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Environmental emergencies
- 4. For patients suffering the effects of hyperthermia (high temperature)
- 5. Heat Illness Increased core body temperature
- 6. Heat Disorders Hyperthermia Heat cramps Heat exhaustion Heat stroke Fever
- 7. Hyperthermia Unusually high core body temperature – Diaphoresis – Increased skin temperature – Flushing – Altered mentation – Altered level of consciousness
- 8. Predisposing Factors Age Health Diabetes (autonomic neuropathy) damages thermoregulatory mechanisms Medications (diuretics, beta blockers, psych) Level of acclimatization – Length of exposure – Intensity – Humidity and wind
- 9. Heat Cramps
- 10. Heat Cramps Signs and Symptoms: muscle cramps in extremities and/or abdomen hot sweaty skin, weakness, dizziness normal temperature
- 11. Heat Cramps Sodium transported to skin Water follows sodium Loss of sodium
- 12. Symptoms
- 13. Heat Exhaustion Signs and Symptoms: cool and clammy skin profuse sweating, nausea/vomiting weakness, dizziness transient syncope, muscle cramps, headache normal or slightly elevated temperature
- 14. Symptoms
- 15. Heat Exhaustion
- 16. Heat Exhaustion Don’t give salt tablets Treat for shock Remove patient from heat PO liquids if alert IV fluids
- 18. Heat Stroke Signs and Symptoms: Hot dry skin (sweating may be present), confusion and disorientation, rapid and shallow respirations (which may later slow) seizures, coma, and an elevated temperature above 105° F.
- 19. Heat Stroke Hypotension with low or absent diastolic BP Deep respirations that become slow Seizures Cessation of sweating
- 20. Heat Stroke Classic (people with chronic diseases) Exertional – May develop severe metabolic acidosis – Hyperkalemia – Renal failure
- 21. Which is worse?
- 23. Basic Level Treatment Initial Assessment (protocol 2.1.1) Airway Management (protocol 2.1.2) Attach monitor Attach pulse ox Remove patient from warm environment
- 24. Basic Level Treatment For heat cramps and heat exhaustion, if patient is alert, encourage drinking water Follow water with salt containing fluids like half strength gatorade
- 26. Basic Level Treatment If findings are suggestive of heat stroke: – Remove to cooler environment – Cool with ice packs or moist sheets – Stop cooling when core temp is 102.2 degrees Farenheit
- 27. Advanced Level Treatment Initiate IV of LR or NS at 125ml/hr If hypotensive and/or tachycardic, bolus with 1L of fluid in 250 mL increments Recheck vitals and lung exam between each increment Discontinue bolus if signs of pulmonary edema or respiratory distress
- 28. Advanced Level Treatment If altered mental status, check serum glucose level – If BGL is 60-80, give ½ amp D50 IV, or Glucagon 1mg IM, or oral glucose – If BGL <60, give 1 amp D50 or Glucagon 1mg IM – If BGL >80 and <200, provide supportive care – If BGL >200 go to hyperglycemia protocol
- 29. Advanced Level Treatment If seizures are present, and suspected to be heat related: – Protect airway with appropriate airway adjuncts – Valium 5-10mg IV/IO or Versed 2- 4mg IV/IO
- 30. More Treatment Avoid vasopressors and anticholinergic drugs These drugs may inhibit sweating
- 31. Cold Emergencies
- 32. Thermal Gradiant Difference in temperature between environment and the body.
