly. Yeah. Why are there three pedals? Yeah. 

Erik: Well, we're gonna talk about Toxidromes today and we kind of hit on it a little bit, but a, a toxidrome is a recognizable pattern of signs and symptoms.

Produced by a class of toxins. So there's certain class of toxins that will, will present a certain way, and we're gonna talk about each of those classes today. 

Matt: Yeah. Constellations, that was the word. 

Erik: Constellation of symptoms. 

Matt: Yes. That's, that's, that was the word I saw. I was like, I've never toxidromes in EMS or.

Constellation. I can't talk const constellations. I was like, isn't that stars? 

Erik: That, that's good. [00:08:00] 

Matt: That is stars. Yeah. I was like, that's an interesting way to put it. Anyway. 

Erik: Well, certain it's a constellation of symptoms, right? That just like a constellation of stars will look like a certain picture. Like the big Dipper.

Right. Which is actually a bear. 

Matt: Yep. 

Erik: Or maybe it's the sisters or the ple, which is the Big Dipper is actually a bear one. Yeah. The Ursa major. Ursa means bear and, and, uh, Greek. 

Matt: But the Big Dipper looks like a, 

Erik: the little 

Matt: big ladle. 

Erik: It does look like a spoon. Yeah. But apparently it's a bear. 

Matt: Really? Okay. Well we won't get off on that topic.

Erik: Big bear, little bear big. 

Matt: Well, I knew there was a big bear and little bear, but anyway, 

Erik: or some major or some minor. 

Matt: We're, we're getting crazy here. 

Erik: Well, anyway, but my point though is, uh, is that, um, the, the, these toxidromes these categories of drugs or toxins that we could be exposed to, right. We'll all look very similar to each other.

Right? So the first one we'll practice with, um, is something very familiar to you. 

Matt: Probably the most common one. 

Erik: Yeah. 

Matt: Yeah. 

Erik: Um, is the opiates 

Matt: Yes. 

Erik: And so an opiate overdose, uh, example of an opiate would be like, like Vicodin. 

Matt: Yep. 

Erik: Norco, 

Matt: Norco, 

Erik: [00:09:00] morphine, heroin, fentanyl, carfentanyl, 

Matt: carfentanyl. Yep. 

Erik: Uh, these opiates will have a certain tox syndrome associated with them.

So you'll see a patient that's got pinpoint pupils. 

Matt: Mm-hmm. 

Erik: Uh, is maybe decreased respiratory, decreased. Right, because it's going to, because you, you put up. Too many opiates on those mu receptors in the brain that shuts your spinal, uh, the, uh, brainstem down. Right? And the pons and the medulla, which control your breathing reflex Yeah.

Uh, are now suppressed and blocked. And so you stop breathing. Yeah. And so to treat these folks, we need Narcan potentially. Mm-hmm. We gotta bag 'em back up. You know, a lot of folks don't realize this, but, uh, giving, slamming some Narcan, Narcan, 

Matt: Narcan, 

Erik: Narcan on someone who's really hypoxic and not breathing really low respiratory rate, not a real good idea.

Be better to bag 'em up first a hundred 

Matt: percent, 

Erik: and then give them the Narcan 

Matt: and carf, fentanyl. And we talked about this in our opioid lecture. That car fentanyl is so potent, oh, 15, 10,000 times stronger than morphine. 

Erik: That's right. 

Matt: So, and we've talked about this with our crew, is that you might not carry enough Narcan [00:10:00] on your truck to overtake that car.

Fentanyl. 

Erik: That's right. 

Matt: So it's better that if you go bag 'em, ventilate 'em. 

Erik: Yep. 

Matt: Tube 'em if you have to. Right. Obviously follow your local protocols. But yeah, with this new car, fentanyl that's out on the street, if you go on somebody pinpoint pupils, zero respirations or very low respirations. Yep. You know, be bagging.

Maybe push. You know, a half a milligram of Narcan. A milligram of Narcan. Yeah. I would go two milligrams of Narcan. And if you're not seeing a lot of improvement in their respiratory effort, either, like you say, continue to bag throwing NPAs, OPAs or maybe consider just innovating the patient. Yep. Because they're gonna need time, uh, for that to get outta their system.

Erik: Yep. That's exactly right. Supporting the respiratory drive is the key management component and concept to an opiate toxidrome. 

Matt: And remember, we're not at least most. Agencies. Most situations we are not giving the Narcan to try to get the person to wake up. 

Erik: Mm-hmm. 

Matt: We are just giving it to, uh, improve their respiratory drive.

That's what we're doing. 

Erik: That's correct. 

Matt: [00:11:00] Yeah. If they wake up, uh, on side of that, that's fine, but that's not the intent. 

Erik: No. 

Matt: Right. So if somebody's breathing fine. And even if they tell you that, you know, I took some fentanyl or I took some heroin or whatever. Okay, well if they're breathing fine and they're talking to you mm-hmm.

They don't need Narcan. 

Erik: That's right. 

Matt: Right. They don't need it. 

Erik: Mm-hmm. 

Matt: So anyway, most protocols are only giving it in that. 

Erik: Yes. And that, uh, and that Right. Follow your protocols. Right. But that's why we do the Narcan if we need it. Um, but bagging them is really the standard of care, 

Matt: control that airway, 

Erik: because they've lost the reflex to breathe.

Sometimes we may need to step in and, and breathe for them. 

Matt: That's right. 

Erik: Um. So that's, that's the, just an example of a common toxidrome. A deadly one actually. A lot of people are dying because of an opioid epidemic. So kind of an important one to talk about. 

Matt: Probably the biggest one. 

Erik: Yeah. A real common one.

Matt: And probably the most one, the most common one we're gonna run across pre-hospitally for sure. 

Erik: Uh, but I would say though that it may not be as deadly as some of the ones we're gonna talk about today, but they're not as common. 

Matt: More common, but less deadly. 

Erik: That's right. Exactly. So, and easily treated. Yes. Um, so, [00:12:00] which makes it sad that so many people are dying from it, right?

Yes. Um, so the, uh, buprenorphine, uh, the Narcan availability from even the nasal 

Matt: Oh yeah. The 

Erik: Narcan 

Matt: cops are carrying it. Everybody's got it. I got it in my truck. 

Erik: Yeah. 

Matt: We were doing a class and a lady came in because her son died from an overdose. Ugh. And so now she got this free, she everywhere she goes, she carries around these Narcan free Narcan, and she's like, if you want some, take it.

And so I grabbed two. I thought, well, heck, it can't hurt to have it in my truck. You never know. 

Erik: You never know. 

Matt: You know, you could run into somebody having an issue and mm-hmm. But there are four milligrams, which is interesting. 

Erik: Yeah. 

Matt: Those in nasal inhale, they're four milligrams, which obviously you're giving it nasal.

It's good. Yeah. Which an IV one, you're giving about half a milligram. So the dosing's way different. 

Erik: It's different. Yeah. 

Matt: Yeah. 

Erik: So, um. We're gonna move into another class of toxidromes, actually. 

