Transcript Enviromental Emergencies - Madison County Emergency Medical

Andrew Scordato
• Pathophysiology, Assessment and management of:
 Submersion incidents
 Temperature-related illness
 Bites and envenomation
 Spiders
 Marine Animals
 Scorpions
 High altitude

Diving injuries
 Lighting injury
• Medical emergencies can result from exposure to
heat or cold.
• Certain populations are at higher risk for heat
and cold emergencies.
 Children
 Older people
 People with chronic illnesses
 Young adults who overexert themselves
• Water recreation can also create medical
emergencies.
 Localized injuries
 Systemic injuries
• Environmental emergencies require prompt
treatment in the hospital.
 Physical condition
 Patients who are ill or in poor physical condition will not
tolerate extreme temperatures wells.
 Age
 Infants have poor thermoregulation and are unable to
shiver.
 Children may not think to put on layers.
 Older adults lose subcutaneous tissues and have poor
circulation.
• Environmental conditions
– Conditions that can complicate or improve
environmental situations:
• Air temperature
• Humidity level
• Wind
– Extremes in temperature and humidity are not needed
to produce injuries.
 Environmental conditions (cont’d)
 Most hypothermia occurs at temperatures between 30°F
and 50°F.
 Most heatstroke occurs when the temperature is 80°F
and the humidity is 80%.
 Examine the environmental temperature of your patient.
 Cold exposure may cause injury to:
 Feet
 Hands
 Ears
 Nose
 Whole body (hypothermia)
 The five ways the body loses heat
 Conduction
 Radiation
 Respiration
 Convection
 Evaporation
 Lowering of the core temperature below 95°F (35°C)
 Body loses the ability to regulate its temperature and generate body
heat
 Vital organs such as the heart slow down.
 Can lead to death
 Air temperature does not have to be below freezing for it to occur.
 People at risk:
 Those with out heat
 Homeless
 Lower income/ fixed income
 Outdoor enthusiast
 Geriatric/ill
 infants and children
 Factors in determining the severity of a local cold injury:
 Temperature and Duration of the exposure
 Wind velocity during exposure
 Exposure to wet conditions
 Inadequate insulation from cold or wind
 Restricted circulation from tight clothing or shoes, or
circulatory disease
 Fatigue/Poor nutrition
 Alcohol or drug abuse
 Hypothermia
 Age and medical Hx i.e. Cardiovascular disease/Diabetes
 Mild
 Occurs when the core temperature is between 90°F and
95°F (32°C and 35°C)
 Patient is usually alert and shivering
 Increased HR/RR.
 Skin may appear red, pale, or cyanotic.
 Severe
 Occurs when the core temperature is less than 90 F or 32C
 Patient is usually alert but confused
 Initially Pulse rate and respirations are rapid
 Bradycardia develops
 V-Fib as the body falls below 86
 Assess for Pulse and respiration Longer than normal
 Skin may appear red, pale, or cyanotic
 No shivering
 Loss of voluntary muscle control
 Ekg shows J-wave (osborn)
 Note the weather conditions (for You and for Pt.)
 ABC
 CPR, Resp./Pulse ?
 Perfusion will be compromised.
 Skin not a good indicator to determine shock.
 Bleeding may be difficult to find.
 Cardiac arrhythmias
 Rewarming
 V/S
 May be altered by the effects of hypothermia, an indicator of its
severity
 Pulse OX ?
 If the patient is AOX3 shivering, and the core body
temperature is between 90°F to 95°F, then the
hypothermia is mild.
 Apply heat packs to the groin, axillary, and neck
 Increase ambient temperature
 Rewarm slowly.
 Warm IV fluids
 Warm humidified O2
 When the Pt.has moderate or severe hypothermia,
never try to actively rewarm
 Active rewarming should be reserved for an appropriate
facility.
 Rewarming shock-reflex peripheral vasodilation
 Cold diuresis-Volume depletion/kidneys remove excess fluid
from core
 The goal prevent further heat loss.
 Remove wet clothing, cover with a blanket, and
transport
 BLS
 Start CPR immediately
 Longer pulse/respiration check
 One shock with AED until temp >86
 ALS
 Start CPR immediately
 Longer pulse/respiration check
 Limit one defibrillation until temp is above 86
 Limit one round of ACLS Rx until temp is above 86
 Remember they are not Dead until
they are Warm and Dead
 Frost bite
 Serious local cold injury tissues are actually frozen
 Gangrene requires surgical removal
 Frost nip
 Prolonged exposure to the cold, skin is freezing but deeper
tissues are okay.