- 33. Thermogenesis The production of heat, especially within the body Work induced (exercise) Thermoregulatory (hormonal) Metabolic or diet-induced- processing food and nutrients
- 34. Heat Loss Conduction Convection Radiation Evaporation Respiration
- 36. Thermoregulation Maintenance of temperature Core temperature 98.6 37 Celsius
- 37. Hypothalmus Base of the brain Temperature regulation
- 38. Thermoreceptors Skin Mucous membranes Spinal cord Abdominal viscera Great veins
- 39. Metabolic Rate BMR- Rate at which body consumes energy to maintain stability
- 40. Cold Disorders Hypothermia Mild Moderate Severe Frostbite Trench Foot
- 41. Factors that predispose or contribute to Hypothermia Geriatric patients Pediatric patients Diabetics Poorly nourished Hypothyroidism Brain tumors Head injury Sepsis Alcohol and drugs Prolonged exposure to water or low atmospheric conditions
- 42. Categories: Mild Hypothermia Moderate Hypothermia Severe Hypothermia Frostbite
- 43. Frostbite Local tissue freezing
- 44. Frostbite Superficial Deep (Epidermal and subcutaneous tissues)
- 45. Frostbite: Treatment Initial patient assessment protocol Airway management protocol (provide Oxygen as needed) Attach cardiac monitor Remove wet clothes and dry patient Protect from heat loss and wind chill Maintain in a horizontal position Check core temperature if possible
- 46. Frostbite: Treatment (cont.) Bandage with dry sterile dressing Avoid pressure, friction, and trauma Do not rub or break blisters Do not allow limb to thaw if there is a chance it will refreeze Do not allow patient to ambulate Maintain core body temperature May administer warm fluids to conscious patients Use pulse ox to assess for peripheral perfusion
- 47. Frostbite: Treatment (ALS) If severe pain, give one of the following: Morphine 2-10 mg IV Fentanyl 50 – 100 mcg IV
- 48. Trench Foot Similar to frost bite Temperatures above freezing Blisters and pain
- 49. Hypothermia Mild Moderate Severe Acute (fall into icy pond) Subacute (mountain climbers trapped) Chronic (urban outdoorsmen)
- 51. Mild to Moderate Hypothermia 86 – 96 ̊ F History of exposure to cold Altered LOC Shivering Muscle stiffness Stumbling or staggering gait Cool or cold skin Mottled or pale skin
- 52. Mild to Moderate Hypothermia: BLS Treatment Warm humidified Oxygen 12 – 15 L/min Maintain pulse ox > 95 % Remove wet garments Cover with blankets Gentle handling Warm environment Give warm fluids orally if no altered mentation
- 53. Mild to Moderate Hypothermia: ALS Treatment Large bore IV of warm saline at 75 mL/hr If altered mental status perform dextrose stick: If sugar 60 mg/dl - 80 mg/dl give; ½ amp of 25gm 50% Dextrose IV or Glucagon 1mg IM or Sublingual glucose paste, may repeat x 1 if after 15 minutes recheck fingerstick glucose < 80 mg/dl b. If Blood sugar < 60 mg/dl 1 amp 25gm 50% Dextrose IV or Glucagon 1 mg IM c. If glucose > 80 mg/dl and < 200 mg/dl provide supportive care, keep NPO d. If glucose > 200 mg/dl, go to Hyperglycemia Protocol 2.8.2.
- 54. Severe Hypothermia: With Vital Signs Present < 86 ̊ F Same as mild to moderate May not be shivering Should have altered mental status May be difficult to detect vital signs
- 55. Severe Hypothermia Treatment BLS and ALS Same as for mild to moderate KEEP PATIENT NPO (NOTHING BY MOUTH)
- 56. Rewarming Shock Caused by reflex peripheral vasodilation May worsen hypothermia
- 57. Cooling Diuresis Volume depletion due to vasoconstriction and increased BP. Kidneys then remove excess fluid
- 58. Severe with NO Vital Signs Same symptoms but patient is without vital signs and is unresponsive
- 59. Severe Without Vitals (BLS) Warm, humidified oxygen via BVM CPR Gentle warming Warm environment as much as possible
- 60. Severe Without Vitals (ALS) Intubate patient and ventilate with warm, humidified Oxygen Cardiac Monitor Defibrillate (200,300,360 for adult) (Peds: 2 J / kg, 4 J / kg, 4 J/kg) Medication Therapy- Hold until core temp reaches > 86 ̊̊ Large Bore IV or IO Administer warm saline 75 mL/hr
- 61. Resusciatation Further shocks should be avoided until core temp is above 86 F
- 64. Fresh water or salt water An incident in which someone is submersed in a liquid that prevents the person from breathing air and that results in respiratory impairment, whether the person lives or dies after the process Drowning
- 65. Overview of drowning When submerged, the lack of ventilation causes hypoxia and acidosis Hypoxia and acidosis damage the cells, tissues, and organs and will lead to cardiac arrest if the person is not pulled from the water in a timely manner Water-Related Emergencies
- 66. Patients who have coughed, vomited and / or rested may initially decline transport… These patients should be strongly encouraged to be transported for evaluation.
