Transcript JUNE 2014 CME

Warm Weather Emergencies
Firework Injuries
Legal Review of Intoxicated Person
JUNE 2014 CME
SILVER CROSS EMS SYSTEM
SUBMERSION INJURIES: DROWNING &
ASSOCIATED CAUTIONS

Definition and description
 Immersion
 Submersion
 Drowning
SUBMERSION INJURIES: DROWNING &
ASSOCIATED CAUTIONS

Immersion syndrome
 Sudden
cardiac arrest caused by massive vagal
stimulation after sudden exposure to cold water

Postimmersion syndrome
 Delayed
deterioration of a previous asymptomatic
or minimally symptomatic patient
SUBMERSION INJURIES: DROWNING &
ASSOCIATED CAUTIONS

Shallow water blackout
 Unconsciousness
after submersion
SUBMERSION INJURIES: DROWNING &
ASSOCIATED CAUTIONS

Epidemiology & demographics
 Second
leading cause of accidental death in US
 Leading cause of accidental pediatric death
 Teenagers second major group
 Elderly third highest group
SUBMERSION INJURIES: DROWNING &
ASSOCIATED CAUTIONS

Etiology
 Classic
sequence starts with panic
 Victim
can no longer hold breath, reflexively takes a
breath, and water enters mouth
 Victim takes several violent intakes of air and water while
flailing
SUBMERSION INJURIES: DROWNING &
ASSOCIATED CAUTIONS

Etiology
 Water
intake hits posterior oropharynx
 Laryngospasm
 Bronchospasm
 Severe
hypoxia
 Acidosis
 Cardiac disturbances
 CNS anoxia
 Coma
SUBMERSION INJURIES: DROWNING &
ASSOCIATED CAUTIONS

Physical findings
 Often
accompanied by trauma
 Cardiac disturbances common
 Hypothermia common
SUBMERSION INJURIES: DROWNING &
ASSOCIATED CAUTIONS

Differential diagnosis
 Trauma
 Spinal
injury
 Cardiac disturbances
 Hypothermia
 Hypoglycemia
 CNS disturbances
 Metabolic abnormalities
SUBMERSION INJURIES: DROWNING &
ASSOCIATED CAUTIONS

Therapeutic interventions
 Priority
is reversing hypoxia
 If any resuscitation is required, patient must be
transported
SUBMERSION INJURIES: DROWNING &
ASSOCIATED CAUTIONS

Complications
 Sudden
respiratory arrest
 ARDS
 Release
of fluid into alveoli
 Inflammation of alveoli and lung tissue
 Loss of surfactant
 Atelectasis
 Aspiration pneumonia
 Pneumothorax
ANATOMY & PHYSIOLOGY REVIEW

Homeostasis
 State

of equilibrium
Homeotherm
 Body
that strives to stay within 1° of norm
ANATOMY & PHYSIOLOGY REVIEW

Thermoregulation







Thermoreceptors
Brain
Skin
Spinal cord
Abdominal viscera
Great vessels
Metabolism

Increases to generate heat
ANATOMY & PHYSIOLOGY REVIEW

External mechanisms of heat and cold response
Radiation
 Exchange heat with surroundings
 Convection
 Air movement moves heat being radiated
 Conduction
 Direct contact with an object
 Evaporation
 Heat transfer mechanisms in tandem

ANATOMY & PHYSIOLOGY REVIEW

External mechanisms of heat and cold
response
 Involuntary
responses
 Perspiration
 Blood
vessels
 Metabolism
 Piloerection
ANATOMY & PHYSIOLOGY REVIEW

External mechanisms of heat and cold
response
 Voluntary
responses
 Seek
shelter from cold or heat
 Add or remove insulation
 Outside
 Wind
contributors
velocity
 Humidity
ANATOMY & PHYSIOLOGY REVIEW

External mechanisms of heat and cold
response
 Predisposing factors
 Age
 Health
 Medical history
 Shock
 CNS insult
 Burns
 Medications
 Skin conditions
 Mental history
ANATOMY & PHYSIOLOGY REVIEW

Measures to prevent heat and cold injury
 Cold
 Avoid
long periods of exposure
 Cover exposed body surfaces
 Layer clothing
 Keep clothing and body dry
ANATOMY & PHYSIOLOGY REVIEW

Measures to prevent heat and cold injury
 Heat
 Avoid
long periods of exposure
 Drink plenty of clear fluids
 Use shade to reduce heat
 Avoid using diuretics
 Avoid using amphetamines
 Limit alcohol intake
HEAT EMERGENCIES

Heat cramps
 Muscle
spasms
 Poor fluid level
 Overexertion with fatigue
 Sodium and electrolyte loss
 Extended exertion in heat
HEAT EMERGENCIES

Heat cramps
 Physical
findings
 Cramps
in fingers
 Arms
 Legs
 Abdomen
HEAT EMERGENCIES

