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Em today 2014 firefighter down (1)

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Em today 2014 firefighter down (1)

  1. 1. + Firefighter Down! Special Consideration for the Resuscitation of the Downed Firefighter Christopher Watford, Michael Herbert
  2. 2. + License  This work is released as Free Open Access Meducation! #FOAM  This work is licensed under a Creative Commons Attribution- ShareAlike 4.0 International License.  You are free to:  Share: copy and redistribute the material in any medium or format  Adapt: remix, transform, and build upon the material for any purpose, even commercially.  We cannot revoke these freedoms as long as you follow the license terms.  Under the following terms:  Attribution: you must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.  ShareAlike: if you remix, transform, or build upon the material, you must distribute your contributions under the same license as the original.  No additional restrictions: you may not apply legal terms or technological measures that legally restrict others from doing anything the license permits. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 2
  3. 3. + Who Are These Guys? Christopher Watford, BS, NRP  Lieutenant, Leland Fire/Rescue  Paramedic, New Hanover EMS  Senior Editor, EMS 12-Lead Blog  Lead Software Engineer, GE Nuclear Michael Herbert, BA, NREMT-P  Clinical Educator, Advanced Circulatory  FF/Paramedic, Leland Fire/Rescue Watford, Herbert - Firefighter Resuscitation - EM Today 2014 3
  4. 4. + Conflict of Interest Disclosure Christopher Watford  None Michael Herbert  Employed by Advanced Circulatory as a clinical educator.  Advanced Circulatory is the manufacturer of the ResQPOD and ResQGARD.  Advanced Circulatory has had no financial or editorial input into this presentation or its contents. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 4
  5. 5. + Disclaimer This presentation and our opinions do not reflect the views or opinions of our employers. We’re not speaking for them, we’re speaking for us. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 5
  6. 6. + Why Listen to Us? We are not the experts. We encourage you to question our assumptions We encourage you to question our assertions. We would like you to ask for our references. We would like your feedback on our proposed solution to a problem. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 6
  7. 7. + Objectives  Understand the epidemiology of Firefighter fatalities  Define physiological changes during stress  Define physiological changes during firefighting  Define risks during firefighting  Understand pathophysiology of HCN exposure  Define barriers to treatment during Firefighter resuscitation  Understand treatment goals during Firefighter resuscitation Watford, Herbert - Firefighter Resuscitation - EM Today 2014 7
  8. 8. + Captain David Heath New Hanover County Fire Rescue Watford, Herbert - Firefighter Resuscitation - EM Today 2014 8
  9. 9. + Epidemiology  CDC/NIOSH Fire Fighter Fatality Investigation and Prevention Program “Each year an average of 100 fire fighters die in the line of duty. To address this continuing national occupational fatality problem, NIOSH conducts independent investigations of fire fighter line of duty deaths. This web page provides access to NIOSH investigation reports and other fire fighter safety resources.” Watford, Herbert - Firefighter Resuscitation - EM Today 2014 9
  10. 10. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 10
  11. 11. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 11
  12. 12. + Fatality Etiologies Medical: 1105 (44%)  Heart Attack: 957  CVA: 59  Heat Exhaustion: 9  Other Medical: 80 Trauma: 1384 (56%)  Crushed: 390  MVC: 345  Struck by Vehicle: 145  Asphyxiation: 218  Burns: 118  Electrocution: 22  Drowning: 19  Other Trauma: 108 Watford, Herbert - Firefighter Resuscitation - EM Today 2014 12
