FLASHBACK – Influenza Case Study

As flu season hits hard, you should remember what it is exactly we are supposed to do for flu patients, and how to protect yourself.

Here, this post from December of 2010 should help…

The Scenario

The day drags on after that first cup of coffee, and seemingly slows down after the second. Waking up is always a hard thing to do, especially when you don’t have that period to ease into your day.

Which is why you’re grumbling at the at the MDT screen on your way to a very early call, the first of your shift, and you haven’t even had a chance to see what destruction lay behind the doors of the box, inflicted by a very tired but well meaning off-going shift. You scan the screen for a glint of additional information beyond the “twenty six alpha one” you read in the code box.

A “26A1”, you know, is a standard sick call, a non-emergency response to what has been prioritized as non-emergency. Sometimes the dispatchers get it wrong (either because they don’t ask all the questions or the caller doesn’t give much help, you usually decide which on the scene), but it is fairly accurate MOST of the time.

The ambulance rounds another corner in the quiet neighborhood, the morning dew settled on all the car windows and a slight haze appears on the horizon. The EMT scans the addresses on his side while you scan for numbers on yours. “What’s the numbers again?” he asks.

“2114,” you reply.

“I wish they would put numbers where we could actually read them.”

“2013… your side about a block up.”

The ambulance drifts to the left side of the street and the scanning begins again. After a few minutes, a young African American girl appears out of a front door and begins flailing her arms in the air. “We see you, we see you, you don’t need to be crazy,” the driver comments and the ambulance pulls to a stop just past the incline into the driveway.

“Unit fifteen, on the scene.”

“Check unit fifteen, zero six thirty eight,” the dispatcher replies. Must looking to be a long morning for her, too.

You roll out of the cab with your radio, sliding the clip into your pocket so it hangs on your leg and jerk the handle to the ALS compartment and produce a blue trauma bag. Pulling on some gloves, you walk up to the door and slowly pull it open. Not a person in sight.

“Fire department!” you yell as you cautiously make your way into the front room. Your radio comes crackles as the dispatcher calls out unit twenty three, also in your battalion, to make a call on the other side of your territory, this time for a cardiac arrest. You sigh. This is going to be a long day.

A voice calls out from a hallway to your right. “Back here! It’s my daughter, she just throwed up and been runnin’ out for hours.”

Your partner shoots you one of those “you have gotta be kidding me” looks, to which you shrug in reply.

You find your patient, a seventeen year old girl, slumped over a toilet. She is dry heaving and getting up only that white foamy stuff that comes out when you have nothing left to vomit up.

“When did this start?” you ask, usually your first line question, behind “what’s going on?” or “what made you call for an ambulance?”

“‘Bout three this mornin’. She throwed up early and whenever she tries to drank somethin’ she throwed it up too.”

The differential list runs through your mind, and the work begins to narrow down the causes to a select few, but based on the presentation, the list is short.

“And she’s had diarrhea as well?” The pale looking girl nods in the affirmative, and you place the back of your ungloved wrist on her forehead, then begin a more focused assessment. You seat the girl on the toilet, as you reach into the bag and produce a thermometer while your partner pulls out your blood pressure cuff and stethoscope. The thermometer goes into her mouth, while you count the pulse rate.

“One thirty four over eighty six, heart rate sounds rapid” your partner reports. You scribble this down on a piece of paper when the thermometer starts beeping at you.

“One zero three point six” you say as you scribble it down in addition to the patient’s name, age, social security number, birthday, and phone number.

The heart rate is counted around 130. Lung sounds are clear with a dry cough, and the patients reports minor abdominal discomfort, a combination of nausea and muscle soreness, and rates it at a 5 out of a 10 pain scale.

“Have you been having chills, headache, or muscle aches or cramps?” you question.

“Yes, all of those.” the girl answers.

“Sounds like you have the flu, have you taken any over the counter medication? Like Tylenol or ibuprofen.”

“No, just started last night,” mother replies.

“Would you like to go to the hospital?”

Discussion

Influenza is a nasty virus, and can be contracted from a number of sources, typically through inhalation of droplets from the cough or sneeze of an infected person, this is known as droplet exposure. It can be very resilient and the only thing that can be done is let it run it’s course.