- 67. Causes of drowning Exhaustion in the water Losing control or being swept into deep water Becoming tangled or entrapped while in the water Using alcohol or drugs in or near the water Losing a support such as a sinking boat Water-Related Emergencies
- 69. Dry Vs. Wet Panic leads to violent inspiratory effort Laryngospasm may occur Significant amount of water does not enter lungs Drowning is due to asphyxia from airway obstruction secondary to aspirated water or larygospasm
- 71. Freshwater Hemodilution Reduction in red blood cell concentration Thickening of alveolar walls Bleeding lung inflammation Destruction of surfactant Atelectasis- alveolar collapse Red blood cells travel to lungs but are not oxygenated Ventricular fibrillation likely
- 72. Mammalian Diving Reflex Breathing inhibited Bradycardia Vasoconstriction Oxygen sent to areas needed (cerebral and cardiac)
- 73. • Mammalian diving reflex – The mammalian diving reflex activates when a person dives into cold water (<70oF) • Larynx spasms • Breathing is inhibited • Heart rate slows • Blood vessels constrict • Blood flow to the brain and heart are increased Water-Related Emergencies
- 74. Saltwater Water drawn from blood stream into alveoli Pulmonary edema Profound shunting Respiratory and metabolic acidosis
- 75. Potential Comlications Pulmonary Edema Aspiration pneumonia
- 76. Basic Level Treatment: BLS / ALS Initial Patient Assessment Protocol 2.1.1 Immobilize cervical spine if trauma is suspected Airway Assessment/Management Protocol 2.1.2 Attach cardiac monitor and Pulse oximeter Maintain body temperature… Start passive re-warming if hypothermic
- 77. Determine Pertinent History Duration of submersion Depth Water temperature Possible seizure activity Drug and/or alcohol use
- 78. ALS Level 1: Paramedic Only Initiate IV LR or NS at 125 mL / hr If patient is hypotensive (<90 systolic) or tachycardic (>110 bpm): Bolus in 250 mL increments up to 1-2 liters Recheck vital signs and lung exam prior to each bolus Discontinue bolus with signs of pulmonary edema or respiratory distress
- 79. If patient is apneic Initiate and maintain mechanical ventilation with 100 % oxygen Endotracheal intubation Treat dysrhythmias per appropriate protocol Transport and contact medical control
- 80. If Apneic AND Pulseless BVM with 100 % Oxygen CPR Intubation with in-line cervical immobilization Treat dysrhythmias as appropriate Transport and contact medical control
- 81. If Altered Mental Status Determine blood glucose If Bgl 60-80 mg/dl: Give ½ amp of D50 IV or 1 mg Glucagon IM or SL paste May repeat if bgl < 80 mg/dl If Bgl < 60 mg/dl: 1 amp (25 gram) Dextrose IV or 1 mg Glucagon IM If Bgl > 80 mg/dl and < 200 mg/dl Give supportive care, nothing PO If Bgl > 200 mg/dl Go to Hyperglycemia Protocol 2.8.2
- 82. ALS Level 2: Medical Control Contact medical control or medical director if any concerns or questions Consider Dopamine drip for patient unresponsive to fluid challenge. Begin infusion at 2 mcg/kg/min and titrate to maintain BP > 90 systolic.
