A. Physical condition 1. Ill or in poor physical condition will not tolerate temperature extremes well. B. Age 1. Age extremes do not tolerate temperature changes well. a. Infants cannot shiver. b. Children will not think to—or cannot—put on extra clothing to warm up. c. Medications taken by older people may affect their ability to regulate temperature. d. Poor circulation also will affect this. C. Nutrition and hydration 1. A decrease in either will aggravate hot or cold stress. 2. Alcohol will change the body’s ability to regulate temperature. D. Environmental conditions 1. Weather will have a large impact on your patient’s condition. 2. Evaluate the scene for clues to help with treatment in temperature extremes. a. Closed windows in the summer, lack of air conditioning b. Lowered thermostat in the winter to save money
A. Normal body temperature must be maintained within a very narrow range. B. Cold exposure may cause injury to individual parts of the body or to the body as a whole. C. There are five ways the body can lose heat. 1. Conduction: Direct transfer of heat to a colder object, as when a warm hand touches cold metal or ice or is immersed in cold water 2. Convection: Transfer of heat to circulating air, as when cool air moves across the body 3. Evaporation: Conversion of any liquid to a gas, the natural mechanism by which sweating cools the body 4. Radiation: Transfer of heat by radiant energy, for example when a person stands in a cold room 5. Respiration: Loss of body heat during normal breathing, as warm air in the lungs is exhaled and cooler air is inhaled.
D. Heat loss or gain in the body can be modified in three ways. 1. Increase or decrease in heat production a. Shivering or increase in movement if cold b. Decrease and limit movement when hot 2. Move to an area where heat loss can be decreased or increased. a. Seek shelter from the wind in cold environments. b. Covering the head can minimize heat loss by 70%. c. Seek shade in a hot environment to cool a patient down. 3. Wear insulated clothing, which helps decrease heat loss in several ways. a. Layers of clothing that trap air provide good insulation. b. Also traps perspiration and prevents evaporation c. Loosen or remove clothing to cool down.
E. Hypothermia (“low temperature”) 1. Core temperature of the body falls below 95°F (35°C) a. Body loses the ability to regulate its temperature and to generate body heat. 2. Physiology a. To protect against heat loss, the body constricts blood vessels in the skin, resulting in blue lips and/or fingertips. b. Secondarily, the body shivers to generate heat. c. As these mechanisms are overwhelmed, body functions begin to slow down. d. Eventually, key organs such as the heart begin to slow down. e. This can lead to death. 3. Conditions for hypothermia a. Can develop quickly, as with cold water immersion b. Can develop gradually, as with exposure to the cold environment for several hours c. Air temperature does not have to be below freezing for hypothermia to occur. 4. People at risk a. Homeless people and those whose homes lack heating b. Swimmers, even in summer c. It is more common among geriatric and ill individuals who are less able to adjust to temperature extremes. d. Also common among the very young i. Unable to put on clothes to protect themselves against the cold ii. Infants and children have a relatively large surface area and less body fat. iii. Children may not be able to shiver as effectively as adults. iv. Infants are unable to shiver. e. Patients with injuries or illness
5. Signs and symptoms of hypothermia become progressively more severe as the body’s core temperature falls. a. Four general stages i. No clear distinction between stages ii. Will help to estimate the severity of the problem b. Assess general temperature i. Pull back your glove and place the back of your hand on the patient’s abdomen. ii. If the abdomen feels cool, the patient is likely experiencing a generalized cold emergency. iii. You may carry a hypothermia thermometer, which registers lower body temperatures. iv. Regular thermometers will not register low temperatures. c. Mild hypothermia occurs when the core temperature is between 90° and 95°F (32° and 35°C). i. Patient is usually alert and shivering. ii. Pulse rate and respirations are usually rapid. iii. Skin may appear red, pale, or cyanotic.
d. More severe hypothermia occurs when the core temperature is less than 90°F (32°C): i. Shivering stops. ii. Muscular activity decreases. iii. Fine muscle activity ceases. iv. Eventually, all muscle activity stops. e. As the core drops toward 85°F (29°C): i. Patient becomes lethargic. ii. Usually loses interest in fighting the cold iii. Level of consciousness decreases. iv. Patient may try to undress. v. Poor coordination and memory loss follow, along with reduced or complete loss of sensation to touch. vi. Mood changes occur. vii. Patient shows impaired judgment. viii. Patient becomes less communicative. ix. Experiences joint or muscle stiffness x. Trouble speaking xi. As the muscles eventually become rigid, the patient appears stiff or rigid.
f. If the body temperature continues to fall to 80°F (27°C): i. Vital signs slow. ii. Pulse becomes weaker. iii. Respirations slow to shallow or become absent. iv. Cardiac arrhythmias may occur as the blood pressure decreases or disappears. g. At a core temperature less than 80°F (27°C): i. All cardiorespiratory activity may cease. ii. Pupillary reaction is slow. iii. Patient may appear dead (or be in a coma). h. Never assume that a cold, pulseless patient is dead.
A. All patients who are severely injured are at risk for hypothermia. 1. Remove wet clothing. 2. Prevent conduction heat loss. 3. Insulate all exposed body parts. 4. Prevent convection heat loss. 5. Remove the patient from the cold environment. B. Local cold injuries 1. Most injuries from cold are confined to exposed parts of the body. 2. The extremities (feet, ears, nose, and face) are vulnerable to cold injury. a. If parts of the body are very cold but not frozen, the patient has frostnip, chilblains, or immersion foot (trench foot). b. When parts of the body become frozen, the injury is called frostbite. 3. Assessment a. Find out duration of the exposure. b. Find out the temperature to which the body part was exposed. c. Find out the wind velocity during exposure. d. Patients with hypothermia should also be assessed for frostbite or other local cold injury. 4. Underlying factors a. Exposure to wet conditions b. Inadequate insulation from cold c. Restricted circulation from tight clothing or shoes or circulatory disease d. Fatigue e. Poor nutrition f. Alcohol or drug abuse g. Hypothermia h. Diabetes i. Cardiovascular disease j. Older age 5. Frostnip and immersion foot a. The skin may be freezing while deeper tissues are unaffected. b. Usually not painful; patient often is unaware that cold injury has occurred. c. Immersion foot, also called trench foot, occurs after prolonged exposure to cold water, such as when hikers or hunters stand in a river or lake. d. Signs i. With both, the skin is pale (blanched) and cold to the touch. ii. Normal color does not return after palpation. iii. Loss of feeling and sensation in the injured area e. Emergency treatment i. Remove patient from the cold, wet environment. Rewarm the affected part. 6. Frostbite a. Most serious local cold injury; tissues are frozen. i. Freezing permanently damages cells. ii. Exact mechanism is not known. iii. Ice crystals within the cells may cause physical damage. iv. Change in the water content in the cells may also cause changes in the concentration of critical electrolytes. v. When ice thaws, further chemical changes occur in the cell. (a) Gangrene: Permanent damage or cell death (b) If gangrene occurs, dead tissues must be surgically removed, sometimes by amputation. (c) Following less severe damage, the exposed part will become inflamed, tender to touch, and unable to tolerate exposure to cold. b. Signs i. Hard, frozen feel of the affected tissues ii. Frostbitten parts are hard and waxy and feel firm to frozen. iii. Blisters and swelling may be present. iv. Skin may appear red with purple and white areas, or may be mottled and cyanotic. c. Depth of skin damage will vary. i. With superficial frostbite, only the skin is frozen. ii. With deep frostbite, the deeper tissues are frozen. iii. May not be able to tell in the field iv. Even an experienced surgeon may not be able to tell until several days have passed.