  13. 13. + Trauma Fatalities Collapsing structures most common traumatic etiology Motor vehicle collisions second most common Being struck by a vehicle also common! Asphyxiation likely if trapped or lost Watford, Herbert - Firefighter Resuscitation - EM Today 2014 13
  14. 14. + Trauma Fatalities (en route) Rollovers very common Too fast, high center of gravity, inexperience, weather Intersection collisions common Too fast, driving without due regard Overuse of lights and sirens? Watford, Herbert - Firefighter Resuscitation - EM Today 2014 14
  15. 15. + Trauma Fatalities (on scene) Working an MVC is one of the most dangerous jobs a firefighter or EMS provider will do. Spend more time blocking the scene Backers are even more important on busy fire scenes Numerous fatalities from apparatus repositioning Watford, Herbert - Firefighter Resuscitation - EM Today 2014 15
  16. 16. + Trauma Fatalities (overhaul) Structure collapse during overhaul is a real concern Toxic gasses during overhaul too Electrocution rare, but happens Watford, Herbert - Firefighter Resuscitation - EM Today 2014 16
  17. 17. + Medical Fatalities Heart Attacks are the number one cause of line of duty deaths in fire fighters. Autopsies of firefighters include findings such as: cardiomegaly, hypertrophy, severe CAD, etc. Heat exhaustion fairly common during training events Heat exhaustion coupled with cardiovascular risks is a dangerous mix! Watford, Herbert - Firefighter Resuscitation - EM Today 2014 17
  18. 18. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 18
  19. 19. + Medical Fatalities (cont.)  CVA’s are comparatively rare  Cardiomyopathies and channelopathies should be considered in younger firefighters who collapse  Do you know what medical problems your crew has?  Comorbid factors may play a large role in FF fatalities  Certain Cancers are now recognized as resulting from Line of Duty incidents! Watford, Herbert - Firefighter Resuscitation - EM Today 2014 19
  20. 20. +Physiological Effects of Firefighting Watford, Herbert - Firefighter Resuscitation - EM Today 2014 20
  21. 21. + Physiological Effects of Firefighting Watford, Herbert - Firefighter Resuscitation - EM Today 2014 21
  22. 22. + The Stress of Firefighting Firefighters: perform strenuous physical work while wearing heavy personal protective equipment (PPE) often in hot environments and under physiologically stressful conditions Watford, Herbert - Firefighter Resuscitation - EM Today 2014 22
  23. 23. + The Stress of Firefighting Firefighting results in significant cardiovascular and thermal strain as a result of: strenuous work heavy and insulating PPE psychological stress environmental extremes Watford, Herbert - Firefighter Resuscitation - EM Today 2014 23
  24. 24. + Physiology of Stress in Firefighting Strenuous firefighting activities can lead to: Attainment of maximal HR Elevated core temperature Dehydration Decreased stroke volume Increased arterial stiffness Alterations of myocardial function Watford, Herbert - Firefighter Resuscitation - EM Today 2014 24
  25. 25. + Other Stress of Fire/EMS Response Alarm Response  “Noxious Arousal” from pager T-wave inversion seen even in healthy subjects Watford, Herbert - Firefighter Resuscitation - EM Today 2014 25
  26. 26. + Cardiovascular Effects of Note  At the Attainment of Maximal Heart Rate… Subendocardial viability ratio (SEVR): Decreases  Index of myocardial oxygen supply and demand  Decrease in myocardial perfusion relative to cardiac workload.  Rate Pressure Product: Increases  Determines the myocardial workload  Increases significantly during firefighting activity due to the increase in myocardial oxygen consumption. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 26
