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CCT Environmental Emergencies
- 1. Andrew Schmidt, DO, MPH Assistant Professor, UF Jax Emergency Medicine CRITICAL CARE TRANSPORT Chapter 18
- 3. Radiation Transfer of heat by electromagnetic waves from warmer object to colder Air T < 35C 60% Radiation 30% Evaporation
- 4. Conduction Heat transfer between surfaces in direct contact
- 5. Convection Heat transfer by air of liquid moving across surface
- 6. Evaporation Heat loss by vaporization of water Air T > 35 C Body dependent on evaporation As humidity increases Evaporation decreases
- 8. Hyperthermia Heat Edema Heat Rash Heat Cramps Heat Tetany Heat Syncope Heat Exhaustion Heat Stroke
- 10. Heat Exhaustion Temp < 40 C No CNS Involvement
- 11. Heat Exhaustion Heat Stroke Temp > 40 C CNS Involvement
- 13. Classic Heat Stroke Elderly, very young, incapacitated, chronically ill Commonly occurs during heat waves Develops slowly
- 14. Exertional Heat Stroke Generally younger/healthy Engaging in strenuous activity Develops rapidly
- 19. Toxicological Alcohol Withdrawl Anticholinergic Aspirin Overdose Malignant Hyperthermia Serotonin Syndrome NMS
- 20. Resuscitation Goals ABCs Start Cooling Prevent end organ damage
- 21. Cooling Do not administer anti-pyretics Dantrolene not benefitial Cool through active means Cool until core T 101.5-102 F (38.6-38.8 C)
- 22. Conductive Cooling Ice Water Immersion Most efficient technique Primarily studied in exertional Use restricted by resources, monitoring, patient condition
- 23. Conductive Cooling Ice Pack Application Axilla, Groin, Neck, Head Cold, wet towels Both techniques less efficient www.wsj.com
- 24. Evaporative + Convective Cooling Mist and Fan Technique Most useful for classic Skin sprayed with tap water Cool, wet gauze on skin
- 25. Other Cooling Techniques Cold IV Fluids Use as adjunct, ineffective alone Cooling Blankets Ineffective, slow
- 26. HYPOTHERMIA Heat and Cold Emergencies
- 28. Causes of Hypothermia Primary Hypothermia Heat production is overcome by stress of excessive cold
- 29. Causes of Hypothermia Primary Hypothermia Heat production is overcome by stress of excessive cold Secondary Hypothermia Impaired Thermoregulation Endocrine, neoplasm, malnutrition, toxins Increased Heat Loss Sepsis, burns, cold infusions, trauma
- 30. Hypothermia SEVERE MODERATE MILD 28 3 2 35 Traditional Staging
- 31. Neuro Depressed consciousness Impaired judgment Slurred speech Shivering
- 33. ECG Changes
- 34. ECG Changes Prolonged QRS Osborne J Wave
- 36. Respiratory Initial increased respirations Prolonged Decreased respiratory drive Decreased lung compliance Respiratory failure
- 37. Renal Cold diuresis Coagulation Decreased clotting function Thrombocytopenia Can also become hypercoaguable
- 38. Hypothermia SEVERE MODERATE MILD Dysarthria, Ataxia Poor judgement Shivering Tachy ď bradycardia Stupor Shivering stops A fib / arrhythmias Decrease pulse / resp Loss of reflex / vol motion Decreased V-fib threshold Significant brady / HypoTN HT IV HT III HT II HT I
- 39. Resuscitation Goals ABCs Donât make things worse Rewarm
- 40. ABCs Check for âsigns of lifeâ for 60 seconds Utilize Ultrasound Cardiac monitor EtCO2 http://www.cardiopulmonaryresuscitation.net/
- 41. ABCs RSI Possibility of hyperkalemia due to hypoxia and rhabdomyolysis Use caution with depolarizing neuromuscular blockers http://www.clarkmedicalmedia.com/
- 42. Resuscitation Modifications Little evidence Primarily animal models Concern for cold myocardial irresponsive to medications and defibrillation No consensus
- 43. Hypothermia 30 Normal med intervals Normal defib guidelines 3 5 Withhold vasoactive meds Single defib at max J Withhold further until > 30 Meds at double intervals Normal defib guidelines CPR performed at normothermic rate The above represents a combination of AHA and ERC guidelines. Poor evidence
- 44. Donât make things worse Avoid CPR on patients with any signs of life, even profound bradycardia Move/transport patients gently Remove cold/wet clothing www. http://medicalonline.pl/
- 46. Passive Rewarming Remove clothes Allow shivering Dry skin Warm blankets Rate: 0.5 C/hr
- 47. Active External Rewarming Forced air device Radiant heat lamp Hot water bottles Warm water immersion
- 48. Frostbite
- 49. Frostbite ⢠Cassification Frostnip 1st Degree 2nd Degree 3rd Degree 4th Degree
- 50. Frostbite ⢠Frostnip â Superficial â Local discomfort â No tissue lost â Symtpoms usually resolve within 30 minutes
- 51. Frostbite ⢠1st Degree â Numbness and erythema â White/yellow firm plaque
- 52. Frostbite ⢠2nd Degree â Superficial vesiculation â Clear/milky fluid surrounded by erythema
- 53. Frostbite ⢠3rd Degree â Deeper blisters â Purple/blood- containing fluid â Indicates injury has extended through dermis into vascular plexis