Matt: Okay. 

Erik: Um, that are related to our autonomic nervous system. It's really our autonomic nervous system that's going to build the constellation of symptoms that's gonna help us to identify these toxidromes.

Mm-hmm. So let's talk [00:13:00] a little bit about the autonomic nervous system first. Okay. Um, so there are two types. You know, we talked about the manual transmission earlier. 

Matt: Mm-hmm. 

Erik: I dunno if I told you this. I love racing cars. Have I told you my racing car stories or I

Matt: think you have told, well, I don't know stories.

I know you've told me about just 

Erik: be a driver for the Baja 1000. Yes. We, we had a race vehicle Yes. That we'd race and then, um, went to, uh, 

Matt: which I would totally do that. Why don't we ever do those cool things? 

Erik: Fun? 

Matt: Why do we get tased and IO ourselves and shoot each other with paintballs and do hot chip challenges?

Well, 

Erik: these vehicles cost millions and 

Matt: well, I mean, it doesn't 

Erik: cost much to get tased because we're 

Matt: any, anybody out there that has millions of dollars and would like to sponsor man Erik to go drive a race car. I, I am a good size for a Formula One driver. I'm a smaller framed guy, so lightweight, move faster.

Erik: Well, I love racing. Uh, it's something, it's one of those things that I wish I would've had more time to do. 

Matt: And money. 

Erik: Yeah. And money. Uh, I had the opportunity to go to a, a race car driving school. 

Matt: Yeah, that's what you told me. You told me about that 

Erik: with Michael Andretti and a bunch of [00:14:00] famous world famous like Lamont's drivers.

And anyway, um, and I was one of the few people that wasn't, most of the people in this room about a hundred guys, um, were professional drivers of some kind. Mm-hmm. A lot of folks in NASCAR truck series carting. Uh, and I remember 

Matt: carting. 

Erik: Carting. Yeah. What's carting? Oh, go-kart. It's like, oh, progression Go-karts.

Yeah. Cart. 

Matt: Okay, got it. 

Erik: And, uh, I pulled up in my Honda Civic at the time. 

Matt: Heck yeah. 

Erik: This was years ago. And I 

Matt: stick shift. 

Erik: Uh, yeah. Uh, a Honda Civic and I pulled up next to a guy in a Ferrari Enzo 

Matt: Okay. 

Erik: With a Nomex gloves and booties and suit and everything. And here I am in my board shorts and a t-shirt and flip flops 

Matt: Sup, bro.

Erik: Yeah. So anyway, I was excited. It was fun 'cause I, I just had always just loved racing. 

Matt: Yeah. 

Erik: Yeah. And uh, and, uh, this was actually my very first taste of racing. 

Matt: Okay. 

Erik: Um, but I'll never forget it though. I, um, all 100 of us ended up cycling through different. Kind of, 

Matt: uh, didn't you beat [00:15:00] them all? 

Erik: I did. I did 

Matt: You have the fastest time?

Erik: Yeah, 

Matt: I was gonna say I'm not, 

Erik: uh, and I got up to accept the award on the, the podium at the end of this event. And he said You played football. Didn't. Well, actually, first he assumed I was a driver and I said, no, no, I'm not. Actually, I came here in my Honda Civic. I, he goes, you played football, didn't you?

Matt: Well, look at you. 

Erik: And I did. I played football in college. Yeah. And I think that he's seen it before, uh, and, uh, is that sometimes some athletes 

Matt: mm-hmm. 

Erik: Are more aggressive mm-hmm. With driving. Mm-hmm. And, uh. Uh, I did it again, niche Spartanburg with another event, won that one too. So I, I love driving. I wish I could do it more, but the autonomic nervous system is a lot like a race car, 

Matt: right.

Erik: When you push that accelerator, that's the sympathetic nervous system. It's that fight or flight response where everything gets ramped up. Mm-hmm. And prepared to run or to fight. 

Matt: Yep. 

Erik: Whereas when you have the parasympathetic nervous system, it's like the brake pedal. 

Matt: That's right. 

Erik: It's like you're slowing down to take that corner.

Matt: Right. 

Erik: Hit that apex just right. Yeah. Anyway, so the, so you got the two [00:16:00] systems. Mm-hmm. The fight or flight mm-hmm. The gas pedal or the feed and breed, the brake pedal. 

Matt: Mm-hmm. 

Erik: The green light versus the red light. Mm-hmm. So by understanding the autonomic nervous system, you can identify some toxidromes that hit those receptors of the autonomic nervous system.

So for example, like, uh, there are beta receptors on the heart. That's why we give people beta blockers for blood pressure, as you know. Um. Hm. So, um, the, the sympathetic nervous system has beta and alpha receptors. 

Matt: Mm-hmm. 

Erik: And so when you bathe the body in something sympathetic, like, uh, norepinephrine, epinephrine, adrenaline, cocaine, methamphetamines, um, you'll have a sympathic mimetic syndrome, a sympathetic nervous system syndrome, basically.

Right, right. The fight or flight. 

Matt: Right. 

Erik: Right. Now, if a Wolverine walked in here and you and I had to. Protect our kids. 

Matt: Yeah. 

Erik: You, you and I are gonna be fully bathed in the sympathetic neurotransmitters 

Matt: pouring in. 

Erik: Right? Yeah. So 

Matt: adrenaline, 

Erik: when that [00:17:00] happens, describe our bodies when we, when the norepinephrine, the adrenaline is there to protect our kiddos.

Matt: Yeah. 

Erik: In a room with a wild animal. 

Matt: Yeah. 

Erik: You and I aren't gonna be thinking about our safety. 

Matt: Pupils are dilated. Respiratory rate has dramatically increased. Exactly. Increased oxygenation to the blood, to the muscles, heart rate, increase, blood flow. All of the things, like you said, is getting ready to fight and defend.

Yes. 

Erik: Isn't it amazing? 

Matt: Oh, it's totally 

Erik: the way the body's designed. All of those body systems with those beta receptors are gonna get turned on and ramped up. 

Matt: Yeah. Hearing even improved hearing, yes. Everything, all your senses are amplified senses are 

Erik: peripheral visions more sensitive. Your reaction time goes down.

Everything is gonna benefit you in a fight or a flight, 

Matt: which is why when people are under the influence of things. They cause accidents because all of those senses are dulled. 

Erik: Yes. 

Matt: Because they're parasympathetic, sys, it's they've taken alcohol, which is a depressant. 

Erik: Exactly. 

Matt: And so their reaction times are slower on things.

Erik: That's exactly it, and that's what I want. Our students to see is by understanding this autonomic [00:18:00] nervous system, you'll be able to identify some toxidromes and, and it'll help to explain some of the other toxidromes, which we're gonna talk about today. Yeah. So if, if somebody were to take cocaine mm-hmm. Which is like the fight or flight kind of narcotic, 

Matt: get fuel of Yeah.

Erik: Yeah. Methamphetamines. Yeah. Uh, it's going to simulate in some ways the adrenaline. Uh, and some of the other things. Right? Um, so, uh, cocaine, let's just use cocaine as an example. Um, what do the pupils do? 

