Transcript Heat Illness

Summer Emergencies
Dan O’Donnell
8/8/06
Indiana University School of Medicine
Department of Emergency Medicine
Case #1
• 34 y/o roofer calls EMS for severe
cramping of right arm
• Denies any trauma
• Patient is new roofer and has never had a
cramp this bad before
• PMHx and Medications: None
• Diagnosis?
Heat Cramps
• Brief, intermittent muscular cramps that
occur most commonly in the muscles that
are fatigued by work
• More common during the first few days on
the job
• Due to an overall salt deficiency
– Patients drinking copious amounts of hypotonic
solution (aka water)
Treatment
• #1: Get patient out of environment
• Salt solutions (i.e. Gatorade, all sport)
• If patient unable to take po it may be a sign
of a more serious condition
• Consider starting IV
• Transport as needed
Case #2
• 35 y/o WF jogging in park during Mid July
(temp 98 °F). EMS called for patient c/o
Headache, lightheadedness, nausea and
vomiting.
•
•
•
•
•
•
•
PMHx: Depression
Meds: Elavil
NKDA
VS: 120; 100/50; 28; 100.4 F
Neuro: GCS 15; A&O x 3; no focal deficits
Skin: hot and diaphoretic
Rest of exam normal
Dx and TX
• Heat Exhaustion
• TX:
–
–
–
–
Remove from warm environment
.9% NS IV until hemodynamically stable
PO fluids
Get that Accu-check
Heat Exhaustion
• Clinical syndrome characterized by volume
depletion that occurs under conditions of
heat stress
Heat Exhaustion
•
•
•
•
Fatigue, HA, N/V, myalgias
Core temp < 104 degrees F/ 40 deg C
Mental status normal
Tachycardia, orthostatic hypotension,
clinical dehydration
Medications that Predispose to
Heat Illness
•
•
•
•
•
•
•
•
Phenothiazines
Anticholinergics
Sympathomimetics
MAO inhibitors
Cyclic antidepressants
Lithium
Diuretics
Beta Blockers
Predisposition to Heat illness
• Coronary artery disease
• Atherosclerosis: inability to vasodilator in
periphery
• Skin or sweat gland disorders
• Hyperthyroidism
• Psychiatric disorders
Case #3
• 19 y/o WM first day of football practice in
full uniform. Mid July. EMS called because
patient collapses in the showers.
Questions??
•
•
•
•
•
•
Pmhx: ??
Meds: ??
Allergies:??
VS: 130; 90/55; 40; 106.8 deg F
GCS 7: posturing then seizing
Skin: hot and dry
Heat Stroke
• Heat stress resulting in Hyperpyrexia and
Neurologic symptoms.
• Life Threatening Emergency
Heat Stoke
Classic Heat Stroke: sedentary, elderly
persons with compromised homeostatic
mechanisms; living in poorly ventilated, hot
conditions.
Exert ional Heat Stroke: previously healthy
person. Strenuous activity in hot, humid
weather.
Both resulting in the failure of thermoregulatory homeostasis.
Heat Stroke
• Exposure to heat stress
• Signs of severe CNS dysfunction (seizure,
coma, delirium)
• Core temp usually greater than 104 deg F/
41 deg C
• Dry, hot skin frequent, but sweating may
persist
Complications
•
•
•
•
•
•
•
Seizure
Liver Failure
Hypo/Hyperglycemia
Cerebral Edema
Renal Failure/Rhabdo
Shock
DIC
Treatment
•
•
•
•
•
ABC’s
Remove Clothing
Cooling: Cornerstone of therapy
Accucheck: hypoglycemia
Fluid replacement: 1-2 Liters
Types of Cooling
• Evaporative Cooling
– Use mist and fans to promote rapid cooling
– Can decrease the temperature to less than 39
degrees in as little as 10-30 minutes
• Ice packs
– Apply to high blood flow areas
Case #2 Addendum
• As you begin to cool the patient, she begins
to start shivering……..
• Diazepam(Benzo) for shivering to prevent
increase in temp.
Case #4
• You are called for a person “found down”
• Upon arrival you find a 30ish year old man
unresponsive in the middle of a field
• Patient is pulse less and apneic
• As you are placing him on the monitor you
notice…
Lightning Injuries
• 5 types
• Direct Injury
– person is directly struck
• Contact
– person touching an object in the pathway of the
lightning current
• Side Flash (aka “Splash”)
– Lightning jumps from primary strike object to a nearby
person on the way to the ground
Lightning Injuries Cont…
• Ground Current or Step Voltage
– Current travels through an individuals feet
rather than the ground
– We are good conductors
• Blunt Trauma (2 mechanisms)
– Person is thrown from the contraction caused
by current passing through body
– An explosion occurs from the rapid heating and
cooling of the lightning pathway
What Kind of Injuries Can it Cause?
• Head and Neck-Burns, cataracts, skull
fractures, c-spine fractures
• CV-Cardiac arrest (asystole or v-fib)
– Can cause a-fib, AMI, prolonged QT,
Hypertension
• Skin-Burns
– Usually not deep (<5%)
– Feathering Burns
– Kissing Burns
Injuries Cont…
• Extremities
– Muscular damage
– Transient vasospasm
• Usually resolves quickly
• CNS
– + LOC, amnesia
– Keraunoparalysis-temporary paralysis of blue
extremities
– Due to severe vasospasm
– Usually resolves
EMS Care
• #1-Secure the scene
– Don’t be the next one struck
• #2-ABCs
– Lightning is a DC counter shock which can
cause asystole with return of cardiac activity
– If there is profound respiratory arrest than their
may be a secondary cardiac arrest
EMS Care Cont…
• #3. Treat this patient as both a trauma and
cardiac/medical patient
– C-spine
– Place on monitor and follow protocols (v-fib is
v-fib is v-fib)
• Report any dysrhthmias to hospital personnel
– IVF-remember burn component
Case #4
• 16 y/o male dove into pond, pulled out by
friends who performed “CPR”
• Alert upon EMS arrival, c/o mild dyspnea
• VS: RR 35 SaO2 92% RA
• Lungs with bibasilar crackles
• Parents do not want him to be transported,
WHAT DO YOU DO???
Drowning vs. Near Drowning
• Drowning
– Death from suffocation by submersion in water
• Near-drowning
– Submersion that results, at least, temporarily in
survival of the victim
Near Drowning
• Peak incidence in toddlers and teens
• Occurs in bathtubs, buckets, toilets in
toddlers
• Swimming pools, lakes in teens
– Associated with ETOH
What if They Look Fine
• At risk for late deterioration
– Intubation
– ARDS
– Death
• Even asymptomatic patients should be
transported
Management
• C-spine precautions
• Airway
– Supplemental O2
• Breathing
• Circulation
• All patients should be transported
Key Historical Factors
• Submersion time
• Events surrounding accident
– Do the police need to be involved
– Is there a higher suspicion of trauma
• Type of liquid the patient was submerged in
– Pool vs. lake vs. puddle
Take Home Points
• Remember the spectrum of heat illness
• IVF are great but no substitute for active cooling
of the patient
• There are many ways to sustain a lightning injury
• Lightning injuries are a combination of trauma
and medical cases
• Transport all near-drowning patients
• Remember C-spine precautions