7. Emergency medical care of local cold injury a. Remove the patient from further exposure to the cold. b. Handle the injured part gently, and protect it from further injury. c. Administer oxygen. d. Remove any wet or restrictive clothing over injured part. e. Never rub the area, as rubbing causes further damage. f. With a late or deep cold injury, such as frostbite, remove any jewelry from the injured part. g. Cover loosely with a dry, sterile dressing. h. Do not apply heat or rewarm the part or apply something warm or hot. i. Rewarming is best accomplished under controlled circumstances in the emergency department. ii. Further injury to fragile tissues is possible by rewarming a frostbitten part. i. Evaluate the patient’s general condition for signs or symptoms of systemic hypothermia. n. Do not break blisters. o. Provide transport.
j. If prompt hospital care is not available, medical control might provide instructions for you to rewarm using a warm-water bath. i. Immerse the frostbitten part in water with the temperature between 100°F and 112°F (38°C and 44.5°C). ii. Check temperature with a thermometer. iii. Recheck it frequently. iv. Temperature should never exceed 112°F (44.5°C). v. Stir continuously to recirculate. vi. Keep the frostbitten part in water until it feels warm and sensation has returned. vii. Dress with dry, sterile dressings, placing them also between injured fingers or toes. viii. Expect severe pain. k. Never attempt rewarming if there is any chance that the part may freeze again. l. Some of the most severe consequences have occurred when parts were thawed and then refrozen. m. Cover the frostbitten part with soft, padded, sterile cotton dressings.
C. Cold exposure and you 1. EMT-Bs at risk for hypothermia when working in a cold environment. 2. Be familiar with local conditions. 3. Be aware of existing and potential weather conditions. 4. Make sure proper clothing is available to wear. 5. Vehicle must be properly equipped and maintained. 6. Never allow yourself to become a casualty!
A. Management of hypothermia in the field, regardless of severity, consists of stabilizing the ABCs and preventing further heat loss. B. Scene size-up 1. Note the weather conditions; they have a large impact on treatment. 2. Identify safety hazards such as icy roads, mud, or wet grass.
C. Initial assessment 1. General impression a. Check temperature by feeling skin on patient’s abdomen. b. Mental status can be affected by intensity of cold problem. 2. Airway and breathing a. Ensure adequate airway. b. Warmed, humidified oxygen helps warm from the inside out. 3. Circulation a. Palpate for carotid pulse and wait 30–45 seconds to decide if patient is pulseless or not. b. American Heart Association recommends CPR on patient who has no detectable pulse or breathing. 4. Transport decision a. Complications can include cardiac arrhythmias and blood clotting abnormalities. b. Transport immediately or if not possible, move to warmer location. c. Consider exposure time in determining transport urgency.
D. Focused history and physical exam 1. If unconscious, do a rapid physical exam. 2. If conscious, attempt to obtain SAMPLE history. a. Determine how long the patient was exposed to the cold. b. Medications can affect the patient’s metabolism. 3. Focused physical exam a. Focus on areas directly affected by cold exposure and degree of damage.
4. Baseline vital signs a. Can be altered by hypothermia b. Monitor for changes in mental status. c. Check for core body temperature.
5. Interventions a. Move the patient from the cold environment. b. Do not allow the patient to walk. c. Remove wet clothing. d. Place dry blankets under and over the patient. e. Handle the patient gently. f. Do not massage the extremities. g. Do not allow the patient to eat, use any stimulants, or to smoke or chew tobacco. h. Give warm, humidified oxygen.
E. Detailed physical exam 1. Aimed at determining degree and extent of cold injury 2. Evaluate skin temperature, texture, and turgor.
F. Ongoing assessment 1. Rewarming can have harmful effects; monitor carefully. 2. Communicate conditions at scene, their clothing, and any changes in mental status during treatment and transport.
A. Normal condition 1. Body temperature is 98.6°F (37°C). 2. Regulatory mechanisms keep this internal temperature constant, regardless of the ambient temperature. 3. Body tries to rid itself of excess heat. a. Sweating (and evaporation of the sweat) b. Dilation of skin blood vessels c. Both methods increase the rate of heat radiation. B. Treatment 1. Remove clothing. 2. Find a cooler environment. C. Conditions of heat exposure 1. Body is exposed to more heat energy than it loses a. Hyperthermia is the result. i. High core temperature is usually 101°F (38.3°C) or more. ii. Mechanisms to decrease heat are overwhelmed and body is unable to tolerate the excessive heat. b. Illness develops i. High air temperature can reduce the body’s ability to lose heat by radiation. ii. High humidity reduces the ability to lose heat through evaporation. iii. Vigorous exercise can cause the body to lose more than 1 L of sweat an hour, causing a loss of fluids and electrolytes. iv. Three types of heat exposure illnesses (a) Heat cramps (b) Heat exhaustion (c) Heatstroke D. People at greatest risk for heat illness 1. Newborns, infants, children and older people 2. Patients with heart disease, COPD, diabetes, and dehydration, and those who are obese 3. Those with limited mobility 4. Those who drink alcohol and use certain drugs
E. Heat cramps 1. Painful muscle spasms that occur after vigorous exercise 2. Occurs in situations in addition to when it is hot outdoors 3. Exact cause not well understood 4. Causes a change in the body’s electrolyte, or salt, balance 5. May be a loss of essential electrolytes from the cells 6. Dehydration may also play a role. 7. Loss of water may affect muscles that are being stressed and cause them to go into spasm. 8. Usually occur in the leg or abdominal muscles a. Abdominal muscle spasms may be so severe that the patient appears to have an acute abdomen problem. 9. Treatment a. Remove the patient from the hot environment. b. Loosen any tight clothing. c. Rest the cramping muscles. d. Replace fluids by mouth. i. Water or a diluted (half-strength) balanced electrolyte solution ii. Do not give salt tablets or solutions that have a high salt concentration. e. If cramps persist, transport to the hospital. f. Once the cramps are gone, the patient may resume activity.
F. Heat exhaustion 1. Most common serious illness caused by heat 2. The body sweats heavily. a. Body loses a significant amount of water and many electrolytes. b. Hypovolemia (fluid depletion) occurs. c. For sweating to cool the body, the sweat must be evaporated. 3. People particularly prone to heat exhaustion a. Those who work or exercise vigorously b. Those who wear heavy clothing in a warm, humid, or poorly ventilated environment. 4. Signs and symptoms a. Dizziness, weakness, or faintness, with accompanying nausea or headache b. Onset i. While working hard or exercising in a hot, humid, or poorly ventilated environment and sweating heavily ii. During rest, in geriatric and infant age groups in hot, humid, and poorly ventilated environments or extended time in hot, humid environments c. Cold, clammy skin with ashen pallor
d. Dry tongue and thirst e. Normal vital signs, although pulse is often rapid and diastolic blood pressure may be low f. Normal or slightly elevated body temperature
5. Treatment a. Remove extra clothing. b. Move the patient promptly from the hot environment, preferably to the back of an air-conditioned ambulance. c. Give the patient oxygen. d. Encourage the patient to lie down and elevate the legs. e. If the patient is fully alert, encourage slow drinking of up to a liter of water, as long as nausea does not develop. f. Never force fluids by mouth on a patient who is not fully alert. g. In most cases, the patient feels better within 30 minutes. h. Be prepared to transport to the hospital for more aggressive treatment, especially in the following circumstances: i. The symptoms do not clear up promptly. ii. The level of consciousness decreases. iii. The temperature remains elevated. iv. The person is young, older, or has an underlying medical condition. i. Transport the patient on his or her side.