Matt: Are we gonna actually use cocaine, or is Oh, you're just talking about it? Yeah. Hold 

Erik: on a second. 

Matt: We're gonna snort a line of cocaine.

This is gonna be one heck of a podcast. Get ready folks. 

Erik: Just wait till we get to the alcohol section in the heroin section. 

Matt: Do you wanna do the upper first or the downer first? 

Erik: Oh gosh, I think I would start, well, you know, I would 

Matt: start with 

Erik: it. I don't, if we started with the downer, we may not live like.

To get to the uppers, 

Matt: be snoring. Somebody called 911. 

Erik: Yeah. 

Matt: All right. 

Erik: So cocaine. So anyway, so cocaine. Sorry, 

Matt: I diverted 

Erik: this. You snort a line of cocaine. Are you okay or you? You, 

Matt: although I've had a friend, I personally have never done cocaine, but I had a friend that did and he [00:19:00] said when he did cocaine, he said he literally could like.

Bench press a truck. 

Erik: Mm. 

Matt: Like he could go just, he, you, I, I don't know, know if that's everybody's experience, but he said you just feel invincible, just like superpower. 

Erik: Well, I'm glad you mentioned that. 'cause I was actually gonna talk about this. Is that, sorry, I'm gonna fa No, this I'll just fast forward.

It's just for a moment is, um, a woman, uh, was, um, her kid was somehow trapped in a car. And this woman was actually able to lift the car in a way where she got her kiddo out. 

Matt: Crazy mom strength. 

Erik: Yeah. Yeah. So when you have the cocaine or when you, when your sympathetic nervous system is fully engaged, your, your muscles are at full capacity, full strength.

You, you're not normally at full capacity all the time. Right. But when you get ramped up with, with, um, with a, with a sympathametic, uh, you, you're going to have great strength. And that's part of the reason why actually why PCP. Folks are in full strength. They're ramped up as part of that. We're not gonna get into PCP today, but, 

Matt: right.

Erik: Anyway, my point is, you take cocaine, [00:20:00] it's gonna hit your beta receptors. So on your eyes, you're gonna have dilated pupils. 

Matt: Right. 

Erik: Um, you're going to have a increased heart rate. 

Matt: Right. 

Erik: Vasoconstriction. 

Matt: Right. 

Erik: You're gonna, you're gonna have, uh, um, uh, anyway, all the, I'm sorry, vasodilation. 

Matt: I was gonna say, 

Erik: I flipped them around.

Matt: It's okay. 

Erik: Uh, the alpha receptors. Mm-hmm. So, um. Anyway. Uh, and then we also have the, uh, um, GI motility's gonna go down. Mm-hmm. Because when you're in the middle of a fight trying to protect your kids or something, yeah. You don't. Wanna be having to shunt blood to the, or a 

Matt: cheeseburger, 

Erik: the large intestine.

Right. 

Matt: You need your blood and your muscles. 

Erik: And that's part of the reason why when you're stressed out and you have a lot of these catecholamines in your body and you eat, you'll get indigestion. Yeah. Uh, because your body, because you're stressed out, is turned off the GI system. So you get that sore stomach and, uh, poured, you know, like.

Just the GI isn't function well. Mm-hmm. Because it's kind of turned off. 

Matt: Yeah. 

Erik: But that's typically what a, uh, the toxidrome would look like for somebody who's taking cocaine or methamphetamines. They're gonna be tachycardic, they're gonna [00:21:00] have dilated pupils, they're gonna be, um, sweating. They're gonna, all these things are gonna be happening.

Yeah. And they. It's gonna be an identifiable source where you can ask, have you been doing cocaine? Have you been doing methamphetamines? Or do they have a history of that? Right? Yeah. You can kind of put things together. Management for these folks. Sometimes they can be pretty agitated and crazy. Um, you take enough of 'em, you can even go into bad heart rhythms.

So EKG may be important or, uh, but a benzo. Uh, benzodiazepine can really calm these people down. Beta blockers can help too, depending upon your protocols. Um, but, uh, because obviously if you're hitting the beta receptors, a beta blocker can help to minimize some of the, the effects. So that's the sympathomimetic.

Syndrome. Now there's another one. Um, it's an anticholinergic syndrome. 

Matt: Well, you didn't talk about parasympathetic. 

Erik: Uh, well, I am going to Oh, you're gonna do that later. 

Matt: Oh, okay. I thought we were going to 

Erik: order Well, no, we could, let's do, let's do that. I like it. We're on podcast. We can do whatever the heck we want.

We 

Matt: do whatever we want. 

Erik: So. 

Matt: So 

Erik: we have 

Matt: [00:22:00] parasympathetic or 

Erik: we sympathetic. Let's do that. It's cholinergic. So the sym, the parasympathetic syndrome or what we say cholinergic. 'cause it's acetylcholine, uh, cholinergic syndrome. Uh, let's talk about that. So if somebody was exposed to a bunch of organophosphates or insecticides mm-hmm.

Uh, um, there's also, or atropine, there's certain types of syndromes or meds that, that will hit the parasympathetics. Mm-hmm. Uh, what will those patients look like? Kind of the opposite actually. Totally. Yeah. 

Matt: Said yes. 

Erik: What will the pupils look like in somebody with a, a parasympathetic or cholinergic syndrome?

Matt: Yeah, they're gonna be very constricted. 

Erik: Constricted. 

Matt: Just like your opioid guys. 

Erik: Right? Um, 

Matt: they're gonna be probably altered, maybe that's right. Maybe not. Totally conscious. 

Erik: Yep. Bradycardic, 

Matt: bradycardic. Respiratory rate's gonna be down. 

Erik: That's right. So all these things are, are, and, uh, um, with the Cholinergic syndrome too, you're gonna, you're gonna have a lot of, uh, um, diarrhea, potentially.

Mm-hmm. Um, you're gonna be, uh, the, a lot of saliva. Yeah. Uh, the tear ducts. I mean, you're [00:23:00] gonna basically be leaking fluids out of every hole. Yeah. Sludge. That's right. Yeah. So that's the cholinergic syndrome. So the GI system's ramped up. It's going crazy. Uh, the, um, your bladder, for example, this is actually an assessment question, but the bladder.

When you're fighting, do you wanna need to take a leak when you're in the middle of a fight? Hold on a second. 

Matt: I mean, it might stop the fight. 

Erik: Let you pee on him. I had, I played football with a guy that would pee on himself to make himself smell bad. And it, it was weird. It was weird. But he, that's being 

Matt: dedicated to your craft.

Erik: I know, I know. It was weird. I 

Matt: would better football than wrestling. 

Erik: Yeah, that's true. A good point. Uh, but anyway, so, um, but your bladder will relax. 

Matt: Yeah. 

Erik: Yeah. When you're in the sympathetics, so you don't have to pee, right. Your bladder relaxes. You don't feel the urge to pee. Yeah. Whereas with parasympathetics, you're gonna get the urge to pee your, your bladder's gonna constrict.

