PTSD

Post-Traumatic Stress Disorder:

Post-Traumatic Stress Disorder Everything you ever wanted to know…and more.

PTSD:

PTSD Pile PTSD

Post-Traumatic Stress Disorder:

Post-Traumatic Stress Disorder PTSD is an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat. (National Institute of Mental Health- www.nimh.nih.gov

Who Suffers from PTSD?:

Who Suffers from PTSD? War veterans Firefighters, EMTs, police officers Survivors of physical or sexual assault Survivors of abuse Victims of serious accidents, disasters Family members or loved ones of someone who has experienced one of the above The sudden, unexpected death of a loved one can also cause PTSD.

Why does PTSD concern us?:

Why does PTSD concern us? As care provider: Increasing numbers of military personnel returning to civilian life. As potential sufferers: We routinely face the types of stressors that can cause PTSD. Co-workers: Recognize the symptoms in co-workers. Many work with returning service members.

Stressors:

Stressors The threat to one’s life and safety General sense of loss Friends (to death) Life changing injury Separation from family Income Inner Conflict Physical wear and tear Sexual harassment and assault

Symptoms of PTSD:

Symptoms of PTSD Reliving the trauma (Intrusive Recollection) Flashbacks Bad dreams Frightening thoughts

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Symptoms of avoidance and numbing Feeling emotionally numb Feeling strong guilt, depression, or worry Losing interest in activities that were enjoyable in the past Having trouble remembering the dangerous event Staying away from places, events, or objects that are reminders of the experience

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Increased Emotional Arousal Being easily startled Feeling tense or “on edge” Having difficulty sleeping, and/or having angry outbursts

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Biological Changes Central and autonomic NS functional changes Mental health issues (depression) High occurrence of substance abuse Memory or cognition problems Physical health issues

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Pediatric Symptoms Bedwetting, when they’d learned how to use the toilet before Forgetting how or being unable to talk Acting out the scary event during playtime Being unusually clingy with a parent or other adult

Diagnosis of PTSD:

Diagnosis of PTSD At least one re-experiencing symptom At least three avoidance symptoms At least two hyperarousal symptoms Symptoms that make it hard to go about daily life, go to school or work, be with friends, and take care of important tasks. Above symptoms for at least one month

Risk Factors:

Risk Factors Living through dangerous events and traumas Having a history of mental illness Getting hurt Seeing people hurt or killed Feeling horror, helplessness, or extreme fear Having little or no social support after the event Dealing with extra stress after the event, such as loss of a loved one, pain and injury, or loss of a job or home.

Resilience Factors:

Resilience Factors Seeking out support from other people, such as friends and family Finding a support group after a traumatic event Feeling good about one’s own actions in the face of danger Having a coping strategy, or a way of getting through the bad event and learning from it Being able to act and respond effectively despite feeling fear.

Treatments:

Treatments Psychotherapy Medications Both

Medications:

Medications Antidepressants which may help control PTSD symptoms such as sadness, worry, anger, and feeling numb inside. Taking these medications may make it easier to go through psychotherapy. Selective serotonin reuptake inhibitors Prozac Paxil Zoloft

Psychotherapy:

Psychotherapy “Talk Therapy”: talking with a mental health professional, one-on-one or in groups. CBT: Cognitive-Behavioral Therapy Exposure therapy. Helps people face and control their fear in a safe way through mental imagery, writing, or visits to the place where the event happened. Cognitive restructuring. This therapy helps people make sense of the bad memories. Sometimes people remember the event differently than how it happened. They may feel guilt or shame about what is not their fault. The therapist helps people with PTSD look at what happened in a realistic way. Stress inoculation training. This therapy tries to reduce PTSD symptoms by teaching a person how to reduce anxiety. Like cognitive restructuring, this treatment helps people look at their memories in a healthy way.

CBT:

CBT Katie Couric CBT

Post-Traumatic Stress Debriefing:

Post-Traumatic Stress Debriefing A debriefing session usually with a group of exposed individuals and a facilitator Usually administered within days of a traumatic event Three to four hours "talk about feelings and reactions to the critical incident" The debriefing facilitator aims "to reduce the incidence, duration, and severity of, or impairment from, traumatic stress" ( Everly and Mitchell, 1999).