G. Heatstroke 1. Least common heat illness, but also the most serious 2. Normal mechanisms are overwhelmed. 3. Body temperature rises rapidly to the level at which tissues are destroyed. 4. Untreated heatstroke always results in death. 5. People at risk a. Persons engaged in vigorous physical activity when outdoors b. Persons in a closed, poorly ventilated, humid space c. During heat waves, among individuals (particularly geriatric patients) who live with no air conditioning or poor ventilation d. Children who are left unattended in a locked car on a hot day 6. Signs and symptoms a. Many patients have hot, dry, flushed skin because their sweating mechanism has been overwhelmed. b. Early in the course, the skin may be moist or wet. i. Keep in mind that a patient can have heatstroke even if he or she is still sweating. c. Body temperature rises rapidly to 106°F (41°C) or more. i. As core temperature rises, the level of consciousness falls. d. Often, the first sign of heatstroke is a change in behavior. e. Patient becomes unresponsive very quickly. f. The pulse is usually rapid and strong, but becomes weaker and the blood pressure falls. 7. Recovery a. Depends on the speed with which treatment is administered i. Identify the patient quickly. b. Treatment has one object: reduce the body temperature.
8. Treatment a. Move the patient out of the hot environment and into the ambulance. b. Set air conditioning to maximum cooling. c. Remove the patient’s clothing. d. Give oxygen. e. Apply cool packs to the neck, groin, and armpits.
f. Cover with wet towels or spray with cool water and fan quickly. g. Aggressively and repeatedly fan the patient. h. Provide immediate transport. i. Notify the hospital as soon as possible.
A. You are the provider 1. Present the following case to the students. a. At 3:12 pm, you and your EMT-B partner are dispatched to the Green Valley Mobile Home Park for a sick person. b. When you arrive in front of the mobile home, you see an older woman standing on the front porch waving at you. As you approach, the woman states that she just got home and found her husband on the couch not responding appropriately. c. As you enter the residence, you note that it is very hot and there appears to be no source of ventilation. You find an older man lying on the couch. He is conscious but disoriented.
d. He has a patent airway and is breathing at a rate of 22 breaths/min. His breathing appears to be very shallow. His skin is red, hot, and dry to the touch. 2. What medical emergency could the patient be experiencing? a. There could be many causes, including the things noted in your scene size-up and initial assessment. These include environmental emergencies, inhaled poisonings, CVA, a diabetic emergency, and a myriad of other ailments. Do not get caught into treating one condition without at least considering other causes.
B. Scene size-up 1. Do environmental assessment, temperature, etc. 2. Protect yourself from heat and biological hazards. 3. ALS may need to give IV fluids.
C. You are the provider (continued) 1. Continue reading the case study presented on the slide. a. As your partner applies high-flow oxygen via a nonrebreathing mask, you call for ALS back-up. b. Further assessment shows a rapid and thready pulse, low blood pressure, pupils that are sluggish to react, and a temperature of 104°F. You find no signs of traumatic injury. You remove any constricting clothing and jewelry. c. With your partner’s assistance, you move your patient out of the hot environment and into your ambulance. 2. Is this patient a priority? a. Yes. The patient presents with a high temperature, an increased pulse rate, and signs of decreased perfusion. This patient should be cooled and rapidly transported to the closest facility.
D. Initial assessment 1. General impression a. Heat illness may be primary or secondary condition. b. Avoid tunnel vision. c. The more altered the mental status, the more severe the exposure. 2. ABCs a. Keep airway patent; watch for nausea and vomiting. b. Oxygen may decrease nausea. c. Hot, dry, or moist skin may indicate elevated core temperature. d. Treat for shock aggressively. 3. Transport decision a. If there are any signs of heatstroke, transport immediately.
E. You are the provider (continued) 1. Continue reading the case study presented on the slide. a. Once in the ambulance, you set the air conditioner on high. You remove the remaining clothing from your patient. You apply cool packs to the patient’s neck, groin, and armpits. b. The patient’s wife provides you with additional information about your patient. She states that her husband had been working out in the yard for about 2 hours when he came in complaining that he was hot and felt a bit dizzy. She had told him to sit down at the kitchen table and eat the sandwich that she had made for him. She went to the neighbor’s for a few minutes.
c. When she returned, she found her husband lying on the couch mumbling inappropriately. She immediately called 9-1-1. d. She then tells you that he has an allergy to milk and cats. He takes Lasix twice a day and a medication for high blood pressure, but she is unsure of the name. He was diagnosed with high blood pressure 4 years ago. He has been relatively healthy for the last few years. 2. Do you expect this patient’s blood pressure to be high? a. The patient takes medication to combat hypertension. Accompanied by the medication, the outside temperatures, and the exertion, the patient could be hypotensive (have low blood pressure) due to low circulatory volume.
F. Focused history and physical exam 1. SAMPLE history a. Note any activities or medications that may make patient susceptible to heat-related problems. b. Determine exposure to heat and humidity and activities prior to symptoms. 2. Focused physical exam a. Assess for muscle cramps or confusion. b. Examine for mental status, skin temperature, and wetness.
3. Baseline vital signs a. May be tachycardic or tachypneic i. In heat exhaustion, patient may have normal skin temperature; may also be cool and clammy. ii. In heat stroke, patient will have hot skin.
4. Interventions a. Remove from hot environment. b. Give cool fluids by mouth. c. Cover patient with a sheet and soak with cool water. d. Set ambulance air conditioner on high. e. Place ice packs on groin and axillae. f. Fan aggressively.
G. Detailed physical exam 1. Pay attention to skin temperature, turgor, and wetness. 2. Turgor is the skin’s ability to resist deformity. In dehydration, the skin will tent when pinched on the back of the hand. 3. Perform careful neurologic exam.
H. You are the provider (continued) 1. Continue reading the case study presented on the slide. a. Your partner tells you that the ALS unit has been delayed and will not be on scene for 25 minutes. You consider the current condition of your patient and you choose to transport immediately and rendezvous with the ALS unit en route. You prepare your patient for transport. b. While en route, you elevate the patient’s legs. You cover the patient with a wet sheet and begin fanning him, constantly reassessing his ABCs and responsiveness. c. You notify the hospital personnel of your patient’s condition and continue with a rapid transport. 2. What actions should you take during transport to the hospital? a. The patient should receive an ongoing assessment to help reprioritize his treatment. ABCs should be reassessed to see if the patient needs additional intervention or if what you are doing is improving his condition. Body temperature should be closely monitored to assure that the patient is not becoming hypothermic.
I. Ongoing assessment 1. Watch for deterioration. 2. Reassess vital signs every 5 minutes. 3. Do not cause shivering when cooling the patient down. 4. Communication and documentation a. Document weather conditions and activities prior to the emergency.
A. Drowning 1. Death from suffocation after submersion in water 2. If left unattended, small children can drown in only a few inches of water. B. Near drowning 1. Survival, at least temporarily, after suffocation in water
C. Drowning process 1. Something goes wrong. a. Swallowing of water b. Fatigue c. Currents d. Injuries e. Cold f. Tangled in kelp g. Loss of orientation h. Nitrogen narcosis 2. Patient panics and loses control. 3. Patient undergoes inefficient breathing. a. Carbon dioxide retention b. Oxygen deprivation 4. Patient has decreased buoyancy. 5. Patient is exhausted. 6. Patient experiences cardiac or respiratory arrest. 7. Inhaling very small amounts of water can severely irritate the larynx, sending the muscles into spasm, called laryngospasm. a. Prevents more water from entering the lungs b. Patient’s lungs cannot be ventilated when significant laryngospasm is present. c. Hypoxia occurs until the patient becomes unconscious. d. At this point, the spasm relaxes, making rescue breathing possible. e. In 85% to 90% of cases, significant amounts of water enter the lungs of the drowning victim.
D. Spinal injuries in submersion incidents 1. Submersion incidents may be complicated by spinal cord injuries. 2. Assume that spinal injury exists with the following conditions: a. Diving mishap or long fall b. Patient is unconscious and no information is available. c. Patient is conscious but complains of weakness, paralysis, or numbness in the arms or legs. d. Witnesses who say they think no spinal injury exists 3. Most spinal injuries in diving incidents affect the cervical spine.