Right. And then, uh, so that's part of the whole, uh, uh, cholinergic syndrome. Mm-hmm. The parasympathetic syndrome. Mm-hmm. Now, [00:24:00] anticholinergic would be. Anti parasympathetic, which would equal sym sympathetic. Sympathetic. So it'd be very similar. Um, the, the anticholinergic would be very similar to the. Colon or the sympathetic?

Sympathetic, yeah. 

Matt: Sympa 

Erik: mimetics, right? So you're basically shutting down parasympathetics. You have unopposed sympathetics. And so these, these drugs, um, are going to create that anticholinergic syndrome. Uh, Benadryls a good example of this, uh, diphenhydramine. And so you overdose on that. You're gonna have a patient who's tachycardic, uh, dilated pupils, um, hypertensive.

Mm-hmm. Um, but one of the things about these is they're mad as a mad, as a 

Matt: mad as a 

Erik: hater, hot as a hair, mad as a hatter. Uh, dry as a bone. Uh, there's a whole acronym, acronym for that we go through in our lecture. 

Matt: Yeah, 

Erik: you should watch it if you want to get into more detail there. But, uh, these folks aren't gonna be sweaty.

They're gonna be dry. 

Matt: Right. Um, 

Erik: which 

Matt: is how you can tell the difference. 

Erik: Correct. [00:25:00] And they're gonna be altered. Right. It is typically not what you'd see with somebody who does cocaine. 

Matt: Cocaine, yeah. They're not altered, they're just 

Erik: Right. 

Matt: Hyped up and maybe agitated. 

Erik: Um, oh, you know, one thing we should go back to cholinergic real quick.

One of the, one of the management priorities for this, one of the most important things is if you're on with somebody who'd been exposed to some sort of a nerve agent or insecticide mm-hmm. Or organophosphate. Mm-hmm. You can get it too. 

Matt: Yeah. Safety. 

Erik: So wear your PPE and protect yourself if you think this could be one of those toxidromes.

Correct. So another reason why it's important to identify them. 

Matt: Yes. 

Erik: Now it's a HAZMAT issue. 

Matt: Yes. 

Erik: So be careful there. So, um, so you can see how the autonomic nervous system understanding that, can really help you to identify some of these toxidromes. And I think that's a big part of, of, um. This OME lectures.

Mm-hmm. It's like teaching somebody how to fish versus giving 'em a fish. Right, right, right. It's like you could, you could identify a bunch of diseases. 

Matt: Yes. Makes a lot of sense. 

Erik: Yeah. 

Matt: So [00:26:00] anticholinergics. 

Erik: Yep. Uh, anticholinergic, uh, would be like cocaine or sympathomimetic syndrome, but dry and then the cholinergic.

Yeah, the cholinergic would be wet everywhere. 

Matt: Yes. 

Erik: Literally. 

Matt: Yeah. Literally everywhere. 

Erik: Uh, and then be careful on protecting yourself with PPE. 

Matt: Mm-hmm. 

Erik: Now we're gonna get into some weird ones. Uh, another common overdose, um, which we'll just cover real quick. You, you know, unfortunately today there's a lot of people who overdose on medications and attempt for self-harm.

Matt: Mm-hmm. 

Erik: Um, the first one we're gonna talk about, I'll, I'll start to describe it and you tell me when you think you know what it is. 

Matt: Okay. So, 

Erik: um, um, and again, like most of these things, the diagnosis isn't hard. Mm-hmm. It's, it's knowing what to do sometimes or being patient and keeping your eyes open. So we got a patient who, uh, mom calls 911 because of, uh, self-harm.

Mm-hmm. 

And you get there. You got this 13-year-old, uh, boy. Uh, with mom, he'd been making threats to overdose and, uh, his kiddo's totally normal, [00:27:00] you know. Um, and, uh, maybe, maybe, uh, 12 hours later you get called back again because he's yellow. He's got abdominal pain in the right upper quadrant. He'd been overdosing on something that hurts the liver, which is a common thing to overdose on.

Uh, what is the medication that hits the liver? Common overdose medication. You know what that one is? 

Matt: Aspirin. 

Erik: Aspirin can do it. Tylenol, ty, acetaminophen. Yep. Uh, and then another common one, uh, that, uh, people, Benadryl is another common one, but in this case, 

Matt: I've never been on a Benadryl overdose. An intentional Benadryl overdose.

Really? You say that's 

Erik: common? That's that's when you'll get the, uh, anticholinergic. 

Matt: Yeah, yeah, yeah. But I'm saying I've never, I've been on several, uh, aspirin overdoses. 

Erik: I feel like it's like I've seen it all. I mean, especially working where I worked at a psych facility. 

Matt: Do you remember that, that patient I brought you?

Uh, 

Erik: which 

Matt: one? That was a Tylenol, uh, Tylenol overdose? 

Erik: No. 

Matt: That, uh, you and one of our colleagues that works here as well. 

Erik: Yeah, yeah. 

Matt: No. 

Erik: Oh, 

Matt: the other one, Uhhuh. Okay. The, the in intubated, [00:28:00] it was his first time he intubated. 

Erik: Oh yeah, that's 

Matt: right. And that kid, he was totally. 

Erik: Yeah. Gorked out. 

Matt: Yep. 

Erik: Yep. 

Matt: Wouldn't respond anyway.

That was a Tylenol overdose. 

Erik: Well, that's it. Okay. So Tylenol overdoses initially are normal. Um, you've really dependent upon, uh, like we talked about with some of our other lectures, like cardiac lectures. Mm-hmm. Like you need parents' history, right. This is the same thing. 'cause a lot of folks who wanna really kill themselves, you won't tell you.

Yeah. And there's no sign to look for 

Matt: Right. 

Erik: Other than maybe an empty pill bottle in their pocket or something like that. Right. But, uh, but folks who overdose on Tylenol initially will have no symptoms. 

Matt: Yeah. 

Erik: But later on. We will see symptoms. Yes. Abdominal pain, jaundice or yellow skin. 

Matt: Oh, horrible boy.

Way to die, by the way. 

Erik: It is. So when you overdose on Tylenol, you're creating a toxin that that pickles your liver. Mm-hmm. So that's a, a toxidrome. That's a delayed toxidrome. That's really important to identify and see. And that's why it's so important to get these people to the ER mm-hmm. Before they become symptomatic.

Matt: Yes. So 

Erik: they can, to get the neck. 

Matt: Yeah. 

Erik: Yeah. Um, another [00:29:00] common one, uh, that's overdosed, um, we already talked about Benadryl, um, is, um, uh, antidepressants. 

Matt: Mm-hmm. 

Erik: So antidepressants are, they basically suppress the re-uptake of serotonin. 

Matt: SSRI. 

Erik: That's right. SSRI. So, um, if you gimme a fist here. Alright, so I am the nerve coming from the brain connected here, like two extension cords linked up.

Matt: Mm-hmm. 

Erik: And then this nerve maybe goes to wherever in the body. Right? Right. Uh, this, this is called the synapse. 

