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Environmental Emergencies & Drowning


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Quick description of environmental emergencies and their presentation in the pre-hospital field and how to limit and manage these conditions.

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Environmental Emergencies & Drowning

  1. 1. (Environmental Emergencies & Drowning) Presented by Louis van Rensburg
  2. 2. Factors Affecting Exposure • Physical condition • Age • Nutrition and hydration • Environmental conditions
  3. 3. Loss of Body Heat (1 of 2) • Conduction – Transfer of heat from body to colder object • Convection – Transfer of heat through circulating air • Evaporation – Cooling of body through sweating • Radiation – Loss of body heat directly into a colder environment • Respirations – Loss of body heat during breathing
  4. 4. • 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)
  5. 5. Hypothermia • 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 to hypothermia.
  6. 6. Signs and Symptoms of Mild Hypothermia • Shivering • Rapid pulse and respirations • Red, pale, cyanotic skin
  7. 7. Signs and Symptoms of More Severe Hypothermia • Shivering stops. • Muscular activity decreases. • Fine muscle activity ceases. • Eventually, all muscle activity stops.
  8. 8. Core Temperature Less Than 80°F • Patient may appear dead (or in a coma). • Never assume that a cold, pulseless patient is dead.
  9. 9. Local Cold Injuries • Frostnip – Freezing of the skin but not the deeper surface • Immersion (trench) foot – Prolonged exposure to cold water • Frostbite – Freezing of a body part, usually an extremity
  10. 10. Emergency Care for Local Cold Injury • Remove the patient from further exposure to the cold. • Handle the injured part gently. • Administer oxygen. • Remove any wet or restrictive clothing. • Never rub the area. • Do not break blisters. • Transport.
  11. 11. Warm-Water Bath • Water temperature should be between 38°C and 44.5°C. • Recheck water temperature and stir to circulate. • Keep body part in water until warm and sensation returns. • Dress with dry, sterile dressings.
  12. 12. 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!
  13. 13. On The Scene: Cold Exposure The following slides walk the student though a cold exposure call.
  14. 14. Scene Size-up • Note weather conditions. • Identify safety hazards such as icy roads, mud, or wet grass.
  15. 15. Initial Assessment • Check temperature on patient’s abdomen. • Mental status can be affected. • Ensure adequate airway. • Warmed, humidified oxygen helps warm from inside out. • Palpate for carotid pulse; wait 30–45 seconds. • Transport immediately or move to warmer location.
  16. 16. Focused History and Physical Exam • If unconscious, do a rapid physical exam. • If conscious, attempt to obtain SAMPLE history. – Determine how long the patient was exposed to the cold. – Medications can affect the patient’s metabolism. • Focused physical exam – Concentrate on areas of body directly affected by exposure.
  17. 17. Baseline Vital Signs • Can be altered by hypothermia • Monitor for changes in mental status. • Check for core body temperature.
  18. 18. Interventions • 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.
  19. 19. Detailed Physical Exam • Aimed at determining degree and extent of cold injury • Evaluate skin temperature, texture, and turgor.
  20. 20. Ongoing Assessment • Rewarming can be harmful; monitor carefully. • Communicate conditions at scene, clothing, changes in mental status.
  21. 21. Heat Exposure • 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.
  22. 22. Heat Cramps • Painful muscle spasms • Remove the patient from hot environment. • Rest the cramping muscle. • Replace fluids by mouth. • If cramps persist, transport the patient to hospital.
  23. 23. Signs and Symptoms of Heat Exhaustion (1 of 2) • Dizziness, weakness, or fainting • Onset while working hard or exercising in hot environment • In older people and young, onset may occur while at rest in hot, humid, and poorly ventilated areas. • Cold, clammy skin
  24. 24. 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
  25. 25. Emergency Medical Care • Remove extra clothing and remove from hot environment. • Give patient oxygen. • Have patient lie down and elevate legs. • If patient is alert, give water slowly. • Be prepared to transport.
  26. 26. 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.