4. Stabilize the suspected injury while the patient is still in the water. a. Turn the patient supine. b. Restore the airway and begin ventilation. c. Float a buoyant backboard under the patient. d. Secure the head and trunk to the board. e. Remove the patient from the water, on the board.
E. Recovery techniques 1. Drowning incidents where patient is not floating or visible in the water 2. Organized rescue efforts in these circumstances call for personnel who are experienced with recovery techniques and equipment. F. Resuscitation efforts 1. Never give up resuscitating a cold-water drowning victim. a. Documented case of a survivor of a 66-minute cold water submersion b. Hypothermia can protect vital organs from the lack of oxygen. c. Exposure to cold water will occasionally activate certain primitive reflexes, which may preserve basic body functions. 2. Whenever a person dives or jumps into very cold water, the diving reflex––slowing of the heart rate caused by submersion in cold water–—may cause immediate bradycardia, a slow heart rhythm. a. Loss of consciousness and drowning may result. b. The person may be able to survive for an extended period of time under water, due to a lowering of the metabolic rate associated with hypothermia. c. Continue full resuscitation efforts no matter how long the patient has been submerged.
A. Descent emergencies 1. Usually due to the sudden increase in pressure on the body as the person dives deeper into the water a. Some body cavities cannot adjust to changes in pressure. b. Typical areas affected are: i. Lungs ii. Sinus cavities iii. Middle ear iv. Teeth v. Area of the face surrounded by the diving mask c. Results in severe pain i. The pain usually forces the diver to return to the surface to equalize the pressure. ii. Problem clears up iii. Diver who continues to complain of pain, particularly in the ear, after returning to the surface should be transported to the hospital. iv. Person with a perforated tympanic membrane (ruptured eardrum) may develop a special problem while diving. (a) If cold water enters the middle ear through a ruptured eardrum, the diver may lose his or her balance and orientation. (b) Diver may then shoot to the surface and experience ascent problems. B. Emergencies at the bottom 1. Rare problem 2. Examples a. Inadequate mixing of oxygen and carbon dioxide in the air the diver breathes b. Accidental feeding of poisonous carbon monoxide into the breathing apparatus c. Both are the result of faulty connections in the diving gear. 3. Can cause drowning or rapid ascent 4. Requires emergency resuscitation and transport C. Ascent emergencies 1. Most serious and dangerous injuries associated with diving are related to ascending. Treatment usually requires aggressive resuscitation. a. Air embolism b. Decompression sickness (also called “the bends”)
2. Air embolism a. Most dangerous and most common emergency in scuba diving b. Diver holds breath during rapid ascent c. Air pressure in the lungs remains high while external pressure on the chest decreases i. Causes the alveoli in the lungs to rupture. ii. Air released from rupture can cause problems. (a) Pneumothorax (b) Pneumomediastinum (c) Air emboli iii. Pneumothorax and pneumomediastinum both result in pain and severe dyspnea. iv. An air embolus will act as a plug and prevent normal flow of blood and oxygen. (a) Brain and spinal cord are the organs most severely affected by air embolism, because they require a constant supply of oxygen. d. Signs and symptoms of air embolism i. Blotching (mottling of the skin) ii. Froth at the nose and mouth iii. Severe pain in muscles, joints, or abdomen iv. Dyspnea and/or chest pain v. Dizziness, nausea, and vomiting
vi. Dysphasia (difficulty speaking) vii. Difficulty with vision viii. Paralysis and/or coma ix. Irregular pulse or cardiac arrest
3. Decompression sickness (“the bends”) a. Bubbles of gas, especially nitrogen, obstruct the blood vessels. b. Results from too rapid an ascent from a dive i. During the dive, nitrogen that is being breathed dissolves in the blood and tissues because it is under pressure. ii. During ascent, the external pressure is decreased and the dissolved nitrogen forms small bubbles within those tissues. c. Problems similar to those that occur in air embolism i. Severe pain in certain tissues or spaces in the body is the most common problem. ii. Most striking symptom is abdominal and/or joint pain so severe that the patient literally doubles up or “bends” d. Dive tables and computers are available to show the proper rate of ascent from a dive, including the number and length of pauses that a diver should make on the way up. i. However, even divers who stay within these limits can suffer the bends. e. Even after a “safe dive,” decompression sickness can occur. i. Driving a car up a mountain ii. Flying in an unpressurized airplane that climbs too rapidly iii. Risk of this diminishes after 24 to 48 hours. iv. Problem is exactly the same as rapid ascent from a deep dive. (a) Sudden decrease of external pressure on the body and release of dissolved nitrogen from the blood forms bubbles of nitrogen gas within the blood vessels. 4. Time frame a. Air embolism occurs immediately upon return to the surface. b. Decompression sickness may not occur for several hours. 5. Treatment a. Same as that for air embolism and decompression sickness b. Treatment is BLS followed by recompression in hyperbaric chamber. i. Usually a small room that is pressurized to more than atmospheric pressure ii. Allows bubbles of gas to dissolve into the blood and equalizes the pressures inside and outside the lungs iii. Once these pressures are equalized, gradual decompression can be accomplished under controlled conditions to prevent the bubbles from reforming.
A. Pay close attention to the body temperature of a person who is rescued from cold water. B. Treat hypothermia caused by immersion in cold water the same way you treat hypothermia caused by cold exposure. C. A person swimming in shallow water may experience breath-holding syncope. 1. Loss of consciousness caused by a decreased stimulus for breathing 2. People at risk are swimmers who breathe in and out rapidly and deeply before entering the water in an effort to expand capacity to stay underwater. 3. This hyperventilation lowers the carbon dioxide level. 4. Because an elevated level of carbon dioxide in the blood is the strongest stimulus for breathing, the swimmer may not feel the need to breathe even after using up all the oxygen in his or her lungs. 5. Emergency treatment is the same as that for a drowning or near drowning. D. Injuries caused by water hazards may be complicated by immersion in cold water. 1. Boat propellers 2. Sharp rocks 3. Water skis 4. Dangerous marine life
A. Health care professionals should be involved in public education efforts. 1. Make people aware of the hazards of swimming pools and water recreation B. Pools should be surrounded with appropriate enclosures. C. Adult and teenage drownings associated with the use of alcohol
A. Scene size-up 1. Never drive through moving water; be cautious driving through still water. 2. Never attempt a water rescue without the proper training and equipment. 3. Trauma and spinal stabilization must be considered in recreational settings. 4. Check for additional patients depending upon the situation.
B. Initial assessment 1. General impression a. Pay attention to chest pain, dyspnea, and complaints of sensory changes. b. Be suspicious of alcohol use. 2. ABCs a. Maintain airway; suction if patient has vomited pink, frothy secretions. b. If pulse cannot be obtained, begin CPR per guidelines. c. Evaluate for shock and adequate perfusion. d. Treat trauma if chief complaint warrants.
3. Transport decision a. Always transport near-drowning patients to hospital. b. Decompression sickness and air embolism must be treated in recompression chamber. c. Perform any interventions en route.
C. Focused history and physical exam 1. If responsive, perform exam on lungs and breath sounds before baseline vital signs. 2. If unresponsive, look for hidden life threats and trauma before obtaining baseline vital signs. 3. Rapid physical exam a. Look for signs of trauma or complications. b. Check divers for indications of air embolism or bends. c. Focus on pain in joints and abdomen. d. Check for signs of hypothermia; complete Glasgow Coma Scale score.
4. Baseline vital signs a. Check pulse rate, quality, and rhythm. b. Check both peripheral and central pulses. c. Check for pupil size and reactivity. 5. SAMPLE history a. Determine length of time patient was underwater or time of onset of symptoms from last dive. b. Note physical activity, alcohol or drug use, or other medical conditions. c. Determine dive parameters in history depth, time, and previous dive activity.