Matt: Mm-hmm. 

Erik: If you're listening to this, our fists are together like two extension cords plugged in. Let's 

Matt: go like this side. So it's 

Erik: same 

Matt: side there. 

Erik: And, uh, you have. This is called a synapse. 

Matt: Yep. 

Erik: And to communicate between the two nerves, we use neurotransmitters.

Matt: Mm-hmm. 

Erik: One of the common ones in the brain is serotonin. Mm-hmm. So the serotonin is leaving the pre-synaptic side, my side. Mm-hmm. And then it's gonna enter or hit. Receptors on your side to continue the message. 

Matt: Mm-hmm. 

Erik: I have these things [00:30:00] that will help to re-uptake my serotonin so I can use it again.

Matt: Mm-hmm. 

Erik: SSRIs are selective serotonin re-uptake inhibitors. Right. If I inhibit the re-uptake, serotonin levels go up. 

Matt: Yeah. 

Erik: So if I overdose on an SSRI, my serotonin levels are gonna go through the roof. 

Matt: Yep. 

Erik: Too much. Serotonin can be really deadly and you get a serotonin syndrome 

Matt: Right. 

Erik: Which is gonna look a lot like a cocaine overdose.

But this is really weird though, when you have an altered patient that looks like, and you're trying to figure out is this anticholinergic or is this, um, you know, sympathomimetic is this cocaine? Is this, yeah. Is this Benadryl? Or, you know, trying to figure it out. You get a good history. Right. If, if they overdosed on an antidepressant, it's probably an SSRI.

Mm-hmm. There are other types too that can. Ramp up your serotonin. Right. Um, but you're going to get this weird rhythmic shaking, uh, of [00:31:00] the, of the, the hands of the feet. 

Mm-hmm. 

Or you move the foot up and it just starts uncontrollably moving around. Mm-hmm. That, that rhythmic shaking of an extremity can be a sign of a serotonin syndrome.

It's a weird reflexive thing that, that they'll do. So on physical exam, if you notice some rhythmic shaking, they're hypertensive and febrile. Tachycardic, altered, dilated pupils, all that stuff happening. It's not always, um, cocaine. It's not always. Some of the other things we talked about, serotonin syndrome would be super deadly.

We, and a lot of it's supportive care. A lot of it is just keeping the fluids in and, and supporting them. These patients may need to go to the ICU for a period of time because this is deadly. 

Matt: Yes. 

Erik: Um, and this typically happens like when, when your patient has a history of starting an SSRI, they can actually get a serotonin syndrome without overdosing 

Matt: unintentionally.

Yeah. 

Erik: Right? 

Matt: Right. 

Erik: But when somebody is taking an [00:32:00] SSRI and then decides to overdose for self-harm, um, you can go into this serotonin syndrome with that weird rhythmic shaking of the Yeah. The hands of the feet and that. Might be your only sign really. And this is a commonly missed syndrome that could be really deadly.

Mm-hmm. And identifying it, uh, the treatment and the management, um, is really, really important. Yeah. And it's, there's another one which I don't want to get into too much, but there's another common medication, uh, called um, uh, neuroleptic Malignant syndrome. 

Matt: Yep. 

Erik: Which is the antipsychotics. So you have this patient that overdosed on their, um, antipsychotic medication.

Um, they will have a similar syndrome too. 

Matt: Mm-hmm. 

Erik: Um, but instead of happening like over one to two days, like a serotonin syndrome, this NMS syndrome happens over like one to two weeks. 

Matt: Right. It's prolonged. 

Erik: Yep. Yeah. And so it's the patient that started a couple weeks ago on a new antipsychotic and [00:33:00] now they've got all those symptoms.

But in this case, instead of the beating hands and feet, they have what's called lead pipe rigidity. Lead, like they're extremities, like a lead pipe. It just doesn't 

Matt: lead pipe. Rigidity 

Erik: will not move, and that's something when you see an overdose syndrome. With that arm and leg or whatever that that will not move.

It's, it's really rigid. Mm-hmm. Then you might want to think about this another, we don't, nothing specific is supportive care. Give 'em IV fluids, get 'em to the right facility. They may need ICU care. Um, but those are those, some of those weird toxidromes. 

Matt: Yeah. 

Erik: We don't need to spend a lot of time on those, but that's an interesting 

Matt: mm-hmm.

Erik: Interesting. toxidrome, it's 

Matt: interesting. 

Erik: Now, you mentioned this earlier, there's another weird toxidrome we need to get an EKG on. 

Matt: Mm-hmm. 

Erik: Uh, the TCAs. 

Matt: That's right. 

Erik: Less common though today. 

Matt: Yeah. They used to be prescribed more often and I think they've kind of backed off. Yeah. Amitriptyline is the one I've seen the most.

Um, 

Erik: still around though. And there are other medications that are TCA, you know, that [00:34:00] create that wide complex tachycardia. 

Matt: That's right. Tricyclics. Yep. Yep. That's, 

Erik: and the cool thing about this toxidrome is that we can treat it. 

Matt: Oh 

Erik: yeah. We can give them the bicarb, 

Matt: give them That's right. 

Erik: And that helps, uh, alkalinize the, the blood and, and, uh, it can help to, to treat these folks.

Matt: That's right. Don't be worried about the bicarb either. It's relatively staged medication, especially in this, but I mean, yeah, like the ones that I've had, usually you find the bottle. Yeah. And you can read it and be like, oh, okay, this is pretty obvious. This is a TCA overdose. You know? 

Erik: Yeah. 

Matt: But yeah, get him on that.

Or get them on that monitor and you'll have that wide complex. 

Erik: Yep. 

Matt: Tachycardia. It won't look like V-tach. It'll be wider. 

Erik: Yep. 

Matt: Uh, it'd be pretty obvious. And if you don't know, like. The bicarb, I mean, obviously the history, right? 

Erik: Yeah. 

Matt: But yeah, 

Erik: it's accessible. It's easy. It's, it's, uh, it, I mean, to the wrong patient, it could be hurtful.

Sure. It's like a, for a dialysis patient, bicarb is like, oh, yeah. Like drinking a bag of potato chips, lot a, uh, potential volume overload with all that sodium. 

Matt: Right. 

Erik: Um, but, [00:35:00] um, but that's a, a common. Uh, kind of a, a classic, I should say, not common, but classic presentation mm-hmm. For a wide complex tachycardia with an overdose TCA given bicarb.

Matt: Yep. 

Erik: Um, and then, uh, I think, uh, one of the, the other ones that just mentioned briefly, um, is, uh, and is again, uh, a different sort of a toxidrome, but something that we commonly see, especially in these winter months. Right now it's cold here, right? Mm-hmm. At the beginning of the winter, you turn the heater on in your house and then you get this history of.

A bunch of family members with headache and dizziness. Uh, even abdominal pain can happen. 

Matt: Yep. 

Erik: Uh, but the carbon monoxide toxidrome carbon mono carbon monoxide syndrome. 

Matt: Yep. 