  27. 27. Care for Heat Stroke (1 of 2) • Move patient out of the hot environment. • Provide air conditioning at a high setting. • Remove the patient’s clothing. • Give the patient oxygen. • Apply cold packs to the patient’s neck, armpits, and groin.
  28. 28. 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.
  29. 29. On The Scene: Heat Exposure The following slides walk the student through a heat exposure call
  30. 30. 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 not responding. • You note that it is very hot with no source of ventilation.
  31. 31. You are the Provider (continued) • The man is on the couch and conscious but disoriented. • Patent airway, breathing shallow at 22 breaths/min • Skin is red, hot, and dry. • What medical emergency could the patient be experiencing?
  32. 32. Scene Size-up • Do environmental assessment. • Protect yourself from heat and biological hazards. • ALS may need to give IV fluids.
  33. 33. 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; temp 104°F • No signs of traumatic injury • You remove constricting clothing, jewelry. • You move patient into ambulance. • Is this patient a priority?
  34. 34. Initial Assessment • 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 temperature. • Treat for shock aggressively. • If any signs of heatstroke, transport immediately.
  35. 35. 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 and dizzy. • She made him a sandwich and went to the neighbor’s for a few minutes.
  36. 36. 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?
  37. 37. Focused History and Physical Exam • Note activities/medications that may make patient susceptible to heat-related problems. • Determine exposure and activities prior to symptoms. • Assess for muscle cramps, confusion. • Examine for mental status, skin temperature, wetness.
  38. 38. 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.
  39. 39. Interventions • 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.
  40. 40. 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 of hand. • Perform careful neurologic exam.
  41. 41. 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. – Reassess. • What actions should you take during transport to the hospital?
  42. 42. Ongoing Assessment • Watch for deterioration. • Reassess vital signs every 5 minutes. • Do not cause shivering. • Document weather conditions and activities prior to emergency.
  43. 43. Drowning and Near Drowning • Drowning – Death as a result of suffocation after submersion in water • Near drowning – Survival, at least temporarily, after suffocation in water
  44. 44. Drowning Process
  45. 45. Spinal Injuries in Submersion Incidents • Suspect spinal injury if: – Submersion has resulted from a diving mishap or long fall. – Patient is unconscious. – Patient complains of weakness, paralysis, or numbness.
  46. 46. 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.
  47. 47. Resuscitation Efforts • Hypothermia can protect vital organs from hypoxia. • Documented case of a survivor of a 66-minute cold water submersion • Diving reflex may cause heart rate to slow.
  48. 48. Diving Problems • 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
  49. 49. Signs and Symptoms of Air Embolism (1 of 2) • Blotching • Froth at the mouth and nose • Severe pain in muscle, joints, or abdomen • Dyspnea and/or chest pain
  50. 50. Signs and Symptoms of Air Embolism (2 of 2) • Dizziness, nausea, and vomiting • Dysphasia • Difficulty with vision • Paralysis and/or coma • Irregular pulse or cardiac arrest
  51. 51. Decompression Sickness (The Bends) • 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 after hours. • Treatment is BLS and hyperbaric chamber.
  52. 52. Other Water Hazards • Hypothermia from water immersion • Breath-holding syncope • Injuries from recreational equipment or marine animals
  53. 53. Prevention • Pools should be surrounded with appropriate enclosures. • Alcohol involved in adult and teenage drownings.
  54. 54. On The Scene: Drowning The following slides walk the student through a drowning call. Consider showing the pediatric drowning call video
  55. 55. Scene Size-up • Never drive through moving water; be cautious driving through still water. • Never attempt water rescue without proper training and equipment. • Consider trauma and spinal stabilization. • Check for additional patients.
  56. 56. Initial Assessment • Pay attention to chest pain, dyspnea, complaints of sensory changes. • Be suspicious of alcohol use. • Maintain airway; suction. • If pulse cannot be obtained, begin CPR per guidelines. • Evaluate for shock and adequate perfusion. • Treat trauma.