- 54. Frostbite ⢠4th Degree â Mummification â Injury completely through dermis
- 55. Clinical Presentation Initial ⢠Numbness (75% of patients) ⢠Body part feels âclumsyâ or absent During re- warming ⢠Extreme pain Hours to days after rewarming ⢠Throbbing pain ⢠Edema ⢠Vesicles or bullae
- 56. Clinical Presentation ⢠Days to weeks after re-warming ⢠Severe injury turns black and mummifies 3 Days 12 Days 3 weeks
- 58. Treatment ⢠Pre-hospital treatment If facility to rewarm is close â˘Transport while protecting tissue from further cold injury If facility to rewarm is far â˘Consider field rewarming
- 59. Treatment Attempt rewarming if there is a chance of refreezing Attempt rewarming if it will be partial or slow Attempt rewarming if patient is severely hypothermic Attempt rewarming of the foot if patient will need to re-apply boot to walk
- 60. Treatment ⢠Rapid Field Rewarming Treat systemic hypothermia before or during treatment of frostbite
- 61. Treatment ⢠Rapid Field Rewarming Fill water container ⢠40 â 42 C ⢠Large enough so extremities wonât touch sides ⢠Ensure additional water available Immerse extremity ⢠Gently circulate water until distal tip becomes flushed ⢠Pain indicates successful rewarming Remove and dry ⢠Allow to dry in warm air ⢠Do not towel dry
- 62. Treatment ⢠Rapid Field Rewarming Evacuate â˘Protect victim from environment â˘Keep well hydrated â˘Do not allow refreezing Extremity care â˘Do not rupture blisters â˘If blisters rupture, apply aloe vera or antibiotic ointment â˘Apply loose/sterile padding â˘Avoid pressure to area Further Treatment â˘Allow active movements â˘Ibuprofen 400mg PO q 12 â˘Monitor for blister rupture or infection, give antibiotics
- 63. Andrew Schmidt, DO, MPH Assistant Professor, UF Jax Emergency Medicine
- 64. The process of experiencing respiratory impairment due to submersion or immersion in a liquid Standard Definition for Drowning
- 65. The process of experiencing respiratory impairment due to submersion or immersion in a liquid Injury No Injury Death Standard Definition for Drowning
- 67. THE DROWNING PROCESS Drowning Resuscitation
- 68. Submersion Struggle Breath Hold Gasp
- 70. HYPOXIA Primary cause of all systemic injury and death associated with drowning
- 77. O2 O2 O2
- 78. Do not try and attempt to remove the foam as it will keep coming. Continue rescue breaths/ventilation until an ALS provider arrives and is able to intubate the victim. If this prevents ventilation com- pletely, turn the victim on their side and remove the regurgitated material using directed suction if possible. ERC 2015
- 81. Cardiac Cause - Tank is full, the engine is broken - Compressions/AED take priority
- 82. Respiratory Cause - The tank is empty, the engine âworksâ - Ventilations take priority
- 83. Eric J. Lavonas, Farida M. Jeejeebhoy and Andrea Gabrielli Terry L. Vanden Hoek, Laurie J. Morrison, Michael Shuster, Michael Donnino, Elizabeth Sinz, Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 12: Cardiac Arrest in Special Situations : 2010 American Heart Association Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright Š 2010 American Heart Association, Inc. All rights reserved. is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation doi: 10.1161/CIRCULATIONAHA.110.971069 2010;122:S829-S861Circulation. http://circ.ahajournals.org/content/122/18_suppl_3/S829 World Wide Web at: The online version of this article, along with updated information and services, is located on the http://circ.ahajournals.org/content/124/15/e405.full.pdf http://circ.ahajournals.org/content/123/6/e239.full.pdf An erratum has been published regarding this article. Please see the attached page for: http://circ.ahajournals.org//subscriptions/ is online at:CirculationInformation about subscribing toSubscriptions: http://www.lww.com/reprints Information about reprints can be found online at:Reprints: document.Permissions and Rights Question and Answerthis process is available in the click Request Permissions in the middle column of the Web page under Services. Further information about Office. Once the online version of the published article for which permission is being requested is located, can be obtained via RightsLink, a service of the Copyright Clearance Center, not the EditorialCirculationin Requests for permissions to reproduce figures, tables, or portions of articles originally publishedPermissions: by guest on April 16, 2013http://circ.ahajournals.org/Downloaded from
- 85. Drowning: Update on a Global Disease
- 86. Drowning: Update on a Global Disease ď AEDs in the aquatic environment Safe and effective to on wet patients as long as pads make good contact with skin Safe for rescuers on wet surfaces Effective in moving boats
- 87. Drowning: Update on a Global Disease ď Question: ⍠Should we do the Heimlich Maneuver on drowning patients?