Erik: And, uh, do you, do you guys measure carboxy hemoglobin? Mm-hmm. You, you have that capability 

Matt: can on my rainbow? The rainbow, uh, attachments on the monitors 

Erik: can.

Oh, okay. Cool. Mm-hmm. I don't know that we do in our, our, our place, but 

Matt: I bet you do. But if they have the rainbow sets on 

Erik: it, 

Matt: yeah. 

Erik: [00:36:00] So the, uh, the O2 sats will be normal in these folks? 

Matt: Yes. 

Erik: Um. No, I know you know this, but maybe some of our listeners don't. But when you do a, a pulse ox, it's, you're not looking at the hemoglobin 

Matt: No.

You're looking at Go ahead. 

Erik: The plasma. Yeah. You're just looking at the plasma and the plasma's full of oxygen 

Matt: and it's the saturation of it. 

Erik: That's right. 

Matt: You're not looking at oxygen. 

Erik: No, 

Matt: that's right. It could be in 200 times. Uh, yeah. Greater affinity. 

Erik: Yep. That's right. And the problem, actually, we kind of talked about this with fever.

Um, when you, when you have a fever, you change the dissociation curve, so you actually offload more oxygen to the tissues, which is really helpful when you're sick. Yeah. And, uh, carbon monoxide's the reverse. 

Matt: Yes. 

Erik: It holds on tightly, so it's not offloading anything. So you're starving your tissues. Yes. 'cause of the affinity that carbon monoxide has with hemoglobin.

Yeah. It's really interesting. So the treatment for, um, well we talked about the presentation. Multiple family members, maybe the beginning of the winter time or 

Matt: Yep. 

Erik: Could be. Maybe they were using the barbecue inside 

Matt: overdose, or, I'm [00:37:00] sorry, attempted suicide. 

Erik: Attempted suicide, that's right. 

Matt: Yep. In a car. Yep.

So 

Erik: what's the management for these people, 

Matt: cyano kits? Well, first off, you get 'em out of the environment. 

Erik: Get 'em outta the environment. 

Matt: Right. Number one, you, first off, you keep yourself safe. Yeah. Make sure you have a breathing apparatus on or something, but you get 'em out. The other one is a structure fire.

Erik: That's right. 

Matt: So, but uh, yeah, get 'em out of the environment, right? Mm-hmm. Get 'em to fresh air. Um, yep. And then get your IVs. If you carry a cyano kit, 

Erik: Uhhuh, 

Matt: uh, you know, you could start doing that. Yeah. And then you're gonna take 'em to a facility probably that has a hyperbaric chamber. 

Erik: That's right. 

Matt: That's 

Erik: exactly right.

Matt: You're gonna want to do that. Yeah. You 

Erik: can do some high flow oxygen and, 

Matt: right. Yes, 

Erik: of course. In the, in route or whatever. You're right. Ultimately, they, they may need, depending upon how high their levels are, 

Matt: right? 

Erik: High carboxyhemoglobin levels are gonna require some pretty invasive care. Yes. Maybe hyperbaric oxygen or whatever, but it's, it's, it can be deadly.

Matt: Oh yeah. 

Erik: In fact, I think they said, I can't remember the. The, the mnemonic, but it's, um, the, the people who die of, of, uh, carbon [00:38:00] monoxide poisoning are just bright, bright red. 

Matt: Yeah. 

Erik: Yeah. 

Matt: There is a famous story of a guy, he was a captain. He was one of the most famous captain that worked on rescue one, uh, in, uh, New York, Manhattan, FDNY.

Very famous captain. He came down to my department one time, taught us a extrication class. But like, you know, everybody thinks when they kind of think of firemen, they think of a guy like you, six foot plus, 200 pounds of muscle, blah, blah, all that stuff, right? And this guy. He's like five eight. Five nine, a hundred eighty pounds just looks like everybody's dead.

Yeah. But this guy's one of the most well-respected captains ever on Rescue one. Awesome. I mean, this guy was the guy. He was the man. Right? Well, a famous story is they were in some tunnel rescue or something, and he had to crawl like five, 600 feet into this tunnel. Yeah. And he became overcome with carbon monoxide and became unconscious in this tunnel.

And they had to drag him out. 

Erik: Oh gosh. 

Matt: Yeah. FI five. We're [00:39:00] talking 500 PE feet below GR great. Yeah, 

Erik: yeah, yeah. 

Matt: He had to be drug out. Well, this was back, I don't remember the show, but there used to be a show where they would follow around the FDNY and whatever, and, uh. It was like a month later, he's back on the truck running calls and all, they're on this other phone and all these guys are coming up to him.

They're like, Hey, Jimmy, how you doing? You know, I heard about you. He's like, eh, yeah. It was nothing. You're like, yeah. He almost died. Almost died. He almost became, he became so toxic that he was unconscious and had to be drug five feet. He's like, yeah, it's no big deal. It's fine. Spend a little time in the hyperbaric chamber.

I'm good. I'm back to work. It's like, oh my God. Wow. Yeah. Famous, famous story, but yeah. Uh, and definitely a threat for us as pharma. Mm-hmm. Again, that's the importance of wearing your breathing apparatus. 

Erik: Yeah. Keeping yourself safe, just like those organo phosphates or the, the cholinergics potentially could, cause you could become a patient right next to them 

Matt: for sure.

Erik: If you're not wearing your PPE. 

Matt: Yes, yes, yes. I remember going on a, a CO alarm call, uh, because most, you know, obviously of, with all the alarms and [00:40:00] the prevention systems. You know, if you have gas in your house, you probably have a CO alarm somewhere, right? 

Erik: Yeah. 

Matt: And so we had gone, a lot of times we'll get called, people come back from vacation and their CO alarm's going off.

Erik: Yeah, 

Matt: right. So while they've been gone for a week, you know, they left a burner on, or it wasn't, you know, whatever. And yeah, we walked into the house and we had little meters that we've walked into the house. And I mean, the second we broke the threshold of that house, that monitor starts screaming, go, whoa, get out, get out.

Uhhuh. There's nobody in the house. They had come home and, um. But yeah, that one, that thing. So we immediately had to put on all of our stuff and go in to find where's this thing leaking at Uhhuh. But uh, yeah, the bright cherry red skin. 

Erik: Mm-hmm. For sure. Yeah. 

Matt: The rainbow. Uh, again, the rainbow. Sometimes they have a different monitor.

Mm-hmm. Uh, SpO2 probe specifically is the RAD 57. Oh, okay. That we used to use. But most of the life packs or the monitors nowadays, if you swap out the cords, 

Erik: yeah. 

Matt: They'll be able to measure co. Oh, okay. Um, so yeah, you should be able to measure that. 

Erik: You know, a couple other stories, uh, [00:41:00] of overdoses. We didn't talk about these.

toxidromes in a, uh, as an overdose on antifreeze is another common one people will do to, to hurt themselves. And that the interesting one there to catch that, you know, obviously the patient's not responsive. It can't help you figure out what they did. 

Matt: Yes, I 

Erik: remember there 

Matt: was a 

Erik: key blue light. Oh, or like black light on the urine.