  27. 27. + Question Is a reduced SEVR and increased RPP related to sudden cardiac events during firefighting? Watford, Herbert - Firefighter Resuscitation - EM Today 2014 27
  28. 28. + Answer We don’t know… More research into the effects of firefighting is needed! Watford, Herbert - Firefighter Resuscitation - EM Today 2014 28
  29. 29. + Hematological and Blood Chemistry Changes  Hemoconcentration  ~15% reduction in plasma volume  Release of platelets from the spleen and lymph tissue  Platelet count increased significantly (18%)  H&H increases  Hemoglobin (Hgb) and hematocrit (Hct) revealed small but significant increases (P<0.001)  Platelet closure time decreased significantly (15% ADP, 20% EPI) Watford, Herbert - Firefighter Resuscitation - EM Today 2014 29
  30. 30. + Hematological and Blood Chemistry Changes *Decreased Platelet closure time == Quicker Clotting Watford, Herbert - Firefighter Resuscitation - EM Today 2014 30 Smith et al. 2013 - Clotting and fibrinolytic changes after firefighting activities
  31. 31. + Fibrinolytic changes Watford, Herbert - Firefighter Resuscitation - EM Today 2014 31 Smith et al. 2013 - Clotting and fibrinolytic changes after firefighting activities
  32. 32. + Coagulatory changes Watford, Herbert - Firefighter Resuscitation - EM Today 2014 32 Smith et al. 2013 - Clotting and fibrinolytic changes after firefighting activities
  33. 33. + Changes from Baseline Coagulation 1.45 1.22 1.38 1.09 200% 175% 150% 125% 100% 75% 50% 25% 0% FVIII TF Pre Post 120Post 450% 400% 350% 300% 250% 200% 150% 100% 50% 0% Fibrinolytic Tpa act Tpa agn Pre Post 120Post Watford, Herbert - Firefighter Resuscitation - EM Today 2014 33 Horn et al 2010: Effects of Fire Fighting and On Scene Rehab on Hemostasis
  34. 34. + Risks of SCA during Firefighting  2007 study by Kales and coworkers clearly demonstrated that the relative risk of suffering from a fatal cardiac event was 10– 100 times greater following fire-suppression activities than during non-fire duties. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 34
  35. 35. + Summary  Studies suggest there is an increased risk of thrombosis due to a procoagulatory state, hours after firefighting.  In effect an increased vulnerability to myocardial infarction after fighting fire. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 35
  36. 36. + How do we address this?  NIOSH and NFPA stress Prevention and Detection as the key!  Reduce modifiable risk factors  Fitness and Nutrition Programs  Smoking Cessation Programs  Screening and Detection  Annual Physicals  Assessment of Cardiovascular Risks Watford, Herbert - Firefighter Resuscitation - EM Today 2014 36
  37. 37. +Chemical Exposures during Firefighting Watford, Herbert - Firefighter Resuscitation - EM Today 2014 37
  38. 38. Used with permission from Capt. Steve Jones – Burlington Fire Dept Ammonia Methane Dioxin Benzene Chloromethane Bromomethane Oxides of Nitrogen Carbonyl Fluoride Furfural Sulfur Dioxide Formaldehyde Phosgene Ethylene Carbon Dioxide Hydrogen Sulfide PCB’s Acrolein Carbon Monoxide Hydrogen Cyanide Benzopyrine Alcohols Acetic Acid
  39. 39. + Let’s concentrate on the “toxic twins”… Watford, Herbert - Firefighter Resuscitation - EM Today 2014 39
  40. 40. + Toxic Twins Hydrogen Cyanide Carbon Monoxide Watford, Herbert - Firefighter Resuscitation - EM Today 2014 40
  41. 41. + Cyanide  Extremely poisonous, colorless chemical, with faint almond* smell.  24 times more toxic then CO  Synergistic toxicity with CO  IDLH – 50ppm  NIOSH REL – 5ppm  OSHA PEL – 10ppm Watford, Herbert - Firefighter Resuscitation - EM Today 2014 41
  42. 42. + Pathophysiology of Cyanide Histotoxic hypoxia  Inability of cells to take up or utilize oxygen from the bloodstream  Despite physiologically normal delivery of oxygen to such cells. Inhibits cytochrome C-oxidase Watford, Herbert - Firefighter Resuscitation - EM Today 2014 42