- 88. Drowning: Update on a Global Disease ď Heimlich Maneuver ⍠Delays much needed ventilations ⍠Recommend against: ⢠American Red Cross ⢠United States Lifesaving Assoc ⢠International Lifesaving Fed ⢠European Resus Council ⢠American Academy Ped ⢠American Heart Assoc
- 89. Drowning: Update on a Global Disease ď Spinal Immobilization ⍠Prevalence of C-spine injury low with drowning ⍠Usually clear signs of trauma ⍠Should not delay resuscitation
- 90. Airway Prioritize establishing ventilation and optimizing oxygenation
- 91. Non-invasive Maintaining patent airway, mentating well Nasal Cannula, Non-rebreather mask
- 92. Non-invasive Positive Pressure Vent Maintaining patent airway, no emesis CPAP/BiPAP: if no rapid improvement, proceed to ETI
- 93. Endotracheal Intubation Not protecting airway, large amount of foam or emesis
- 94. Mechanical Ventilation No large drowning-specific trials Most recommendations follow ARDSnet protocols (VT 6-8ml/kg, Augment PEEP)
- 95. Andrew Schmidt, DO, MPH Assistant Professor, UF Jax Emergency Medicine
- 96. Injuries of Ascent Pulmonary Barotrauma Expansion of gas trapped in lungs May rupture into thoracic cavity or diffuse into capillaries Worse with breath holds taken close to the surface
- 97. Injuries of Ascent Pulmonary Barotrauma Pulmonary hemorrhage Pneumothorax Pneumomediastinum Arterial Gas Embolism
- 98. Injuries of Ascent ⢠Arterial Gas Embolism â Air bubbles entering pulmonary venous circulation from ruptured alveoli â Pulmonary vein ď Left Ventricle ď Aorta ď Systemic â Bubbles become stuck in small capillaries ⢠Brain: ischemia and infarction ⢠Heart: arrhythmias
- 99. Injuries of Ascent ⢠Arterial Gas Embolism â Presentation ⢠Sudden and often life-threatening ⢠Classic: LOC during ascent or upon resurfacing ⢠Any diver who loses consciousness or has signs of serious neuro injury within 10 minutes of surfacing must be considered to have AGE
- 100. Injuries of Ascent ⢠Arterial Gas Embolism â Treatment ⢠Resuscitate ⢠High flow oxygen ⢠IV Fluids (avoid hypotension) ⢠Hyperbaric oxygen therapy â The earlier, the better â Even if symptoms improve â Transport at sea-level pressure
- 101. Indirect Effects of Pressure ⢠Nitrogen Narcosis â Intoxication from increased partial pressure of nitrogen at increased depth â Typically occurs deeper than 20-30 meters below surface â Symptoms ⢠Lightheaded ⢠Loss of fine motor ⢠Poor judgment ⢠Giddiness ⢠Euphoria â Treatment: ascend to shallower depth
- 102. Indirect Effects of Pressure ⢠Oxygen Toxicity â CNS poisoning due to increased partial pressure of oxygen at increased depth for prolonged period â Symptoms ⢠Apprehension ⢠Nausea ⢠Muscle twitching ⢠Seizures â Treatment ⢠Ascend to shallower depth ⢠Removal of supplemental oxygen, unless needed to resus
- 103. Decompression Sickness ⢠Decompression Sickness â Formation of nitrogen bubbles within intravascular and extravascular spaces from reduction in ambient pressure Gas Gas in solution Gas Gas in solution Gas in solution Gas 1 ATA 2 ATA 1 ATA
- 104. Decompression Sickness ⢠Musculoskeletal Decompression Sickness â Most common manifestation of DCS â âThe Bendsâ â Pain in and around major joints ⢠Shoulders and elbows most common ⢠Characterized as dull ache ⢠Worse with movement