It'll glow. 

Matt: Oh, okay. 

Erik: The way that, 

Matt: yeah. 'cause antifreeze close. Yeah. Yeah. And then there's also the, the way of, you know, if you wanna slowly kill somebody, put eyedrops in their drinks over time. 

Erik: Eyedrops. 

Matt: Yeah. You slowly put eyedrops. There's been numerous people eye 

Erik: drops. Like what? 

Matt: I'm trying to remember.

What's the ca? It's the chemical and eye drops. But if you over, if you take a massive amount of it and it's antifreeze, same thing with antifreeze too. Oh, they'll, they'll try to slowly kill their. Loved ones by putting, kind of 

Erik: reminds me of the movie of Sixth Sense. Remember that there's one of the, the parents was.

Making their kiddos sick. Munchausen syndrome. Munchausen by proxy. 

Matt: Yeah, in, in the sixth thens. Yeah. I don't remember that part. 

Erik: Yeah, I think it was [00:42:00] that. Maybe it 

Matt: probably was. I just don't 

Erik: remember. Anyway. Yeah. But the WAS syndrome, you can identify some of these things. One of the coolest ones I caught actually was a woman who is.

Diagnosed with breast cancer. She was living in a commune somewhere out in the stick somewhere. And she was the pilot for the community. 

Matt: The pilot. 

Erik: Pilot, the pilot. That was kind of an interesting story. But anyway, they, where 

Matt: was it? Like what 

Erik: area? I didn't ask a lot of specifics, but I'm assuming they must have like an airs strip or something out there.

And this commune anyway. Okay. She'd been diagnosed with cancer recently, uh, breast cancer. And so she had, uh, was doing some sort of a thing with, with, uh, apricot pits. Eating apricot pits is the treatment for her breast cancer because it's, uh, uh, apricot pits are really high in cyanide. 

Matt: Mm. 

Erik: And it's a, it's a poison, obviously, right?

But at low levels. By taking a certain amount of apricot pits, you can either cyanide, uh, the. The thought was is it would kill the cancer cells. I'm not saying this is the right treatment at all, but I'm just saying this is what she was doing. Right. And we didn't know that though. We [00:43:00] got this unresponsive patient that were called out to this community brought into the hospital where I was working and um, we were trying to figure out what the heck was going on.

Matt: Yeah. 

Erik: And finally I got this history of the apricot pits, and I realized what it was, the syndrome that we were looking at, which was kind of, it just looked like this patient just no matter what we did, the patient just kept getting worse. 

Matt: Mm-hmm. 

Erik: Pressors didn't help, nothing was helping with this patient.

Well, what was happening is, what cyanide does is it just strangles every cell. It basically uncouples or it basically destroys your mitochondria. Mm-hmm. Or it makes them useless. And the powerhouse of the cell. Those mitochondria are absolutely essential for all your 37 trillion cells to be able to use fuel to make energy.

So you can do stuff. Well, every cell was basically inoperable. 

Matt: Right. 

Erik: Or getting to the place of being totally inoperable, uh, where no matter what we did because the cells couldn't do anything. Yeah. It didn't matter. And when we figured out what [00:44:00] was going on with the cyanide. We finally, we could, we could fix it.

And we went to the ICU and what we got the history later, she had actually increased her dose, um, thinking more so how, how many was she 

Matt: eating a day? 

Erik: Well, 

Matt: curious. 

Erik: I, I don't, I don't know where she got it, but it was, I think a, it was 

Matt: a, yeah. Where do you get that many apricot pits? 

Erik: Well, she wasn't actually eating the apricot pits.

You can purchase the apricot pit powder or whatever, and you put it in a drink. 

Matt: Oh. 

Erik: I don't know specifically really. I don't know how she was getting it. Got it. But it is a common treatment using apricot pits, uh, because of the cyanide levels. There are some, there are other pits too, that have this. We actually talked about some of this in our, um, poisons.

Mm-hmm. Lecture we did, we injected ourselves with Botox, remember? Mm-hmm. Mm-hmm. Um, anyway, um, but we, um. But she was taking, uh, these, uh, apricot pits and it was basically cyanide poisoning. 

Matt: Yeah. Yeah. 

Erik: Another toxidrome. Mm-hmm. [00:45:00] You can see it. Once you see it. It's like, oh, okay. That's interesting. I, we're not gonna teach that today, but, 

Matt: right.

Pretty rare. 

Erik: Pretty rare. Yeah. I think the common ones, like we go, just to review kinda what we talked about today. We talked about opiates, opioids, so if I said. Pinpoint pupils and, and, uh, decreased, decreased decreas respiratory drive. What's your management? Well, BVM and maybe Narcan, right? Yeah. What if I told you we had a patient with dilated pupils in tachycardic?

Okay. Well there's a lot of things that can be, need more information. Need more information. Exactly. So, um, that's cool that, that we can see that, right? Okay. We need to dig deeper. Is this cocaine? 

Matt: Yeah. 

Erik: Or is this an anticholinergic? Is this Benadryl overdose or, or is it a serotonin syndrome? 

Matt: Right? 

Erik: Oh, maybe it's an antipsychotic.

Maybe it's the neuro neuroleptic malignant syndrome. Uh, if you remember that, kudos to you. It won't be in your assessment, and we just kind of mentioned that, but, but those are, those are important things. And it's all built on that autonomic nervous system that we talked about. Two parts, [00:46:00] right? 

Matt: Yep.

Sympathetic, 

Erik: parasympathetic. Yeah. So, um, and then the fight or flight versus the feed and breed, 

Matt: right? So if they're peeing a lot. They're leaking a lot and they're sleepy. 

Erik: Yeah. And they're bradycardic. 

Matt: And they're bradycardic. Everything's slowed down and they're super relaxed. 

Erik: Parasympathetic.

Matt: Parasympathetic. 

Erik: Or colon. 

Matt: Yeah, exactly. Exactly. If they're amped up, you need to ask more questions to figure out, 

Erik: and if they're. Hot as a hare, mad as a hatter. Dry as a bone. Dang it. I wish I could remember all of 'em. But, uh, that's the, an, that's the, the, uh, anticholinergic syndrome. 

Matt: Let's see if we can find 

Erik: it.

And I think there's a, there's an acronym for it, which I think, um, well, I can't remember. Oh, no, not that, but that's, that's the, uh, anticholinergic, it's gonna look a lot like a cocaine overdose. Uh, but it's certainly not cocaine. It's just you're shutting down your. Parasympathetics. 

Matt: Yes. I'm looking it up to see 

Erik: Too much sympathetics.

Matt: There we go. [00:47:00] Here it is. Red as a beet. Dry as a bone. Blind as a bat. Mad as a hatter, hot as a hare, full as a flask and the bow and bladder lose their tone. And the heart runs alone. 

Erik: Interesting. I did not know all of that. 

Matt: The most common anticholinergic, mnemonic describes toxicity as those, yeah. Or boats. Uh, 

Erik: boats.

Matt: Yeah. 