 Ear, nose, and fingers
 Usually not painful, Pt. often is unaware that a cold injury has
occurred
 Immersion Foot
 Prolonged exposure to cold water
 Hikers and Hunters
 Assess the areas of the body affected by cold exposure.
 degree and extent of damage.
 attention to skin temperatures, textures, and turgor.
 Frost Nip and Immersion foot
 Skin= pale/cold to the touch
 Normal color does not return after palpation of the skin.
 The skin of the foot, wrinkled but remains soft.
 The Pt. reports loss of feeling/sensation
 Frost Bite
 Hard and waxy with blisters and swelling
 Feels firm to frozen as you gently touch it.
 In light-skinned individuals with a deep injury, the skin may appear
red with purple and white, or mottled and cyanotic.
 Depth of Injury (unknown)
 Superficial
 Deep
 Treatment
 Note the weather conditions (for you and for Pt.)
 ABC
 With frostnip, contact with a warm object may be all
that is needed.
 With immersion foot, remove wet shoes, boots, and
socks, and rewarm the foot gradually.
 With a late or deep cold injury, do not apply heat or
rewarm the part.
 Move the patient from the cold environment.
 Do not allow the patient to walk.
 Remove any wet clothing.
 Place dry blankets over and under the patient.
 If available, give the patient warm, humidified oxygen.
 Handle the patient gently.
 Do not massage the extremities.
 Normal body temperature is 98.6°F.
 The body tries to rid itself of excess heat.
 Sweating
 Dilation of skin blood vessels
 Removal of clothing and relocation to a cooler environment
 Hyperthermia is a core temperature of 101°F (38.3°C) or
higher.
 Risk factors of heat illness include:
 High air temperature/Humidity (reduces
radiation/evaporation)
 Lack of acclimation to the heat
 Exercise (loss of fluid and electrolytes)
 Persons at risk for heat illnesses are:
 Children (especially newborns and infants)
 Geriatric patients
 Patients with heart disease, COPD, diabetes,
dehydration, and obesity
 Patients with limited mobility
 Assess for:
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High temperature
Red, dry skin
Tachycardia
Poor perfusion
Absence of perspiration
Confusion/Decreased level of consciousness
Muscle cramping
Nausea/Vomiting
 Three types of Heat Emergencies
 Heat Cramps
 Heat Exhaustion
 Heat Stroke
 Cramps
 Painful muscle spasms that occur after exercise , usually
in the leg or abdominal muscles
 Do not occur only when it is hot outdoors
 Exhaustion
 Common illness
 Causes include:
 Heat exposure
 Stress/Fatigue
 Fluid replenishment
 Signs and symptoms
 Cold, Pale, Diaphoretic
 Dry tongue and thirst
 Normal vital signs/or slightly elevated body temperature
 Dizziness, weakness, Syncopal episode
 Change in LOC
 Muscle cramping, nausea, vomiting, or headache
 Onset =working hard or exercising in a hot, humid, or
poorly ventilated area, sweating heavily
 Least common but most serious
 The body is subjected to more heat than it can handle
and normal mechanisms are overwhelmed
 Typical situations
 Physical activity
 Outdoors or in a closed, poorly ventilated, humid space
 During heat waves
 Elderly/Homeless/Fixed income
 Child left unattended in a car on a hot day
 Untreated heatstroke always results in death.
 Signs and symptoms
 Hot, dry, flushed skin/Early on, skin may be moist or wet.
 Rising body temperature
 Changes in LOC/behavior
 Unresponsiveness
 Seizures
 Strong, rapid pulse at first, becoming weaker with falling
blood pressure (signs of Shock)
 Increasing respiratory rate
 Note:
 Inadequate oral intake
 Diuretics
 Certain psychiatric medications
 Cramps/Exhaustion
 Remove the patient from the hot environment.
 O2,IV fluids (cool), EKG
 Rest cramping muscles.
 Cool the patient (remove clothing, turn on air conditioning)
 Stroke
 All the above plus apply cold packs to neck, groin and axillary
 Avoid Vasopressors and Anticholinergic RXs
 Rapid transport
 Process of experiencing respiratory impairment from
submersion/immersion in liquid
 Prevention
 Drowning VS. Near drowning.