  43. 43. + Signs & Symptoms of CN toxicity  Headache  Confusion  Anxiety  Blurred vision  Loss of judgment  Increased respiratory rate  Dyspnea  Cardiac arrhythmias  Seizures  Coma  Death MODERATE EXPOSURE SERIOUS EXPOSURE Used with permission from Capt. Steve Jones – Burlington Fire Dept
  44. 44. + Cyanide Poisoning Cyanide exposure: Expected in those exposed to smoke in closed-space fires Important cause of incapacitation and death in smoke-inhalation victims Cyanide can act independently of, and perhaps synergistically with, carbon monoxide to cause morbidity and mortality (“Toxic Twins”) Watford, Herbert - Firefighter Resuscitation - EM Today 2014 44
  45. 45. + Columbia Fire Department Study  Eight month study monitoring CO and HCN at fires.  Found extremely high HCN levels at calls  Found no correlation between CO and HCN production Used with permission from Capt. Steve Jones – Burlington Fire Dept
  46. 46. + Food for thought… Air monitoring of these firefighters at this moment found HCN levels to be: 38 ppm 46 Used with permission from Capt. Steve Jones – Burlington Fire Dept
  47. 47. + Treatment Watford, Herbert - Firefighter Resuscitation - EM Today 2014 47
  48. 48. + Suggested Literature Review Watford, Herbert - Firefighter Resuscitation - EM Today 2014 48 Report of the Investigation Committee into the Cyanide Poisonings of Providence Firefighters. J. Curtis Varone, Thomas N. Warren, Kevin Jutras, Joseph Molis, Joseph Dorsey. May 30, 2006.
  49. 49. + Special Considerations during Resuscitation Watford, Herbert - Firefighter Resuscitation - EM Today 2014 49
  50. 50. + RIT If the downed firefighter is inside a structure, you’ll need to effect rescue. MAYDAY incidents are chaotic and communication will be poor. Frequent training for RIT will improve chance of a rescue. Consider that it may take upwards of 15 minutes to rescue a downed firefighter. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 50
  51. 51. + Determining the Etiology RIT has just rescued a downed firefighter. Does not appear to be breathing. Is it trauma?  Blunt? Penetrating? Asphyxiation? Is it medical? Does it matter initially? Watford, Herbert - Firefighter Resuscitation - EM Today 2014 51
  52. 52. + Getting them out of their gear! Extrication. We’re at an impasse until we get these guys out of their turnout gear. Their gear is going to be hot, wet, maybe even contaminated. Their gear is in the way of what we need to be doing: Chest Compressions! Watford, Herbert - Firefighter Resuscitation - EM Today 2014 52
  53. 53. + FD-CPR Concept began with Hilton Head Island Fire & Rescue  Video showing the time delay to get firefighter out of gear  Thanks to Capt. Tom Bouthillet for sharing their experience on Youtube Revised with the help of input from numerous firefighters and EMS providers. Proposed Process: FD-CPR  10 Steps to Doff Gear and perform CPR Watford, Herbert - Firefighter Resuscitation - EM Today 2014 53
  54. 54. +FD-CPR Video Watford, Herbert - Firefighter Resuscitation - EM Today 2014 54
  55. 55. + Treatment CPR, CPR, and more CPR. Consider the etiology Was their air cylinder empty? Early adv airway. Was their mask off? Early adv airway and consider HCN.  Did they simply collapse suddenly? Std pit crew.  Structure collapse? Check rhythm, transport decision? Watford, Herbert - Firefighter Resuscitation - EM Today 2014 55
  56. 56. + Your Plan? What is your plan for: EMS response to structure fires? Rehab? RIT? Downed firefighters? Cyanide exposure? Watford, Herbert - Firefighter Resuscitation - EM Today 2014 56
  57. 57. + FD-CPR References  Us:  Christopher.Watford@lelandfirerescue.com  Mike.Herbert@lelandfirerescue.com  Leland Volunteer Fire/Rescue Department  http://www.lelandfirerescue.com  http://www.facebook.com/lelandfirerescue  http://www.facebook.com/LelandFireRescueTraining FD-CPR  http://www.fd-cpr.com (Coming Soon!)  http://www.facebook.com/fd-cpr (Coming Soon!) Watford, Herbert - Firefighter Resuscitation - EM Today 2014 57