Erik: What is the 

Matt: boats? Oh, those are the meds. 

Erik: Oh, the meds, okay. 

Matt: Yeah, yeah, yeah, yeah. Okay. And then while a CB anticholinergic burden and tool measure kit, 

Erik: what's the, what's the o in boats? 

Matt: Oxy Buttin. 

Erik: Oxy Buttin, okay, cool. Yeah. Okay. And then, 

Matt: yeah, benzo, Tripp. Benzatropine, Uhhuh, Oxy Butin, atropine and 

Erik: Scopolamine.

Okay. Yeah. The Scopolamine patch. The 

Matt: scopolamine patch used to put those on all the time as a, yeah. As a pre-op er or uh, uh, rn. Yep. Uhhuh. Yep. Oh, that's 

Erik: good. 

Matt: Oh, good topic. Yeah, very. Um, obviously the opioids is probably the most common one. [00:48:00] Pre-hospital that we've run on. We talk a lot about anticholinergic was our atropine and stuff like that.

Erik: Yeah. 

Matt: Um, but, uh, those are probably the two, you know, I've never, like, I've been on several people on cocaine. Yeah. Um, and never had an issue that the most violent patients were the K two ones. 

Erik: Yeah. 

Matt: Stuff like that. When they were taking all that synthetic stuff, those, those guys were super violent. 

Erik: I've had a few, actually, just recently I had a patient that came in in SVT.

Matt: Mm-hmm. 

Erik: And, um, no, I'm sorry, they went into AFib. AFib with RVR, young kid. Mm-hmm. The guy's in his twenties. 

Matt: Mm-hmm. 

Erik: And he'd been doing cocaine for almost 10 years. And, uh, he shared that with me and 

Matt: Good lord, 

Erik: young kid too, 

Matt: apparently. 

Erik: Yeah. 

Matt: Started young. 

Erik: Um, and, uh, that it's just, uh, when you combine cocaine and alcohol, it's a terrible cardiotoxin.

And you're really, I mean, that he may have only been 28 or 29, but um, his heart was probably 60 or 70. 

Matt: Did I if I said the name Len Bias to you? No, 

Erik: no, no. 

Matt: You're a sports guy. 

Erik: Yeah. Where is it? 

Matt: Len [00:49:00] Bias. You remember this? 

Erik: You have to teach 

Matt: me. Boston Celtics. Rookie. They drafted him. 

Erik: Uhhuh. 

Matt: He, I think he was like this.

We're talking like 1990 maybe. 

Erik: Oh, okay. 

Matt: Yeah, he was, I want to say he was maybe the number one draft pick for the Boston Celtics. 

Erik: Yeah. 

Matt: And, uh, I wanna say it was like the night or the week that he got drafted. He was out at a party Uhhuh, allegedly. He had never done cocaine before. Did one line of cocaine and dropped dead.

Erik: Oh, that's terrible. 

Matt: Yeah. That's tragic. I'll never forget that story. I don't know why that name sticks in my head, but that's why I was like this professional athlete, as healthy as he was, took one hit of cocaine and dropped. I mean, who knows What else? Was going on, but 

Erik: No, that's, it's interesting you mention that because, um, the, uh, we were talking about some cardiac stuff earlier today.

Mm-hmm. 

Matt: Mm-hmm. 

Erik: And some of these congenital heart abnormalities don't show up until you really stress the heart in some way. Yeah. Whether you're super dehydrated or hit up some cocaine or something like that, or methamphetamines. Yeah. It's, it's the, these, these drugs that we're talking about today are very, very powerful.

Matt: Yes. Yep. Not good [00:50:00] stuff. 

Erik: You know, one thing we forgot to mention, which I'll just say briefly. I'm sorry, I forgot to mention this. Um, well, for those watching or listening, our typical guide to help us through this was not working, so we're doing this straight off of just our memory. 

Matt: Oh yeah. 

Erik: Which is not normal.

Matt: Yeah. 

Erik: Um, but we did forget one what? Uh, sedative syndrome. The sedative hypnotic syndrome. 

Matt: Oh yeah. 

Erik: So overdose on benzos. 

Matt: Mm-hmm. 

Erik: Overdose, which would actually, it's, it's hitting the same receptor as alcohol. 

Matt: Mm-hmm. 

Erik: So somebody who overdoses on, on Ativan or or Xanax is gonna look very similar to somebody who's drunk.

Matt: Right. 

Erik: Slurred speech, altered mental status. Uh, these, these patients, uh, there's not a lot you can do. It's really supportive care, 

Matt: right? 

Erik: There are some reversal agents you can use and you gotta be careful. We wouldn't carry these things. I was 

gonna 

Matt: say most of 'em are gonna be 

Erik: in the hospital. Yeah, in the hospital.

Uh, but it's actually fallen out of favor to even use 'em. But you can use 'em to reverse these. These, uh, benzodiazepines, but, but [00:51:00] alcoholics, or excuse me, an intoxicated patient will look very similar to somebody who's overdosed on benzos. It actually hits the same receptor in the brain. Uh, but this is another relatively common toxidrome that we can see.

Mm-hmm. Is those altered patients. Uh, you're gonna have a lot of ataxia or they have, um, trouble coordinating their movements. Yep. But no alcohol. You might want to go think Xanax or Ativan or something like that. Uh, these are very common. Um, overdoses that we need to be able to manage. And the concern for these, of course, is same thing with an alcoholic, same thing with, uh, an intoxicated patient or a benzo or a hip, uh, sedative.

Overdose is airway. 

Matt: Yeah. 

Erik: Yeah. 

Matt: Vomit and aspirate. 

Erik: That's right. You, you're so altered. You can't control your airway. I've had to intubate intoxicated patients with really high alcohol levels. Mm-hmm. I've had to intubate Xanax overdoses just temporarily, just to be able to protect their airway. 

Matt: Mm-hmm. 

Erik: So that's, that's another important overdose 

Matt: Yeah.

Erik: To discuss. 

Matt: That's good. 

Erik: I think we hit 'em all. Carbon monoxide, [00:52:00] uh, is one, uh, common with a bunch of group of family members on the winter morning. Mm-hmm. Uh, and then, uh, the, uh, what was the other one we discussed that we, oh, Tylenol. Um, initially normal, get a good history. 

Matt: Yep. 

Erik: Because you may be coming back with a, a very, very sick patient.

Matt: Yellow pain, abdominal pain. Yep. 

Erik: Yep. The toxidromes really important. These can be lifesaving and we can do a lot for these patients in the prehospital environment. Mm-hmm. Which is good. Good to identify 'em. And the cool thing about learning the autonomic nervous system is it helps you with so many other things.

Matt: That's right. 

Erik: Because it's one of those common processes in the body that, uh, we can identify. And that that autonomic nervous system is what compensates for other disease processes too, right? Yeah. So, 

Matt: yeah. Interesting. 

Erik: A good thing to learn. So 

Matt: well see you on the next one. 

Erik: Be safe out there.

Narrator: Thank you for listening to EMS, the Erik and Matt Show.