Influenza belongs to a set of RNA viruses family Orthomyxoviridae. Unlike cells, the virus does not have DNA, and it relies on host cells to replicate it’s RNA strand, and it does so in a very ruthless way, here’s how it works:

  1. A viron (virus RNA) binds to sailic acid on the surface of a host cell through hemagglutinin (the virus causes blood proteins to bind with it). This is typically done to the epithelial cells of the nose, throat, and lungs.
  2. The blood cells are removed from the virus by a protease (breaks down proteins) and is allowed to enter the cell through endocytosis (allows the cell to absorb molecules)
  3. The RNA chain of the virus enters the nucleus of the cell and “rewrites” the instructions that the nucleus provides to the cell.
  4. The cell begins producing viral proteins, some of which are secreted to the cell surface, and others are returned to the nucleus to assemble a viron. The viron leaves the cell through bulge of proteins on the cell surface.
  5. Once the viron is released, the cell dies.

So that you know how it works, how does this apply in the pre-hospital?

The most common symptoms of the disease are chills, fever, sore throat, muscle pains, severe headache, coughing, weakness and general discomfort. If you suspect the flu, you should ask these questions, but they may not all be present at once, so a good recent medical history is an important part of a correct diagnosis. Pay attention to duration of onset for fever and length of fever, if the fever has only been noticed within a few hours, it is generally not dangerous. When it has been allowed to continue unchecked for several days, or has been increasing, it is a medical emergency. May produce nausea and vomiting, as well as diarrhea, most often EMS clinicians are presented with these complaints, but you should not rule out other causes such as food poisoning or other acute abdominal conditions.

This table illustrates the likelihood of influenza infection when presented with common complaints:

Symptom:                    sensitivity        specificity

Fever                                      68-86%                  25-73%

Cough                                     84-98%                   7-29%

Nasal congestion               68–91%                 19–41%

Source: Call S, Vollenweider M, Hornung C, Simel D, McKinney W (2005). “Does this patient have influenza?”. JAMA 293 (8): 987–97

I gotta feva, and the only prescription is… well, available “OTC”

Fevers are a natural inflammatory response to infection, and can cause thermoregulatory problems including shivering as hypothermia is perceived by the brain and it begins active rewarming as well as making the patient feel the need to “bundle up.”

Hyperpyrexia is defined as an oral or axillary temperature greater than 104 or a rectal temperature greater than 106 and can cause brain damage, and prolonged fever and resulting dehydration is dangerous, resulting in cellular damage. This will literally “cook” the brain. If you have ever hardboiled an egg and just left the heat on high and let the water boil away, yeah, same effect. Patients that have had an unchecked fever for days and are hyperpyrexic may require active cooling using ice packs depending on medical control, aggressive airway management, and lots of IV fluids as they will be extremely dehydrated.

Patients presenting with flu symptoms rarely require transport, unless it has progressed to where the patient is neurologically or hemodynamically unstable.

Advise patients with flu symptoms to:

  • Stay at home
  • Get plenty of rest
  • Drink a lot of liquids (electrolyte solutions of water and sports drinks)
  • Do not smoke or drink alcohol
  • Consider over-the-counter medications to relieve flu symptoms (not ASPIRIN)
  • Consult a physician early on for best possible treatment
  • Remain alert for emergency warning signs

Warning signs are symptoms that indicate that the disease is becoming serious and needs immediate medical attention. These include:

  • Difficulty breathing or shortness of breath
  • Pain or pressure in the chest or abdomen
  • Dizziness
  • Confusion
  • Severe or persistent vomiting

Source: http://en.wikipedia.org/wiki/Influenza_treatment

Fluid therapy may be necessary if patient is unable to properly take on liquids or has had a persistent mild fever (100-102 oral) as dehydration caused by this is dangerous. Passive cooling measures (exposing the patient, cold packs or wet cloths) should be used whenever possible during transport of a stable influenza patient. Avoid rapid cooling as this may cause seizures. Consider anti-emetics during transport to suppress nausea and reduce vomiting.

Remember to get your flu shots, and if the patient is vomiting or coughing you should wear a mask to prevent inhalation of those droplets.