Heat cramps
 Differential
diagnosis
 Tetany
 Other
heat emergency
 Simple muscle cramps
 Therapeutic
 Remove
interventions
from heat
 Oral hydration of electrolytes
 IV solutions – nacl or LR
HEAT EMERGENCIES

Heat exhaustion
 Dehydration
& compensated hypovolemia
 Sweating
 Sodium
& electrolyte loss
 Vasodilation with venous pooling
 Extended exertion in heat
HEAT EMERGENCIES

Heat exhaustion
 Physical
 Rapid
findings
shallow breathing
 Weak rapid pulse
 Flushed or pale skin
 Cool clammy skin
 Heavily sweating
 Normal core temp which can rise to 100-105° F
 May present with dehydration
HEAT EMERGENCIES

Heat exhaustion
 Differential
diagnosis
 Uncomplicated
 Hypoglycemia
 Infection
 Intoxication
 Fatigue
dehydration
HEAT EMERGENCIES

Heat exhaustion
 Therapeutic
 Similar
interventions
to heat cramps
 Remove from heat
 Supine
 Oral hydration of fluids/electrolytes
 IV solutions – nacl of LR
 Manage core temp
HEAT EMERGENCIES

Heat stroke
 Increase
in core temp over 105°F with decreased
LOC
 Hypothalamic temperature regulation lost
 Chain reaction within tissue
 Cellular death of brain, kidneys, liver
 Hallmark is altered mental status
 Metabolic acidosis
 Hyperkalemia
HEAT EMERGENCIES

Heat stroke
 Classic
 Long
heat stroke
periods of heat and humidity exposure
 Affects very young, very old, diabetics,
alcoholism and cardiac history
 Risks from diuretics, psychotropics, anticholinergics
 Late sign – hot red dry skin
HEAT EMERGENCIES

Heat stroke
 Exertional
 Sudden
heat stroke
rise in core temp during exertion
 All age groups susceptible
 Patient not fluid deprived
 Skin may be sweaty
HEAT EMERGENCIES

Heat stroke

Physical findings
 Altered
LOC – disorientation, combative
 Unconsciousness
 Hallucinations
 Seizures
 Core temp above 40.6°C or 105°F
 Ataxia
 Tachycardia that slows near death
 Tachypnea progressing to bradypnea
 Hypotension often lacking diastolic
HEAT EMERGENCIES

Heat stroke
 Differential
diagnosis
 CVA
 Hypoglycemia
 Infection
 Uncomplicated
dehydration
 Intoxication
 Neuroleptic
malignant syndrome
HEAT EMERGENCIES

Heat stroke
 Therapeutic
 Goal
interventions
-cooling core temperature
 Goal –replenish fluid
 Airway management
 Cardiac monitoring
FIREWORK INJURIES

NFPA Statistics
 In
2011, 9600 firework related injuries treated in
emergency rooms
 8 out of 9 (89%) of injuries involved “consumer
use” fireworks
 In 2011, 17,800 reported fires were started by
fireworks
STATS CONT’D
26% of victims were under 15 years old
 Injury rates apply to a range of ages; the
greatest being 5-19 years old and 25-44 years
old
 Males account for 68% of firework related
injuries

AREAS OF FIREWORK INJURIES

61% to extremities
46% to the hands or finger
 11% to the legs
 4% to the wrist

34% to parts of the head
including the eye (17% of
the total)
 Sparklers, fountains, and
novelties accounted for
one-third (34%) of ER
visits

INJURY TYPES



More than half are
thermal (burn) related
One quarter resulted in
bruises or lacerations
3% of injuries occur as
people are trying to
escape an area of
danger; sustaining a
fracture or sprain
IN PERSPECTIVE…
TREATMENT FOR FIREWORKS INJURIES
SCENE SAFETY is always the priority
 Assess trauma triage criteria

Burns >10% BSA of 2nd or 3rd degree should be
considered
 Burns with involvement to head, neck, or airway are
high priority patients
 Impaled objects through the abdomen or airway
 Amputation of digits or extremities
 Spinal cord injuries associated with blunt trauma or
falls

TREATMENT, CONT’D


Establish level of responsiveness
Immobilize c-spine if indicated





check the neck prior to placing c-collar
Airway assessment for patency
Get good lung sounds if risk of inhalation, assess work
of breathing
Identify and treat any life threatening hemorrhages
Check for neurological deficits



AVPU
Motor & Sensory
Pupils
BURNS

SMO’s Code 22 (Thermal)




Initial trauma care
100% Oxygen for stridor, hoarseness, or wheezing
(accelerated transport)
Check for distal pulses in extremity burns
Burn wound care
Use sterile gloves and mask if available
 Cool burns with sterile water or saline (<20% BSA)
 Dry sterile dressing or burn sheets for >20% BSA


Consider pain management
Nitrous Oxide inhalation
 Morphine Sulfate 5-10mg IVP in 5mg increments every 5 minutes, if
SBP>90. Do not give Morphine IM.