 D=Patient dies with in 24 hours after suffocation in water
 ND=Refers to a patient who survives at least temporarily (24
hours) after suffocation in water
 Drowning's may be complicated by spinal fractures and
spinal cord injuries. Suspect Spinal Injury if:
 Diving or long fall.
 ALOC/Unconscious.
 Complaints of weakness, paralysis, or numbness.
 Never give up on resuscitating a cold-water drowning
victim.
 Hypothermia can protect vital organs from the lack of oxygen.
 The diving reflex may cause immediate bradycardia.
 Always transport near-drowning patients to the hospital.
 Inhalation of any amount of fluid can lead to delayed
complications.
 Drowning patients may deteriorate rapidly due to:
 Pulmonary injury
 Fluid shifts in the body
 Cerebral hypoxia
 Hypothermia
 Dry Vs. Wet drowning
 Dry-Lungs don’t fill with water because of Laryngospasm
 Salt Vs. Fresh
 Fresh water causes the alveoli to collapse from a lack of surfactant.
 Salt water causes pulmonary edema and eventual hypoxemia due to
its hypertonic nature.
 Factors affecting survival
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Cleanliness of Water
Length of Time Submerged
Victim’s Age and Health
Water Temperature
 Cold-water drowning.
 Mammalian diving reflex.
 Scene
 Never drive through moving water; be cautious driving
through still water.
 Never attempt a water rescue without proper training
and equipment.
 Consider trauma (MOI) and spinal stabilization.
 Check for additional patients.
 Assess and Treat:
 Determine the length of time the patient was underwater or
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the start symptoms
Remove patient from water. If needed start ventilations in the
water
Suspect head and neck injuries
Protect the patient form heat loss
ABC/CPR
 It may be difficult to find a pulse.
 When in doubt start CPR
 EKG/Capnography?
 Normal temp follow normal ACLS guidelines
 Hypothermic treat with one defib and one round of drugs
until temp >86 degrees
 The cold-water drowning patient is not dead until he is warm
and dead.
 Divided into Injuries on the surface, Descent, injuries
at the bottom and Ascent
 Injuries at the Surface
 Lines or kelp fields
 Panic/fatigued
 Drown
 Boats
 Cold water
 Shivering and pass-out
 Descent (barotrauma)
 Caused by the increase in pressure
 Typical areas affected
 Lungs
 Sinus cavities
 Middle ear
 Teeth
 The pain forces the diver to return to the surface to equalize the
pressures, and the problem clears up by itself.
 Perforated tympanic membrane
 Cold water may enter the middle ear through a ruptured eardrum.
 The diver may lose his or her balance and orientation and run into
ascent problems.
 Emergencies at the Bottom
 Rare=Commercial divers/Oil Rig
 Caused by faulty connections in the diving gear
 Inadequate mixing of oxygen and carbon dioxide
 Accidental feeding of poisonous carbon monoxide into the breathing
apparatus
 Can cause drowning or rapid ascent
 Nitrogen Narcosis
 Occurs During a Dive
 Can contribute to accidents during the dive.
 Signs and Symptoms
 Altered levels of consciousness and impaired judgment.
 Diver misjudges amount of air left for dive
 Ascent
 Sudden decrease in pressure/Not enough “off Gassing”
 Several big Problems
 Air Embolism
 Dangerous and common
 Bubbles of air in the blood vessels
 Air pressure in the lungs remains at a high level while pressure on
the chest decreases
 Signs-Sharp tearing pain, mimics stroke with confusion, vertigo,
visual disturbances and LOC
 Treatment
 Hyperbaric
 O2,Iv,EKG
 Steriods?
 Decompression sickness (the bends)
 Bubbles of gas, especially nitrogen, obstruct the blood
vessels.
 Conditions (dive charts)
 Rapid ascent
 Too long of a dive at too great of a depth
 Repeated dives on the same day
 Complications
 Blockage of tiny blood vessels deprives the body of
nutrients
 Severe pain in certain tissues or spaces
 Decompression
 Occur within 36 hours
 Fatigue, paresthesias, and CNS disturbances
 Abdominal/joint pain so severe that the patient doubles
up
 May find it difficult to distinguish between air embolism
and decompression sickness.
