Weak and Sick
Angel Clark Burba, MS, EMT-P
Assistant Professor, Program
Coordinator EMS Program
Howard Community College
Howard County, Maryland
The Call
2PM Sunday afternoon
“Sick patient” who is unresponsive per her
husband
Upon Arrival
Very pale, thin 38 y/o woman in bed lying
under a big blanket
Her night clothes are drenched in sweat
Audiable wheezing and coughing weakly
Note onset of a nose bleed with 1-2 ccs
blood collected in both nares
A bright red rash is noted on her body
Treatment Plan?
???
Crew’s Treatment Plan
Infectious disease precautions (HEPA
mask, gown, face shield)
Support ABCs (BVM ventilation, suction)
Vital signs
SAMPLE survey from family
Rapid transport as Priority 1
Obtain IV and ECG en route
SAMPLE Survey
Signs and symptoms
Husband states patient was seen in ED last
evening and not yet diagnosed but strep
throat was suspected
Throat culture and chest x-ray was obtained
Chest x-ray ruled negative by radiologist
Results not yet available for culture
Biaxin (antibiotic) started as a precaution
SAMPLE Survey
Husband states wife in bed since last PM
When he brought her some soup at noon she
appeared to be sleeping
When he came to pick up dishes around 1:30
he noted she had not eaten, she “looked
worse” and was breathing “funny” so he
called 911
SAMPLE Survey
Allergies
Penicillin
Past medical history
Hysterectomy in 1978
Last meal / oral intake
Orange juice in AM
Events
As stated
Vital Signs
HR: 116, irregular, thready at wrist
RR: 32, labored, frothy, some blood noted
in sputum Lungs: wheezes and rhonchi
BP: 68/42
Pulse ox: 86% on BVM with 100% oxygen
ECG: sinus tachycardia with PVCs
Otic temperature: 104.6 F
Physical Examination
HEENT
Note increased bleeding from nares
Pupils: sluggish but reactive
Note increased bleeding from mouth
Chest / abdomen
Abdomen noted to be slightly distended
Lungs sound increasingly congested
Physical Examination
Extremities
Note bleeding coming from IV site in R
antecubital
Requires direct pressure and pressure point
to control and continues to ooze after that
IV DC’d in attempt to control bleeding
Patient Deteriorates
Increased frequency of PVC’s noted
Patient intubated
Difficult due to copious bloody secretions
Unit arrives at hospital and patient is
rushed into treatment area
ED Treatment
Unable to stabilize patient
Unable to obtain IV
Patient continues to deteriorate:
ventricular tachycardia to ventricular
fibrillation then asystole
What Happened???
Take a couple minutes to discuss what
you think might have happened to this
patient
Additional Information
Autopsy results:
Death due to severe
anticoagulation
Throat culture results:
+ for group A
Streptococcus pyogenes
How These Toxins Work
Toxins: specific chemical products that
are posionous to other organisms
Toxigenicity: the power to produce toxins
Exotoxin: unbound toxin molecule
secreted by a living bacteria cell into
infected tissues
Endotoxin: substance is released upon
damage or lysis of the bacteria
What Precipitated This?
Pathogenic bacteria, protozoa, fungi, and
worms secrete exoenzymes that can
break down or damage tissues
Affect mucous membranes, digest keratin,
collagen, or important acids or substances in
the body
What Precipitated This?
Some enzymes react with blood
components
Coagulase: produced by staphylococci
causes clotting of blood or plasma
Bacterial kinases: dissolve fibrin clots and
expedite the invasion of damaged tissue
Examples: streptokinase and staphylokinase
How These Toxins Work
Several enzymes for digesting
macromolecules are given off by group A
streptococci
Streptokinase (thrombolytic effects)
Activates a pathway leading to the digestion
of fibrin clots (fibrinolytic substance)
It is produced commercially and use in AMI
patients to lyse (break up) blood clots
How These Toxins Work
Strep infections are
common in childhood
Usually they do not
cause any problems
The bacteria is present
all the time
How These Toxins Work
“Flesh eating bacteria” hysteria of early
1990s
Necrotizing fasciitis (deadness of connective
tissue sheath around muscles and organs)
Some of group A strep are very toxic
Enzymes digest connective tissue
Toxins poison epidermis and dermis
Open pathways for deeper infection
Antibiotic Therapy
Clarithromycin (Biaxin) is a microlide
antibiotic and is related to erythromycin
It kills certain bacteria or stops their growth
It treats respiratory (nose, throat and lung)
and skin infections
It will not work on viruses, colds or the flu
Antibiotic Therapy
Side effects of clarithromycin:
severe or watery diarrhea
skin rash, itching
nausea and vomiting
headache
stomach pain or cramps
What About Mary?
Human beings are the only significant
reservoir for S. pyrogenes
Infection is transmitted through direct
contact, droplets, food, or fomites
Bacteria invade during periods of lowered
host resistance through skin and pharynx
What About Mary?
The medical examiner ruled that in her
weakened state her immune system was
unable to combat the infection despite the
use of the appropriate antibiotic (Biaxin)