  58. 58. + References  NIOSH Fire Fighter Fatality Investigation and Prevention Program.  http://www.cdc.gov/niosh/fire/  Brandt-Rauf PW, et al. Health hazards of fire fighters: exposure assessment. Br J Indust Med. 1988; 45:606-612.  Smith DL, et al. Effect of strenuous live-fire fire fighting drills on hematological blood chemistry and psychological measures. J Therm Biol. 2001; 26:375-379.  CDC. Fatalities Among Volunteer and Career Firefighters: United States, 1994-2004. Morbidity and Mortality Weekly Report. 2006; 55(16):453-455.  Dweck MR, et al. Noxious arousal induces T-wave changes in healthy subjects. J Electrocardiol. 2006; 39:324-330.  NIOSH. Preventing Fire Fighter Fatalities Due to Heart Attacks and Other Sudden Cardiovascular Events. Publication Number 2007-133. June 2007. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 58
  59. 59. + References  Geibe JR, et al. Predictors of On-Duty Coronary Events in Male Firefighters in the United States. Am J Cardiol. 2008; 101:585-589.  Fahs CA, et al. Impact of Excess Body Weight on Arterial Structure, Function, and Blood Pressure in Firefighters. Am J Cardiol. 2009; 104:1441-1445.  Horn GP, et al. The Effects of Fire Fighting and On-Scene Rehabilitation on Hemostatis. University of Illinois Fire Service Institute. November 2010.  Estes CR, Marsh SM, Castillo DN. Surveillance of Traumatic Firefighter Fatalities: An Assessment of Four Systems. Pub Health Rep. 2011; 126:540-551.  Kunadharaju K, Smith TD, DeJoy DM. Line-of-duty deaths among U.S. firefighters: An analysis of fatality investigations. Acc Anal and Prev. 2011; 43:1171-1180.  Smith DL, et al. Effect of Live-Fire Training Drills on Firefighters’ Platelet Number and Function. Prehosp Emerg Care. 2011; 15:233-239. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 59
  60. 60. + References  Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment stragies. Scand J Trauma Resus Emerg Med. 2013; 21(31):1-15.  IAFF. Heart Disease in the Fire Service. 2013.  http://www.iaff.org/hs/index.htm  Smith DL, Barr DA, Kales SN. Extreme sacrifice: sudden cardiac death in the US Fire Service. Extr Phys Med. 2013; 2(6):1-9.  Mbanu I, et al. Seasonality and Coronary Heart Disease Deaths in United States Firefighters. Chronobiol Int. 2007; 24(4):715-726.  Poston WSC, et al. An examination of the benefits of health promotion programs for the national fire service. BMC Pub Health. 2013; 13(805):1-14.  Yang J, et al. Sudden Cardiac Death Among Firefighters ≤45 Years of Age in the United States. Am J Cardiol. 2013; 112:1962-1967. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 60
  61. 61. + References  Fent KW, et al. Systemic Exposure to PAHs and Benzene in Firefighters Suppressing Controlled Structure Fires. Ann Ccup Hyg. 2014; 58(7):830-845.  Hostler D, et al. A Randomized Controlled Trial of Aspirin and Exertional Heat Stress Activation of Platelets in Firefighters during Exertion in Thermal Protective Clothing. Prehosp Emerg Care. 2014; 18:359-367.  Hunter A, et al. Abstract 27: Fire simulation exposure causes impairment of endothelial function and increased thrombogenicity in healthy firefighters. Heart. 2014; 100(Suppl 3):A14-A15.  Kales SN, Smith DL. Sudden cardiac death in the fire service. Occup Med. 2014; 64:228-232.  Perroni F, et al. Psychophysiological Responses of Firefighters to Emergencies: A Review. Open Sport Sci J. 2014; 7(Suppl-1, M3):8-15.  Smith DL, et al. Clotting and Fibrinolytic Changes after Firefighting Activities. Med Sci Sports Exerc. 2014; 46(3):448-454. Watford, Herbert - Firefighter Resuscitation - EM Today 2014 61

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