 Air embolism generally occurs immediately on return to the
surface.
 Symptoms of decompression sickness may not occur for
hours.
 Tx-Hyperbaric chamber
 Pulmonary Overpressure Accidents
 Air becomes trapped on ascent
 Trapped by
 Mucus
 Bronchospasm
 Holding breath
 Ambient pressure drops, trapped air expands in the
lungs
 Alveoli Rupture
 Hemorrhage
 Decreased 02 c02 trans
 Air escaping
 Treatment-tx for possible pneumothorax
 Pneumomediastinum
 Caused by Pulmonary Overpressure
 Release of air into the mediastinium and the pericardial
sac
 Signs
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Chest pain
Irregular pulse
Decreased BP
Narrow pulse pressure
Changes in the Voice
 Treatment
 ABC
 O2,IV,EKG
 Rapid transport
 Determine the dive parameters
 Depth
 Time
 Previous dives
 Rate of Ascent
 Experience of the diver
 Equipment
 Use of medication or alcohol
 Assess for:
 Peripheral pulses
 Skin color and discoloration
 Pain
 Paresthesia (numbness and tingling).
General Treatment
 ABC
 O2 (NRB or BVM prn),IV,EKG
 Unconscious should be intubated
 Supine or Left lateral recumbent
 Pulse OX/Capnnogrpahy
 Protect from excessive cold or heat
 Monitor for neurological symptoms
 Valium
 Send patients dive equipment if possible
 Assess for Decompression illness
 Reverse of dive injuries/Lack of Pressure
 (Dsybarims injuries)
 Altitude illness
 Caused by diminished oxygen at high altitudes
 Effects
 CNS
 PULMONARY
 Three Altitude illness (progressive)
 Acute Mountain Sickness
 HAPE
 HACE
 AMS (Acute Mountain Sickness)
 diminished oxygen pressure at altitudes above 8,000′
 Ascending too high too fast or not being acclimatized to
high altitudes
 HAPE (High Altitude Pulmonary Edema)
 Fluid collects in the lungs, blocks passage of oxygen into
the bloodstream.
 Altitudes of 10,000
 HACE (High Altitude Cerebral Edema)
 Occurs above 12,000
 Follows HAPE
 AMS
 Fatigue
 Loss of appetite/N&V
 Shortness of breath during physical exertion
 Swollen face
 Headache/Lightheadedness
 Tx Mild-high flow 02 use of antiemtics
 Severe- Dissent, hyperbaric chamber PRN
 HAPE
 Shortness of breath/Cyanosis
 Dry cough with pink sputum
 Rapid pulse
 Crackles in the lungs
 Tx
Earlier recognition
High flow 02
Dissent
Hyperbaric Bag (pressure bag simulates a dissent of
5,000 ft)
 Meds-Morphine, Procardia, and Lasix
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 HACE
 Severe headache
 Ataxia
 Fatigue
 Vomiting
 ALOC/Changes in Bx/Unconscious
 Tx Dissent
 High flow 02
 steroids
 Hyperbaric Bag
 Common targets
 outdoor activities (boaters, swimmers, golfers)
 Anyone in a large, open area
 Individuals are indirectly struck when standing near
an object that has been struck by lightning.
 Cardio and Nervous System injury
 Cardiac arrest
 Injuries range from mild to severe
 S/SX assessment
 Tx
 Move patient quickly
 ABC
 O2, IV, EKG (monitor for EKG changes)
 Reverse triage
 Signs and Symptoms
 Localized pain, redness, swelling, skin wheal.
 Idiosyncratic reactions
 Observe for signs of an allergic reaction.
 Localized pain, redness, swelling, skin wheal
 Generalized flushing of the skin or itching
 Tachycardia, hypotension, bronchospasm, laryngeal
edema, facial edema, uvular swelling
 Wash the area.
 Remove stingers, if present.
 Use care not to disturb the venom sac.
 Apply cool compresses to the injection site.
 Observe for and treat allergic reactions and/or
anaphylaxis.
 Numerous spider and spiders species
 Two to worry about
 Black Widow
 Brown Recluse
 Black Widow
 Black with a, bright red-orange marking in the shape of
an hourglass on its abdomen
 Every state except Alaska
 Prefers dry, dark places
 Venom is Neurotoxic
 Brown Recluse
 Dull brown in color and 1″ long and has a violin-shaped
mark on its back
 Lives mostly in the southern and central parts of the country
but can be found throughout the U. S.