6. Drowning interventions a. Artificial ventilations should begin as soon as possible. b. Stabilize and protect the spine in any diving or suspected diving accidents. c. Maintain a patent airway. If there is no spinal injury, turn patient on side to allow draining from upper airway. d. Make sure patient is warm, especially after cold-water immersion.
7. Diving interventions a. Remove patient from the water. b. Begin BLS and administer oxygen. c. Place the patient in the left lateral recumbent position with the head down. d. Provide prompt transport to nearest recompression facility. e. Air bubbles can block blood vessels that supply the brain, spinal cord, or central nervous system; permanent damage is imminent without treatment. f. Administer oxygen and provide rapid transport.
D. Detailed physical exam 1. Examine respiratory, circulatory, and neurologic systems for deficiency. 2. Distal circulatory, sensory, and motor function tests will determine extent of injury. 3. Examine for peripheral pulses, skin color, and discoloration, itching, pain and paresthesias (numbness, tingling).
E. Ongoing assessment 1. May deteriorate rapidly 2. Assess mental status frequently. 3. Communication and documentation a. Document: i. Circumstances of drowning and extrication ii. Time submerged iii. Temperature of the water iv. Clarity of water v. Possible spinal injury b. Bring dive log or dive computer if available for dive history. c. Bring all dive equipment to the hospital. Document disposition of all these materials.
A. There are an estimated 25 million cloud-to-ground lightning strikes each year in the United States. B. Lightning is the third most common cause of death from isolated environmental phenomena. C. Most common strikes hit: 1. Boaters, swimmers, golfers, and anyone in a large, open area D. Many are direct strikes; others are victims of indirect strikes that “splash” off an object such as a tree. E. Cardiovascular and nervous systems are most commonly injured. 1. Cardiac arrest is common. 2. Tissue damage F. Three categories of lightning injuries 1. Mild: Loss of consciousness, amnesia, tingling, superficial burns, if any 2. Moderate: Seizures, respiratory arrest, asystole (spontaneously resolves), superficial burns 3. Severe: Cardiopulmonary arrest. Due to distances, many of these patients do not survive.
G. Emergency medical care 1. Protect yourself. 2. Move patient to a sheltered area. 3. If not possible, make sure to be away from tall objects; stay close to the ground. 4. Use reverse triage—anyone who is in cardiac or respiratory arrest is first priority, others who may have been struck will not develop cardiac complications. 5. Treat as for other electrical injuries. a. Stabilize spine and maintain patent airway. b. If pulse is present, assist ventilations. c. If no pulse present, use AED as soon as possible. d. Transport to nearest facility.
A. Spider bites 1. Spiders are numerous and widespread in the United States. a. Many species of spiders bite. b. Only two—the female black widow spider and the brown recluse spider—deliver serious, even life-threatening bites. c. Your safety is of paramount importance.
2. Black widow spider a. The female black widow spider is fairly large, measuring approximately 2&apos;&apos; across with its legs extended. b. Usually black with a distinctive, bright red-orange marking in the shape of an hourglass on its abdomen c. Female is larger and more toxic than the male. d. Found in every state except Alaska e. Prefer dry, dim places around buildings, in woodpiles, and among debris f. Bite is sometimes overlooked. g. If the site becomes numb right away, the patient may not even recall being bit; however, most black widow spider bites cause localized pain and symptoms, including agonizing muscle spasms. h. Bite on the abdomen may cause muscle spasms so severe that they resemble an acute abdomen. i. The main danger is the venom, which is poisonous to nerve tissues. Other systemic symptoms include dizziness, sweating, nausea, vomiting, and rashes. j. Tightness in the chest, difficulty breathing, severe cramps, and a board-like rigidity of the abdominal muscles develop within 24 hours. Generally, these signs and symptoms subside over 48 hours. k. A physician can administer a specific antivenin, but because of a high incidence of side effects, its use is reserved for very severe bites, for the aged or very feeble, and for children younger than 5 years. l. Muscle spasms are usually treated in the hospital with IV benzodiazepines such as diazepam (Valium) or lorazepam (Ativan). m. Emergency treatment: BLS for the patient in respiratory distress. n. Transport as soon as possible. o. If possible, bring the spider in a container.
3. Brown recluse spider a. Dull brown in color and 1? long b. Short-haired body has a violin-shaped mark, brown to yellow in color, on its back. c. Lives mostly in the southern and central parts of the country, but may be found throughout the continental United States. d. Tends to live in dark areas, such as in the corners of old, unused buildings; under rocks; and in woodpiles e. In cooler areas, moves indoors to closets, drawers, cellars, and old piles of clothing. f. Venom is not neurotoxic but cytotoxic; causes severe local tissue damage. g. Typically, bite is not painful at first but becomes so within hours. h. Area becomes swollen and tender, developing a pale, mottled, cyanotic center and possibly a small blister. i. A scab of dead skin, fat, and debris will form and dig down into the skin, producing a large ulcer that may not heal unless treated promptly. j. Transport patients with such symptoms as soon as possible. k. Rarely cause systemic symptoms and signs
B. Snake bites 1. Snake bites are a worldwide problem of some significance. a. More than 300,000 injuries from snake bites occur worldwide. b. Each year 30,000 to 40,000 people die of snake bites worldwide. 2. Snake bites in the United States occur less often. a. Approximately 40,000 to 50,000 are reported yearly. b. Snake bite fatalities in the United States are extremely rare—about 15 a year for the entire country. 4. Snakes usually do not bite unless provoked, angered, or accidentally injured, as when they are stepped on. a. Exception: Cottonmouths are often aggressive. 5. Most snake bites occur between April and October and tend to involve young men who have been drinking alcohol. 6. Almost any time you are caring for a patient with a snake bite, another snake could come along and create a second victim—you. 7. Use extreme caution on these calls and wear the proper protective equipment for the area. 8. Only one third of snake bites results in significant local or systemic injuries. 9. Often, envenomation does not occur because the snake recently struck another animal and exhausted its supply of venom. 10. With the exception of the coral snake, poisonous snakes native to the United States have hollow fangs in the roof of the mouth that inject the poison from two sacs at the back of the head. 11. The classic appearance of the poisonous snake bite is two small puncture wounds, usually about 1?2” apart, with discoloration, swelling, and pain. 12. Nonpoisonous snakes can also bite, usually leaving a horseshoe of tooth marks. 13. Fang marks are a clear indication of a poisonous snake bite.
3. Of the approximately 115 different species of snakes in the United States, only 19 are venomous. A. These include the rattlesnake, the copperhead, the cottonmouth or water moccasin, and the coral snakes. b. At least one of the poisonous species is found in every state except Alaska, Hawaii, and Maine.
C. Pit vipers 1. Rattlesnakes, copperheads, and cottonmouths are all pit vipers, with triangular-shaped, flat heads. 2. They have small pits located just behind each nostril and in front of each eye that contain poison. 3. The pit is a heat-sensing organ that allows the snake to strike accurately at any warm target. 4. The fangs are special hollow teeth that act much like hypodermic needles connected to a sac containing a reservoir of venom. 5. The most common form of pit viper is the rattlesnake. a. Have many patterns of color, often with a diamond pattern. b. Can grow to 6&apos; or more in length. 6. Copperheads are smaller than rattlesnakes. a. Reddish coppery color crossed with brown or red bands b. Typically inhabit woodpiles and abandoned dwellings c. Account for most of the venomous snake bites in the eastern United States. d. Bites are almost never fatal, but the venom can destroy extremities. 7. Cottonmouths grow to about 4&apos; in length. a. Also called water moccasins, they are olive or brown, with black cross-bands and a yellow undersurface. b. They are water snakes with an aggressive pattern of behavior. c. Although fatalities from these snake bites are rare, tissue destruction from the venom may be severe.