Post-Traumatic Stress Debriefing:

Post-Traumatic Stress Debriefing Some new data suggests it is ineffective After conducting a meta-analysis of randomized, controlled trials (RCTs) on debriefing, Rose et al. (2001) concluded, “There is no current evidence that ... psychological debriefing is a useful treatment for the prevention of post traumatic stress disorder after traumatic incidents. Compulsory debriefing of victims of trauma should cease. Another meta-analysis revealed that individuals exposed to Mitchell's version of debriefing failed to experience symptomatic relief, whereas individuals who were not exposed to CISD did show improvement “(van Emmerik et al., 2002). Psychiatric Times. Vol. 21 No. 4

Post-Traumatic Stress Debriefing:

Post-Traumatic Stress Debriefing Bisson et al. (1997) randomly assigned hospitalized burn victims to either a debriefing session or to a no-treatment (assessment-only) condition. Burn victims in the treatment condition received a single one-on-one debriefing session that lasted between 30 and 120 minutes At three month and 13 month follow-ups, debriefed groups had a higher incidence of PTSD. Bisson et al. concluded that even if debriefing is merely inert, rather than toxic, "its routine use should be discontinued." Psychiatric Times. Vol. 21 No. 4

Post-Traumatic Stress Debriefing:

Post-Traumatic Stress Debriefing Hobbs et al. (1996) assessed victims of road traffic accidents who had been randomly assigned to either a one-on-one debriefing session or to a no-treatment (assessment-only) condition. Individuals assigned to the debriefing condition received a single one-hour session between 24 and 48 hours after their accidents. Three years later, the debriefed group reported significantly more PTSD symptoms, general psychiatric symptoms and fear of traveling as a passenger in an automobile than did the non-debriefed group ( Mayou et al., 2000). The authors concluded, "Psychological debriefing is ineffective and has adverse long-term effects. It is not an appropriate treatment for trauma victims" ( Mayou et al., 2000). Psychiatric Times. Vol. 21 No. 4

EMS Response:

EMS Response Scene Safety: Many (especially military) are armed due to a heightened perception of a threat. Use PD to secure scene Transport to ER.

DFD Protocol:

DFD Protocol

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Behavioral Emergency and Patient Restraint Definition of a “Behavioral Emergency:” When the patient acts abnormally in a way that is unacceptable or intolerable to the patient, family, or community. Behavioral changes may be due to psychological, emotional, physical, or medical conditions. Psychological causes include depression, mania, paranoia, suicidal, and environmental changes. Physical causes may include excessive heat or cold, lack of oxygen, lack of blood flow to the brain, head injuries, stroke, alcohol or drug abuse, high or low blood sugar, metabolic disorders, and neurologic disease. Continually reassess ABCDEs and intervene as needed .

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EMT-Basic / EMT-Intermediate Make the scene safe. Law enforcement should be used, as needed, to determine scene safety. Never turn your back on the patient. Never leave the patient alone. Encourage the patient to talk. Listen carefully. Be confident. Be respectful. Be calm. Be honest. Explain all movements and procedures. Provide interventions for possible medical causes. Transport to an appropriate facility

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USE OF RESTRAINT: PATIENT RESTRAINT MAY BE USED UNDER THE FOLLOWING CONDITIONS: It is understood that the use of restraint is a "last resort" measure to ensure safe transport. All efforts should be made to avoid this AND must be PROPERLY DOCUMENTED . After patient is physically restrained, use wide leather or cloth restraints to immobilize THE REASONING FOR RESTRAINT, EITHER PHYSICAL OR CHEMICAL, MUST BE SUFFICIENTLY DOCUMENTED ON THE PATIENT CARE REPORT

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USE OF RESTRAINT (cont.) 1 2 3 Patients may ONLY be restrained face up on the cot. The patient MUST be fully conscious and protecting his/her airway with stable vital signs prior to physical restraint. Consult with law enforcement. Law enforcement should perform physical restraint if possible.

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Physical restraints MAY NOT BE USED In situations where the combative behavior of the patient is due to severe trauma, burns, pain, or any life threatening medical condition (i.e. asthma, COPD, anaphylaxis, hypoglycemia, etc.) In such cases the underlying condition resulting in the patient's behavior must be addressed. If interventions to address the underlying condition cannot ensure safe transport, then soft physical restraints may be applied. This must be painstakingly documented.

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EMT-Paramedic Chemical restraint may be used if necessary, especially in the case of drug/illegal substance overdoses. When chemical restraint is necessary or to decrease severe anxiety, agitation, or combativeness only as a last resort: Administer Lorazepam ( Ativan ) – 1-2 mg slow IV, IO, IM or Midazolam ( Versed ) 2-5 mg IV, IO, IM, IN for patients with presumed substance abuse. May repeat x 1 in 15-20 minutes. Administer Haloperidol ( Haldol ) 2-5 mg IM . After administration place the pt on cardiac monitor. Treat Dystonic reaction with Diphenhydramine ( Benadryl ) 25-50 mg IV, IO, IM. Carefully and continually monitor the patient’s ABCDE’s and vitals, most importantly airway adequacy and pulse oximetry.

Any questions?:

Any questions?

References:

References JEMS, March 2011, “Heroes to Hometowns” National Institute of Mental Health, www.nimh.nih.gov American Psychiatric Association, www.psych.org Psychiatric Times, www.psychiatrictimes.com IAFF.org, Reactions to Traumatic Stress