  57. 57. Transport Decision • Always transport near-drowning patients to hospital. • Decompression sickness and air embolism must be treated in recompression chamber. • Perform interventions en route.
  58. 58. Focused History and Physical Exam • If responsive, perform exam on lungs and breath sounds. • If unresponsive: – Look for signs of trauma or complications. – Check divers for indications of air embolism or bends. – Focus on pain in joints and abdomen. – Check for signs of hypothermia; complete Glasgow Coma Scale score.
  59. 59. Baseline Vital Signs/ SAMPLE History • 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 medical conditions. • Determine dive parameters in history depth, time, previous dive activity.
  60. 60. Drowning Interventions • 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 airway. • Make sure patient is warm, especially after cold- water immersion.
  61. 61. Diving Interventions • Remove patient from water. • Begin BLS; administer oxygen. • Place patient in left lateral recumbent position with head down. • Provide prompt transport to nearest recompression facility. • Administer oxygen and provide rapid transport.
  62. 62. Detailed Physical Exam • Examine respiratory, circulatory, neurologic systems. • Distal circulatory, sensory, and motor function tests determine extent of injury. • Examine for peripheral pulses, skin color, and discoloration, itching, pain, numbness/tingling.
  63. 63. Ongoing Assessment • May deteriorate rapidly • Assess mental status frequently. • Document: – Circumstances of drowning and extrication – Time submerged – Temperature of water – Clarity of water – Possible spinal injury • Bring dive log, dive computer, and dive equipment to hospital.
  64. 64. Lightning • 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, superficial burns 2. Moderate: Seizures, respiratory arrest, asystole (spontaneously resolves), superficial burns 3. Severe: Cardiopulmonary arrest
  65. 65. Emergency Medical Care • Protect yourself. • Move patient to sheltered area or stay close to ground. • Use reverse triage. • Treat as for other electrical injuries. • Transport to nearest facility.
  66. 66. Spider Bites • 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 bites. • Your safety is of paramount importance.
  67. 67. 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
  68. 68. 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.
  69. 69. Snake Bites • 40,000 to 50,000 reported snake bites in the US annually. • 7,000 bites in the US come from poisonous snakes. – Death from snake bites is rare. – About 15 deaths occur each year in the US.
  70. 70. Four Types of Poisonous Snakes in the US Copperhead Cottonmouth Coral snake Rattlesnake
  71. 71. Pit Vipers • Rattlesnakes, copperheads, and cotton mouths • Store poison in pits behind nostrils • Inject poison to victim through fangs
  72. 72. 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
  73. 73. 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.
  74. 74. Care for Pit Viper Bites (2 of 2) • If the patient is bitten on the trunk, lay the patient supine and transport quickly. • Monitor patient’s vital signs. • Mark the swollen area with a pen. • Care for shock if signs and symptoms develop. • Bring the snake to hospital if it has been killed.
  75. 75. Coral Snakes • 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
  76. 76. Care for Coral Snake Bites (1 of 2) • Quiet and reassure the patient. • Flush the area with 1 to 2 quarts of warm, soapy water. • Do not apply ice. • Splint the extremity. • Check and monitor baseline vital signs.
  77. 77. 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.
  78. 78. Scorpion Stings • 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
  79. 79. Tick Bites (1 of 3) • Ticks attach themselves to the skin. • Bite is not painful, but potential exposure to infecting organisms is dangerous. • Ticks commonly carry Rocky Mountain spotted fever or Lyme disease.
  80. 80. Tick Bites (2 of 3) • Rocky Mountain spotted fever develops 7 to 10 days after bite. • Symptoms include: – Nausea, vomiting – Headache – Weakness – Paralysis – Possible cardiorespiratory collapse
  81. 81. 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 – Rash – Painful swelling of the joints
  82. 82. 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 for identification. • Provide any necessary supportive emergency care and transport.
  83. 83. 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.
  84. 84. Care for Marine Stings • Limit further discharge by minimizing patient movement. • Inactivate nematocysts by applying alcohol. • Remove the remaining tentacles by scraping them off. • Provide transport to hospital.