8. Signs of envenomation by a pit viper are severe, burning pain at the site of injury, followed by swelling and a bluish discoloration (ecchymosis). 9. Signs are evident within 5 to 10 minutes and spread over the next 36 hours. 10. In addition to destroying tissues locally, the venom of the pit viper can also interfere with the body’s clotting mechanism and cause bleeding at various distant sites. 11. Other signs that may or may not occur include weakness, sweating, fainting, and shock. 12. If the patient has no local signs an hour after being bitten, it is safe to assume that envenomation did not take place. 13. If swelling has occurred, mark its edges on the skin. 14. Do not confuse a fainting spell with shock. 15. If shock occurs, it will happen much later.
16. When treating a bite from a pit viper, take the following steps: a. Calm the patient. b. Have the patient lie flat, face up, and explain that staying quiet will slow the spread of any venom through the system. c. Locate the bite area and clean it gently with soap and water. d. Do not apply ice. e. If the bite occurred on an arm or leg, splint the extremity to decrease movement. f. Be alert for vomiting, which may be a sign of anxiety rather than the toxin itself. g. Do not give anything by mouth.
h. If the patient was bitten on the trunk, keep him or her supine and quiet and transport as quickly as possible. i. Monitor vital signs and mark the skin with a pen over the area that is swollen. j. If there are any signs of shock, treat for it. k. If the snake has been killed, bring it with you. l. Notify the hospital; if possible, describe the snake. m. Transport promptly. 17. If the patient shows no signs of envenomation, provide BLS as needed, place a sterile dressing over the suspected bite area, and immobilize the injury site. 18. All patients with a suspected snake bite should be taken to the emergency department. 19. Treat the wound as you would any deep puncture wound to prevent infection. 20. Know the local medical protocol for handling snake bites.
D. Coral snakes 1. Small reptile with a series of bright red, yellow, and black bands completely encircling the body 2. “Red on yellow will kill a fellow; red on black, venom will lack.” 3. A relative of the cobra snake, it lives in most southern states and in the Southwest. 4. It injects the venom with its teeth and tiny fangs by a chewing motion, leaving puncture wounds. 5. Because of its small mouth and teeth and limited jaw expansion, the coral snake usually bites its victims on a small part of the body, such as a finger or toe. 6. Coral snake venom is a powerful toxin that causes paralysis of the nervous system. 7. Within a few hours of being bitten, a patient will exhibit bizarre behavior, followed by progressive paralysis of eye movements and respiration. 8. Successful treatment depends on positive identification of the snake and support of respiration. 9. Antivenin is available, but most hospitals do not stock it.
10. Emergency care a. Immediately quiet and reassure the patient. b. Flush the area of the bite with 1 to 2 quarts of warm, soapy water to wash away any poison. c. Do not apply ice. d. Splint the extremity. e. Check and monitor the patient’s baseline vital signs.
f. Keep the patient warm and elevate the lower extremities to help prevent shock. g. Give oxygen if needed. h. Transport promptly, giving hospital personnel notice that the patient has been bitten by a coral snake. i. Give the patient nothing by mouth.
E. Scorpion stings 1. Scorpions are eight-legged arachnids with a venom gland and a stinger at the end of their tail. 2. They are rare and live primarily in the southwestern United States and in deserts. 3. With one exception, a scorpion’s sting is usually very painful but not dangerous. a. The exception is the Centruroides sculpturatus. b. The venom of this species may produce a severe systemic reaction that brings about circulatory collapse, severe muscle contractions, excessive salivation, hypertension, convulsions, and cardiac failure. c. If you are called to care for a patient with a suspected sting from Centruroides sculpturatus, notify medical control as soon as possible. d. Administer all the elements of BLS and transport the patient as rapidly as possible.
F. Tick bites 1. Ticks are tiny insects that usually attach themselves directly to the skin. 2. They are found most often on brush, shrubs, trees, sand dunes, or other animals. 3. They can easily be mistaken for freckles. 4. The bite is not painful. 5. The danger with a tick bite is from infecting organisms. 6. Ticks commonly carry Rocky Mountain spotted fever and Lyme disease. a. Both are spread through the tick’s saliva.
b. Rocky Mountain spotted fever occurs within 7 to 10 days after the bite. i. Symptoms include nausea, vomiting, headache, weakness, paralysis, and possibly cardiorespiratory collapse.
c. Lyme disease has received extensive publicity. i. Lyme disease has now been reported in 35 states. ii. The first symptom, a rash that may spread to several parts of the body, begins about 3 days after the bite of an infected tick. iii. In one third of patients, the rash eventually resembles a target bull’s-eye pattern. iv. After a few more days or weeks, painful swelling of the joints, particularly the knees, occurs. v. Lyme disease may be confused with rheumatoid arthritis and may result in permanent disability. vi. If it is recognized and treated promptly with antibiotics, the patient may recover completely.
7. Tick bites occur most commonly during the summer months. a. Transmission of the infection from tick to person takes at least 12 hours, so if you are called on to remove a tick, you should proceed carefully and slowly. b. Do not attempt to suffocate or burn the tick. c. Using fine tweezers, grasp the tick by the body and pull it straight out of the skin. d. This will usually remove the whole tick. e. Once the tick is removed, paint the area with disinfectant and save the tick in a glass jar for identification. f. Do not handle the tick with your fingers. g. Provide any necessary supportive care and transport the patient to the hospital.
A. Coelenterates such as fire coral, Portuguese man-of-war, sea wasp, sea nettles, true jellyfish, sea anemones, true coral, and soft coral are responsible for more envenomations than any other marine animals. 1. The stinging cells are called nematocysts. 2. Envenomation causes very painful, reddish lesions in light-skinned individuals; the lesions extend in a line from the site of the sting. 3. Systemic symptoms include headache, dizziness, muscle cramps, and fainting.
B. To treat a sting from jellyfish, a Portuguese man-of-war, various anemones, corals, or hydras, remove the patient from the water and pour acetic acid (vinegar) on the affected area to inactivate the nematocysts. 1. Do not try to manipulate the remaining tentacles; this will only cause further discharge. 2. Remove the tentacles by scraping them off with the edge of a sharp, stiff object such as a credit card. 3. Persistent pain may respond to immersion of the area in hot water (110° to 115°F) for 30 minutes. C. On rare occasions, a patient may have a systemic allergic reaction. 1. Treat such a patient for anaphylactic shock. 2. Give BLS and provide immediate transport to the hospital. D. Toxins from the spines of urchins, stingrays, and certain spiny fish such as the lionfish, scorpion fish, or stonefish are heat sensitive. 1. The best treatment is to immobilize the affected area and soak it in hot water for 30 minutes. 2. Patient still needs to be transported. E. If you work near the ocean, you should be familiar with the marine life in your area. F. Emergency treatment of common coelenterate envenomations: 1. Limit further discharge of nematocysts by avoiding fresh water, wet sand, showers, or careless manipulation of the tentacles. 2. Keep the patient calm and reduce motion of the affected extremity. 3. Inactivate the nematocysts by applying vinegar (isopropyl alcohol may be used if vinegar is not available, but may not be as effective). 4. Remove the remaining tentacles by scraping them off with the edge of a sharp, stiff object. 5. Persistent pain may respond to immersion in hot water. 6. Provide transport.
Environmental Emergencies & Drowning
(Environmental Emergencies & Drowning)
Presented by Louis van Rensburg
Factors Affecting Exposure
• Physical condition
• Nutrition and hydration
• Environmental conditions
Loss of Body Heat (1 of 2)
– Transfer of heat from
body to colder object
– Transfer of heat through
– Cooling of body through
– Loss of body
heat directly into
– Loss of body
• Rate and amount of heat gain or loss can be
modified in three ways:
– Increase or decrease heat production.