 Venom is Cytotoxic
 Like dark areas
 Black Widow
 bite is sometimes overlooked.
 Localized pain and symptoms, including muscle spasms
 Dizziness
 Sweating
 Nausea/Vomiting
 Rashes
 Chest tightness/Difficulty breathing
 Symptoms end after 48 hours
 Brown Recluse
 Local tissue damage
 The skin is swollen and tender, with pale, mottled, cyanotic
center
 The bite is not painful at first
Chills, fever,
 nausea, vomiting,
 joint pain may also develop.
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 Black Widow
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ABC
O2,IV,EKG monitor for dysthymias
Treat signs and symptoms
Consider using muscle relaxants to relieve severe muscle
spasms.
 Diazepam 2.5–10 mg IV
 calcium gluconate solution 0.1–0.2 mg/kg of a 10% IV
 Brown Recluse
 ABC
 O2,IV,EKG
 Note area and extent of damage
 BEE, ANTS,WASP
 ABC monitor for Allergic reaction
 O2,IV,EKG
 EPI PRN
 Remove stinger
 Scorpions
 Eight-legged arachnids/ venom gland/stinger at the end
of their tail.
 Rare and live southwest
 Usually not very dangerous One exception
 Centruroides sculpturatus
 Circulatory collapse
 Severe muscle contractions
 Excessive salivation
 Hypertension
 Convulsions and cardiac failure
 (Sludge mm)
 Tx
 ABC
 O2,IV,EKG
 Rapid transport
 Apply a constricting band?
 Ticks
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Burrow under skin
Mostly during summer months
Less than an inch long, found in wooded areas/beaches
Saliva carries disease/Transmission 12 hours
Rocky Mountain Spotted Fever
 Mechanism
 7 to 10 days after the bite
 S/Sx
 Petechial Rash-Palms to feet
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Nausea/Vomiting
Headache
Weakness/Paralysis
Cardiorespiratory collapse
 Ticks cont.
 Lyme disease
 Mechanism
 Rash to bull-eyes pattern
 Disease of the joints/Pain and Swelling
 Ohio reports
 Tx
 Do not attempt to suffocate or burn the tick.
 KY Jelly?
 Use tweezers, grab the tick by the body and pull it straight
out of the skin.
 Disinfect the area
 Ohio exotic animal problem
 Over a hundred different species in US
 Most are defensive not aggressive
 19 are venomous
 Rattlesnakes, copperheads, cottonmouths or water
moccasins, and coral snakes
 PitVipers
 Small pits that contain poison located just behind each
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nostril and in front of each eye.
Triangular heads
Rattlesnakes
Copperheads
Cottonmouths
Most Common in Ohio?
 Burning or pain at the site of injury
 Swelling and bluish discoloration
 Weakness
 Nausea and vomiting
 Sweating
 Seizures/Fainting
 Blurred Vision or changes in vision
 Altered level of consciousness
 “Red on Black venom lack, Red on Yellow kill a fellow”
 King Sakes Vs. Coral Snakes
 Venom causes paralysis of the nervous system.
 Within a few hours of being bitten
 Bizarre behavior
 Paralysis of eye movements
 Paralysis of respiratory system
 Other S/SX
 Numbness, weakness, drowsiness, ataxia, slurred speech,
excessive salivation,
 Drooping of the eyelids, double vision, dilated pupils, abdo pain,
N&V, LOC, SZR hypotension
 Antivenin is available, but most hospitals do not stock
it.
King
Coral
 ABC
 O2,IV,EKG
 Note injury area
 Flush it and Splint it
 Keep Pt. Calm and as still as possible
 DO NOT apply constricting bands, ice, cold packs,
tourniquets
 Hospitals with Antivenom?
 Include: Jelly Fish, Portuguese Man O War, sea
Anemones
 Nematocysts
 Acids (Vinegar, Urine?)
 S/Sx
 Painful, reddish lesions
 Man O War extremely painful
 Headache/Dizziness
 Muscle cramps
 Fainting
 Establish and maintain the airway.
 Apply a constricting band above the site.
 Apply heat or hot water.
 Inactivate or remove any stingers.
 Vinegar
PMOW
Sting