- 105. Decompression Sickness ⢠Musculoskeletal Decompression Sickness â Diagnosis ⢠Inflate BP cuff around joint to 150-200 mmHg ⢠Pain will decrease ⢠High specificity, low sensitivity (does not rule out) â Limb bends not immediately life/limb threatening, but indicates bubbling in venous system and possible danger
- 106. Decompression Sickness ⢠Cutaneous Decompression Sickness â Relatively uncommon â Cutis Marmorata (mottling) can be sign of severe DCS
- 107. Decompression Sickness ⢠Pulmonary Decompression Sickness â Relatively uncommon â âThe Chokesâ â Represents massive pulmonary venous air embolism â Burning substernal pain ⢠Worse on inhalation ⢠Cyanosis ⢠Nonproductive cough
- 108. Decompression Sickness ⢠Neurologic Decompression Sickness â Spinal ⢠Lower thoracic and lumbar most common ⢠Low back pain ⢠Heaviness in legs ⢠Paresthesias/paralysis
- 109. Decompression Sickness ⢠Treatment â Initiate resuscitation on scene â Prioritize oxygenation ⢠Use high-flow oxygen ⢠Tight fitting mask â Improve tissue perfusion ⢠IV fluids
- 110. Decompression Sickness ⢠Treatment â Locate and contact closest operating hyperbaric chamber â Rapid transport ⢠Aircraft which can maintain sea-level pressurization ⢠If helicopter, no greater than 800 ft altitude
- 111. Andrew Schmidt, DO, MPH Assistant Professor, UF Jax Emergency Medicine
- 112. Altitude Illness (1 of 4) ⢠Affects experienced mountain climbers pushing limits as well as people who travel from lower to higher elevations in everyday life ⢠People with preexisting medical conditions, extremes of age, sedentary lifestyles, and people with unhealthy lifestyles at greatest risk
- 113. Altitude Illness (2 of 4) ⢠Symptoms can range from imperceptible sleep disturbances to life-threatening pulmonary edema, cerebral edema, and hypoxia. ⢠Altitude sickness is most commonly associated with mountain climbing and skiing at elevations of 3,000ââ8,000â above sea level.
- 114. Altitude Illness (3 of 4) ⢠Lake Louise criteriaâat least two criteria in each group must be present. ⢠Group A â Crackles or wheezing in the lungs â Central cyanosis â Tachypnea (sleep disturbances) â Tachycardia
- 115. Altitude Illness (4 of 4) ⢠Group B â Dyspnea at rest â Cough â Weakness or decreased exercise performance â Chest tightness or congestion
- 116. HAPE (1 of 2) ⢠High-altitude pulmonary edema (HAPE) ⢠People who change altitudes frequently are at highest risk. ⢠Symptoms â Cough â Respiratory distress â Chest tightness â Fatigue â Fever
- 117. HAPE (2 of 2) ⢠Implications â Pulmonary hypertension from alveolar hypoxia â Capillary or arterial thromboses ⢠Rapid descent is the preferred treatment. â Give supplemental oxygen. â Give nifedipine and salmeterol. â Use portable hyperbaric bags.
- 118. HACE ⢠High-altitude cerebral edema (HACE) â Life threatening â Suspect in any person who experiences a significant change in altitude and has a mental status change â Thought to be result of vasodilation from hypoxia
- 119. Flight Considerations ⢠CCTP may be asked to perform a rescue or evacuation function. ⢠Locations may be difficult to reach, especially for ground transportation. ⢠CCTP should carefully consider safety issues such as training, experience of personnel, and capabilities and condition of equipment.
- 120. www.JaxEMS.com
- 121. Andrew Schmidt, DO, MPH Assistant Professor, UF Jax Emergency Medicine