- 88. Safety measures in water-related emergencies Must be a good swimmer Trained in water rescue Have a personal floatation device Accompanied by other rescuers Water-Related Emergencies
- 92. Diving emergencies Submersion events can be complicated with head and spinal injuries If a patient dove into the water, always assume that he has sustained a spinal injury and manage with the appropriate precautions Water-Related Emergencies
- 93. Assessment and care Scene size-up If the patient is in the water and is suspected of having a spinal injury, take the appropriate spinal precautions: Water-Related Emergencies
- 94. Assessment and care Spinal precautions (continued) Water-Related Emergencies
- 95. Assessment and care Spinal precautions (continued) Water-Related Emergencies
- 97. • For patients who suffer the effects of sudden changes in atmospheric pressure due to diving related emergencies
- 98. Barotrauma/Decompression Sickness • Caused by changes in the surrounding atmospheric pressure beyond the body’s capacity to compensate for excess gas load
- 99. Barotrauma/Decompression Sickness • These injuries are most commonly associated with the use of SCUBA (Self Contained Underwater Breathing Apparatus)
- 100. Barotrauma/Decompression Sickness • Can occur at any depth • If a patient took a breath underwater, from any source of compressed gas, while greater than 3’ depth, they might be a victim of barotrauma • May cause several types of injuries
- 101. The Effects of Air Pressure on Gases • Water has density of 62.4 pounds per cubic foot • Atmospheric air pressure normally 14.7 pounds per square inch: • 760 mmHg
- 102. Boyle’s Law • Volume of gas inversely proportional to its pressure if temperature is kept constant. • P1V1=P2V2
- 106. Dalton’s Law • Partial Pressures
- 107. Henry’s Law • P= concentration of dissolved gases / solubility coefficient In other words: The amount of a gas dissolved in a given volume of fluid is proportional to the pressure of the gas above it.
- 109. Barotrauma • Injuries caused by changes in pressure.
- 110. The ‘Squeeze’ • Barotrauma during descent – Middle ear pain – Dizziness – Ringing in ears – Hearing loss – Rupture of eardrum – Sinus infection while diving = bad
- 111. Injuries at the Bottom • Nitrogen Narcosis (state of stupor) • “Raptures of the Deep”
- 112. Injuries During Ascent • Decompression Sickness- The Bends • Pulmonary Overpressure • Arterial Gas Embolism • Pneumomediastinum • Pneumothorax
- 113. Barotrauma/Decompression Sickness • Types of injuries Arterial Gas Embolism (Gas bubble(s) in an artery which can occlude blood flow)
- 114. Barotrauma/Decompression Sickness • Types of injuries Pneumothorax (Air in the space around the lungs)
- 115. Barotrauma/Decompression Sickness • Types of injuries Pneumo- mediastinum (air in the space in the middle of the chest, Between the lungs)
- 116. Barotrauma/Decompression Sickness • Types of injuries Subcutaneous Emphysema (Bubbles of air in the subcutaneous tissue)
- 117. Barotrauma/Decompression Sickness • Types of injuries Aerosinusitis (“the squeeze”-an inflammatory reaction in the nasal sinuses)
- 118. Barotrauma/Decompression Sickness • Types of injuries Decompression Sickness (“the bends”-A build up of nitrogen bubbles in the body)
- 119. Arterial Gas Embolism • AGE • A large air bubble… May obstruct blood flow and cause ischemia…. • Devastating effects triggered by cardiac, pulmonary, cerebral compromise
- 120. Basic Level Treatment • Place patient in a supine, head-down, left lateral decubitus position
- 121. Basic Level Treatment • Complete the Dive Accident Signs and Symptoms Checklist – Found in Section VIII of EMS Protocols and SOGs • Start the Dive History Profile – Found in Section VIII of EMS Protocols and SOGs
- 122. Basic Level Treatment • Protect against hypothermia and hyperthermia • Monitor closely for complications and treat per protocols • Transport to nearest ED or Trauma Center – Consider transport to a hyperbaric facility
- 123. Basic Level Treatment • Contact Diver’s Alert Network at Duke University Medical Center for assistance as needed • (989)684-4326 • Bring dive computer to the hospital if available
- 124. Advanced Level Treatment • Initiate IV of LR or NS TKO