– Move to sheltered area where heat loss is
increased or decreased.
– Wear insulated clothing.
Loss of Body Heat (2 of 2)
• Lowering of the body temperature below 95°F (35°C)
• Weather does not have to be below freezing for
hypothermia to occur.
• Older persons and infants are at higher risk.
• People with other illnesses and injuries are susceptible
Signs and Symptoms
of Mild Hypothermia
• Rapid pulse and respirations
• Red, pale, cyanotic skin
Signs and Symptoms of More
• Shivering stops.
• Muscular activity decreases.
• Fine muscle activity ceases.
• Eventually, all muscle activity stops.
Less Than 80°F
• Patient may appear dead (or in a
• Never assume that a cold,
pulseless patient is dead.
Local Cold Injuries
– Freezing of the skin but not the deeper surface
• Immersion (trench) foot
– Prolonged exposure to cold water
– Freezing of a body part, usually an extremity
for Local Cold Injury
• Remove the patient from
further exposure to the
• Handle the injured part
• Administer oxygen.
• Remove any wet or
• Never rub the area.
• Do not break blisters.
• Water temperature should be between 38°C and
• Recheck water temperature and stir to circulate.
• Keep body part in water until warm and sensation
• Dress with dry, sterile dressings.
Cold Exposure and You
• EMS Personnel are at risk for hypothermia when
working in a cold environment.
• Stay aware of local weather conditions.
• Dress appropriately and be prepared.
• Vehicle must be properly equipped and maintained.
• Never allow yourself to become a casualty!
On The Scene: Cold Exposure
The following slides walk the student though a cold
• Note weather conditions.
• Identify safety hazards
such as icy roads, mud, or
• Check temperature on
• Mental status can be affected.
• Ensure adequate airway.
• Warmed, humidified oxygen
helps warm from inside out.
• Palpate for carotid pulse; wait
• Transport immediately or
move to warmer location.
Focused History and Physical
• If unconscious, do a rapid physical exam.
• If conscious, attempt to obtain SAMPLE history.
– Determine how long the patient was exposed to
– Medications can affect the patient’s metabolism.
• Focused physical exam
– Concentrate on areas of body directly affected
Baseline Vital Signs
• Can be altered by hypothermia
• Monitor for changes in mental status.
• Check for core body temperature.
• Move from cold environment.
• Do not allow patient to walk, eat, use any
stimulants, or smoke or chew tobacco.
• Remove wet clothing.
• Place dry blankets under and over patient.
• Handle gently.
• Do not massage extremities.
• Give warm, humidified oxygen.
Detailed Physical Exam
• Aimed at determining degree and extent of cold
• Evaluate skin temperature, texture, and turgor.
• Rewarming can be harmful; monitor carefully.
• Communicate conditions at scene, clothing,
changes in mental status.
• Normal body temperature is 37°C.
• Body attempts to maintain normal temperature
despite ambient temperature.
• Body cools itself by sweating (evaporation) and
dilation of blood vessels.
• High temperature and humidity decrease
effectiveness of cooling mechanisms.
• Painful muscle spasms
• Remove the patient from
• Rest the cramping
• Replace fluids by mouth.
• If cramps persist,
transport the patient to
Signs and Symptoms
of Heat Exhaustion (1 of 2)
• Dizziness, weakness, or fainting
• Onset while working hard or exercising in hot
• In older people and young, onset may occur while
at rest in hot, humid, and poorly ventilated areas.
• Cold, clammy skin
Signs and Symptoms
of Heat Exhaustion (2 of 2)
• Dry tongue and thirst
• Patients usually have normal vital signs, but pulse
can increase and blood pressure can decrease.
• Normal or slightly elevated body temperature
Emergency Medical Care
• Remove extra clothing and remove from hot
• Give patient oxygen.
• Have patient lie down and elevate legs.
• If patient is alert, give water slowly.
• Be prepared to transport.
Signs and Symptoms of Heatstroke
• Hot, dry, flushed skin
• Change in behavior leading to unresponsiveness
• Pulse rate is rapid, then slows.
• Blood pressure drops.
• Death can occur if the patient is not treated.
Care for Heat Stroke (1 of 2)
• Move patient out of the hot
• Provide air conditioning at a
• Remove the patient’s
• Give the patient oxygen.
• Apply cold packs to the
patient’s neck, armpits, and
Care for Heat Stroke (2 of 2)
• Cover the patient with wet towels or sheets.
• Aggressively fan the patient.
• Immediately transport patient.
• Notify the hospital of patient’s condition.
On The Scene: Heat Exposure
The following slides walk the student through a heat
You are the Provider
• You are dispatched to the Green Valley Mobile
Home Park for a sick person.
• An older woman found her husband on the couch
• You note that it is very hot with no source of
You are the Provider (continued)
• The man is on the couch and conscious but
• Patent airway, breathing shallow at 22 breaths/min
• Skin is red, hot, and dry.
• What medical emergency could the patient be
• Do environmental assessment.
• Protect yourself from heat and biological hazards.
• ALS may need to give IV fluids.
You are the Provider (continued)
• Your partner applies high-flow oxygen via
nonrebreathing mask; you call for ALS backup.
• Rapid, thready pulse; low BP; sluggish pupils;
• No signs of traumatic injury
• You remove constricting clothing, jewelry.
• You move patient into ambulance.
• Is this patient a priority?
• The more altered the mental status, the more
severe the exposure.
• Keep airway patent.
• Oxygen may decrease nausea.
• Hot, dry, or moist skin may indicate elevated core
• Treat for shock aggressively.
• If any signs of heatstroke, transport immediately.
You are the Provider
(continued) (1 of 2)
• You set A/C on high, remove patient’s clothing,
apply cool packs.
• Patient’s wife states that husband came in after
working outside 2 hours. Complained he was hot
• She made him a sandwich and went to the
neighbor’s for a few minutes.
You are the Provider
(continued) (2 of 2)
• He has an allergy to milk and cats.
• Takes Lasix twice a day and a medication
for high BP.
• Do you expect this patient’s blood pressure
to be high?
Focused History and Physical Exam
• Note activities/medications that may make patient
susceptible to heat-related problems.
• Determine exposure and activities prior to
• Assess for muscle cramps, confusion.
• Examine for mental status, skin temperature,
Baseline Vital Signs
• May be tachycardic or tachypneic
• In heat exhaustion, patient may have normal skin
temp; may also be cool and clammy.
• In heat stroke, patient will have hot skin.
• Remove from hot environment.
• Give cool fluids by mouth.
• Cover with sheet and soak with cool water.
• Set A/C on high.
• Place ice packs on groin and axillae.
• Fan aggressively.
Detailed Physical Exam
• Pay attention to skin temperature, turgor, wetness.
• Turgor = skin’s ability to resist deformity
• In dehydration, skin will tent when pinched on back
• Perform careful neurologic exam.
You are the Provider (continued)
• ALS is 25 minutes away.
• You choose to rendezvous.
• En route, you:
– Elevate the patient’s legs.
– Cover patient with wet sheet.
– Fan him.
• What actions should you take during transport
to the hospital?
• Watch for deterioration.
• Reassess vital signs every 5 minutes.
• Do not cause shivering.
• Document weather conditions and activities prior to
Drowning and Near Drowning
– Death as a result of suffocation after
submersion in water
• Near drowning
– Survival, at least temporarily, after suffocation
Spinal Injuries in Submersion
• Suspect spinal injury if:
– Submersion has resulted from a diving mishap or
– Patient is unconscious.
– Patient complains of weakness, paralysis, or
Spinal Stabilization in Water
• Turn the patient supine.
• Restore the airway and begin ventilation.
• Secure a backboard under the patient.
• Remove the patient from the water.