IMPALED OBJECTS
Secure object in place using whatever you can,
however you can!
 NEVER remove an impaled object unless it
interferes with the patients airway, or EMS
airway management
 Think of “what lies below” to determine
potential internal injuries, risk of hemorrhagic
shock

LEGAL REVIEW OF THE INTOXICATED PERSON

“Intoxicated” may include
 Alcohol
(ethanol)
 Illicit drugs (LSD, heroin, cocaine, GHB, ecstasy,
methamphetamine, etc.)
 Legally prescribed medications(Hydrocodone,
Oxycontin, Valium, etc.)
 Mind altering substances such as inhaled
chemicals, etc. (720 ILCS 690/ Use of Intoxicating
Compounds Act)
LEGAL VS. MEDICAL

Legal definition
 “The
state of being poisoned; the condition
produced by the administration or introduction into
the human system of a poison. But in its popular
use this term is restricted to alcoholic intoxication,
that is, drunkenness or inebriety, or the mental and
physical condition induced by drinking excessive
quantities of alcoholic liquors, and this is its
meaning as used in statutes, indictments, etc.”

Black’s Law Dictionary

Medical definition
 Substance
intoxication: “Reversible, substancespecific, maladaptive behavioral or psychological
changes directly resulting from physiologic effects
on the central nervous system of recent ingestion
of or exposure to a psychoactive substance,
particularly alcohol”

http://medical-dictionary.thefreedictionary.com/intoxication
COMMONALITIES?
Both definitions refer to “alcohol” as a primary
substance leading to intoxication
 Both refer to a diminishment in psychomotor
and cognitive function
 Neither refer to any risk of harm

CRITICAL DETERMINATIONS

Assumption: There is some degree of Altered
Mental Status
1.
2.
3.
4.
Is there a non-alcohol cause for Altered Mental Status?
Is there risk of harm?
Does the individual have capacity to refuse care?
Is there someone who can take responsibility for the
patient?
ESSENTIAL H&P ELEMENTS
Thorough history and physical examination
 Blood glucose level
 Pulse oximetry
 EtCO2 if available

CRITICAL HISTORY CONCERNS
ANY history of trauma
 ANY suicidal threats or depression
 ANY significant co-ingestants
 ANY alcohol ingestion in the last hour
 ANY significant medical complaints
 ANY combative behavior
 ANY involvement of less-than-lethal devices

CRITICAL PHYSICAL EXAM CONCERNS
ANY evidence of trauma beyond minor
extremity
 ANY significant derangement of blood glucose
 ANY evidence of airway compromise
 ANY significant hypoxia/hypercarbia
 ANY abnormal vital signs

RISK OF HARM
Is there a responsible caretaker?
 Is there an inherent danger in refusal?
 Is there a possibility of worsening BAL?
 Alcohol consumption history

 What
was consumed?
 What was the time period of consumption?
Trauma
 Rage (combative)

RISK OF HARM, CONT’D
Airway compromise
 Narcotics/Co-ingestants
 Suicidal/Depression/Psychotic
 Pain (chest/abdomen/other medical
complaints)
 Oxygen low or CO2 high
 Risk of harm to self or others
 TASER (other less-than-lethal devices)

RISK OF HARM, CONT’D
Ingestion recent/Extremely large (EtOH)
 Not normal vital signs
 Glucose low or high

DETERMINING CAPACITY
Adult or qualified minor
 Alert and oriented
 GCS 15
 Must appreciate the situation
 Must understand the medical
concern/diagnosid
 Must understand the consequences of refusing
care

HARD DECISION?
EMS and the Hippocratic Oath
•We are not bound by Oath to “DO NO
HARM”
•As licensed agents through the Illinois
Department of Public Health, and our EMS
System Physicians, we are required to be
competent in action and decision
•Medical Control is NOT in place to defer
provider risk
•Regardless of Medical Control’s advice,
ALL parties involved in patient care are
responsible for outcome
THE “ART OF THE REFUSAL”
•Using the combination of
“Determining Capacity” and
“Risk of Harm” will lead you
to the right decision.
•This is the most subjective
decision any EMS
professional has to
determine
•If there is ever any doubt,
your best defense is to act in
the best interest of the
patient
WHAT WOULD YOU DO?
You are summoned to a possible overdose. You
assess and treat a 25 yr old male that is
unresponsive with gasping respirations at
6/min. After administration of Narcan, the
patient regains full sensorium; is alert and
oriented to person, place, time, and events;
admits to overdosing on heroin; and is refusing
further care or transportation to a medical
facility.
???
What lasts longer, the effects of Narcan or
heroin?
 What is his Determining Capacity?
 Are there any Risks of Harm to the patient if he
is allowed to refuse care?

Discussion……
THANK YOU!
Any Questions???