• Cover the patient with a blanket.
• Hypothermia can protect vital organs from hypoxia.
• Documented case of a survivor of a 66-minute cold
• Diving reflex may cause heart rate to slow.
• Descent problems
– Usually due to the sudden increase in pressure on
the body as the person dives
• Bottom problems
– Not commonly seen
• Ascent problems
– Air embolism and decompression sickness
Signs and Symptoms
of Air Embolism (1 of 2)
• Froth at the mouth and nose
• Severe pain in muscle, joints, or
• Dyspnea and/or chest pain
Signs and Symptoms
of Air Embolism (2 of 2)
• Dizziness, nausea, and vomiting
• Difficulty with vision
• Paralysis and/or coma
• Irregular pulse or cardiac arrest
• Occurs when bubbles of gas
obstruct blood vessels
• Can result from rapid ascent
• Most common symptom is
abdominal and/or joint pain.
• Symptoms may develop
• Treatment is BLS and
Other Water Hazards
• Hypothermia from water immersion
• Breath-holding syncope
• Injuries from recreational equipment or
• Pools should be surrounded with
• Alcohol involved in adult and teenage
On The Scene: Drowning
The following slides walk the student through a
Consider showing the pediatric drowning call video
• Never drive through moving water;
be cautious driving through still
• Never attempt water rescue
without proper training and
• Consider trauma and spinal
• Check for additional patients.
• Pay attention to chest pain, dyspnea, complaints of
• Be suspicious of alcohol use.
• Maintain airway; suction.
• If pulse cannot be obtained, begin CPR per
• Evaluate for shock and adequate perfusion.
• Treat trauma.
• Always transport near-drowning patients to
• Decompression sickness and air embolism
must be treated in recompression
• Perform interventions en route.
Focused History and
• If responsive, perform exam on lungs and breath
• If unresponsive:
– Look for signs of trauma or complications.
– Check divers for indications of air embolism or
– Focus on pain in joints and abdomen.
– Check for signs of hypothermia; complete
Glasgow Coma Scale score.
Baseline Vital Signs/
• Check pulse rate, quality, rhythm.
• Check peripheral, central pulses.
• Check for pupil size, reactivity.
• Determine length of time patient was underwater or
time of onset of symptoms.
• Note physical activity, alcohol/drug use, other
• Determine dive parameters in history depth, time,
previous dive activity.
• Begin artificial ventilations as soon as possible.
• Stabilize and protect spine.
• Maintain patent airway. If there is no spinal injury,
turn patient on side to allow draining from upper
• Make sure patient is warm, especially after cold-
• Remove patient from water.
• Begin BLS; administer oxygen.
• Place patient in left lateral recumbent position with
• Provide prompt transport to nearest recompression
• Administer oxygen and provide rapid transport.
Detailed Physical Exam
• Examine respiratory, circulatory, neurologic
• Distal circulatory, sensory, and motor function tests
determine extent of injury.
• Examine for peripheral pulses, skin color, and
discoloration, itching, pain, numbness/tingling.
• May deteriorate rapidly
• Assess mental status frequently.
– Circumstances of drowning and extrication
– Time submerged
– Temperature of water
– Clarity of water
– Possible spinal injury
• Bring dive log, dive computer, and dive equipment
• Strikes boaters, swimmers, golfers, anyone in
large, open area
• Cardiac arrest and tissue damage are common.
• Three categories of lightning injuries
1. Mild: Loss of consciousness, amnesia, tingling,
2. Moderate: Seizures, respiratory arrest,
asystole (spontaneously resolves), superficial
3. Severe: Cardiopulmonary arrest
Emergency Medical Care
• Protect yourself.
• Move patient to sheltered
area or stay close to ground.
• Use reverse triage.
• Treat as for other electrical
• Transport to nearest facility.
• Spiders are numerous and widespread in the US.
• Many species of spiders bite.
• Only the female black widow spider and the brown
recluse spider deliver serious, even life-threatening
• Your safety is of paramount importance.
Black Widow Spider
• Found in all states except Alaska
• Black with bright red-orange marking in
hourglass shape on abdomen
• Venom poisonous to nerve tissue
• Requires patient transport as soon as possible
Brown Recluse Spider
• Mostly in southern and central US
• Short-haired body has violin-shaped mark, brown
to yellow in color, on its back.
• Venom causes local tissue damage.
• Area becomes swollen and tender, with pale,
mottled, cyanotic center.
• Requires patient transport as soon as possible.
• 40,000 to 50,000 reported snake bites in the
• 7,000 bites in the US come from poisonous
– Death from snake bites is rare.
– About 15 deaths occur each year in the
Four Types of Poisonous Snakes
in the US
• Store poison in pits
• Inject poison to
victim through fangs
Signs and Symptoms
of a Pit Viper Bite
• Severe burning at the bite site
• Swelling and bluish discoloration
• Bleeding at various distant sites
• Other signs may or may not include:
– Weakness – Fainting
– Sweating – Shock
Care for Pit Viper Bites (1 of 2)
• Calm the patient.
• Locate bite and cleanse the area.
• Do not apply ice.
• Splint area to minimize movement.
• Watch out for vomiting caused by anxiety.
• Do not give anything by mouth.
Care for Pit Viper Bites (2 of 2)
• If the patient is bitten on the trunk, lay
the patient supine and transport
• Monitor patient’s vital signs.
• Mark the swollen area with a pen.
• Care for shock if signs and symptoms
• Bring the snake to hospital if it has
• Small snake with red, yellow, and black bands
• “Red on yellow will kill a fellow, red on black,
venom will lack.”
• Injects venom with teeth, using a chewing
motion that leaves puncture wounds
• Causes paralysis of the nervous system
Care for Coral Snake Bites (1 of 2)
• Quiet and reassure the patient.
• Flush the area with 1 to 2 quarts of warm,
• Do not apply ice.
• Splint the extremity.
• Check and monitor baseline vital signs.
Care for Coral Snake Bites (2 of 2)
• Keep the patient warm and elevate the lower
extremities to help prevent shock.
• Give supplemental oxygen if needed.
• Transport promptly. Give advance notice to
hospital of coral snake bite.
• Give the patient nothing by mouth.
• Venom gland and stinger found
in the tail end.
• Mostly found in southwestern US
• With one exception, the
Centruroides sculpturatus, most
stings are only painful.
• Provide BLS care and transport.
• “Real world” call Poison Control
– Transport may not be needed
Tick Bites (1 of 3)
• Ticks attach themselves
to the skin.
• Bite is not painful, but
potential exposure to
infecting organisms is
• Ticks commonly carry
Rocky Mountain spotted
fever or Lyme disease.
Tick Bites (2 of 3)
• Rocky Mountain spotted fever develops 7 to
10 days after bite.
• Symptoms include:
– Nausea, vomiting
– Possible cardiorespiratory collapse
Tick Bites (3 of 3)
• Lyme disease has now been reported
in over 35 states.
– 1995-2004, 35 AZ cases reported
• Lyme disease symptoms may begin 3
days after the bite.
• Symptoms include:
– Target bull’s-eye pattern
– Painful swelling of the joints
Caring for a Tick Bite
• Do not attempt to suffocate or burn tick.
• Use fine tweezers to grasp tick by the body and
pull it straight out.
• Cover the area with disinfectant and save the tick
• Provide any necessary supportive emergency
care and transport.
Injuries from Marine Animals
• Coelenterates are responsible for more
envenomations than any other marine life animal
• Have stinging cells called nematocysts
• Results in very painful, reddish lesions
• Symptoms include headache, dizziness, muscle
cramps, and fainting.
Care for Marine Stings
• Limit further discharge by minimizing
• Inactivate nematocysts by applying
• Remove the remaining tentacles by
scraping them off.
• Provide transport to hospital.