Environmental Emergencies

1. Environmental Emergencies Condell Medical Center EMS System CE August 2009 Site Code #107200E-1209 Prepared by: Captain Tony Carraro Greater Round Lake F.P.D. Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of the this module, the EMS provider will be able to: • Identify the various ways that the body loses and gains heat. • Identify the differences of cold emergencies (frostbite, mild hypothermia, severe hypothermia). • Identify the signs and symptoms of cold emergencies • Identify the management for cold emergencies. • Identify the differences between the heat emergencies heat cramps, heat exhaustion and heat stroke.

3. Objectives cont’d • Identify the signs and symptoms of heat emergencies. • Identify the management of heat emergencies. • Define drowning. • Identify the complications of drowning in fresh water versus salt water. • Identify management of drowning cases. • Identify complications related to diving. • Identify the differences between allergic reactions without airway involvement, with airway involvement, and anaphylaxis.

4. Objectives cont’d • Identify signs and symptoms of allergic reactions. • Identify the emergency medical care of bites and stings. • Identify management of allergic reactions. • Participate in case scenario presentations. • Return demonstrate use of an EpiPen®. • Demonstrate drawing up and administration of Epinephrine 1:1000 IM and SQ. • Describe when to use CPAP and how to monitor effectiveness.

5. Loss and Gain of Body Heat • Conduction: Heat flows from warmer material (body) to cooler one (environment). • Convection: Currents of air or water pass over the body, carrying away heat. • Radiation: Sending out energy, such as heat, in waves into space.

6. Loss and Gain of Body Heat cont’ • Evaporation: The change from a liquid to a gas. • When the body perspires or gets wet, evaporation of the perspiration or liquid has a cooling effect on the body • Respiration: Breathing during respiration; body heat is lost as warm air is exhaled from the body

7. Water Chill Water chill: conducts heat away 25 times faster than still air

8. Wind Chill • Wind Chill: Chilling caused by convection of heat from the body in the presence of air currents. • The more wind, the greater the heat loss. At 10 degrees and a 20 mph wind the amount of heat lost is the same as if it was minus 25 degrees.

9. Hypothermia • Cooling that effects the entire body • Causes a state of low body temperature, specifically low core temperature • A core temperature dropping below 950F (35.50C) is considered hypothermic • FYI – 98.60F = 370C

10. 0F to 0C 0C = 5/9 (0F – 32) Ex: 98.20F = ?0C - 5/9 (98.2 – 32) - 5/9 (66.2) - 5 x 66.2 / 9 - 331/9 - 36.80C 0C to 0F 0F = 9/50C +32 Ex: 28.40C = ?0F 9/5(28.4) + 32 9/5 x 28.4 + 32 9x28.4/5 + 32 255.6/5 + 32 51.12 + 32 83.10F Conversion Formula For Temperature

11. Degrees of Hypothermia • Mild: A core temperature greater than 900F (320C) with signs and symptoms of hypothermia. • Severe: A core temperature of less than 90 0F (320C) with signs and symptoms of hypothermia.

12. Predisposing Factors • Age – Very Young • Larger skin surface area/less fat compared to adults • Little or no shivering • Shivering mechanism immature so can’t generate heat via shivering • Too immature in skills to independently put on or take off clothing

13. Predisposing Factors • Age – Very Old • Failing body systems • Chronic illness • Lack of exercise • Certain medications

14. Localized Cold Injuries • Superficial Frostbite (frost nip) • Some freezing of the epidermal tissue • Redness followed by blanching • Diminished sensation • Skins remains soft • As area is re-warmed it begins to tingle

15. Signs & Symptoms ofDeep (Late) Local Cold Injury Severe frostbite White, waxy skin Firm or frozen on surface Swelling and blisters may occur Skin blotchy, mottled, or grayish yellow or blue

16. Severe Frostbite

17. Partial Thickness (2nd Degree) Burn • It can be difficult to tell the difference between injuries from heat versus cold exposure

18. Localized Cold Injury • Clear boundaryseparates injured/ uninjured areas

19. Emergency Care ofSuperficial (Early) LocalCold Injury Remove patient from environment Re-warm patient Protect area from further injury Splint and cover extremity Do not rub or massage Do not re-expose to cold

20. Trench Foot • Trench Foot - immersion foot • Similar to frostbite, but occurs in temperatures above freezing • Pain may be present • Blisters form on spontaneous re-warming • Treatment • Early recognition • Warm, dry, aerate, & elevate feet • Prevention more effective • Avoid prolonged exposure standing in water and remove wet socks/shoes

21. Trench Foot • Trench foot could also develop following prolonged exposure to urine soaked clothing in contact with feet • Consider a patient who lies undiscovered for several days in their home

23. Signs and Symptoms Mild Hypothermia Severe Hypothermia No Shivering Dysrhythmias, asystole Loss of voluntary muscle control Hypotension Undetectable pulse and respirations • Lethargy • Shivering • Lack of coordination • Pale, cold, dry skin • Early rise in blood pressure, heart and respiratory rate

24. Treatment for Hypothermia • Remove wet garments • Prevent further heat loss • Protect from further wind chill exposure • Use passive external warming methods • Blankets • Maintain patient in horizontal position.

25. Treatment for Hypothermia cont’ • Avoid rough handling, which can trigger dysrhythmias • Monitor temperature • Monitor the cardiac rhythm

26. Passive vs. Active Re-warming Passive Allows body to re-warm itself Remove wet clothing Cover with blanket(s) Active Application of external heat sources to patient

27. Region X SOP – Hypothermia/Cold Emergencies Frostbite Routine Medical Care Move pt to warm environment as soon as possible and prevent re-exposure Rapidly re-warm frozen areas with tepid (warm) water (if feasible) Hot packs wrapped in a towel may be used HANDLE SKIN LIKE A BURN Protect with light, dry, sterile dressing Do not let affected skin surfaces rub together

28. Hypothermia SOP cont’d SYSTEMIC HYPOTHERMIA Routine Medical Care Avoid rough handling and excess activity Apply heat packs to axilla, groin, neck and thorax Assess pulse Pulse present Pulse Absent Transport (see next page)

29. Hypothermia SOP cont’d Yes Follow appropriate cardiac protocol but extend times between meds – repeat defib as core temp rises Transport No Follow appropriate cardiac protocol, but limit shocks to 1 and withhold IV medications Transport Pulse absent Can extremities be flexed?

30. Region X SOP – Hypothermia/Cold Emergencies Pediatric Considerations Assess for severe cardiorespiratory compromise: Shivering, decreased LOC, cyanosis despite oxygen administration, increased/decreased respiratory rate, dysrhythmias, dilated sluggish pupils, decreased reflexes, or weak/thready pulses

31. Heat Emergencies • Hyperthermia: a state of unusually high body temperature, specifically the core temperature • A fever (pyrexia) is the elevation of the body temperature above normal for that person • A person’s normal temperature may be one or two degrees above or below 98.6 degrees FYI: 98.60F = 370C

32. Types of Heat Emergencies • Heat cramps • Muscle cramps from over exertion and dehydration • Heat exhaustion • Mild heat illness; acute reaction to heat exposure • Heat stroke • True environmental emergency occurring when the body’s hypothalamic temperature regulation is lost

33. Predisposing Factors to Consider Preexisting Illness Heart disease Dehydration Obesity Infections/fever Fatigue Diabetes Drugs/medications Age

34. Predisposing Factors Young age – Newborns/Infants • Poor thermoregulation system (under developed) • Can’t remove own clothing (skills immature) Older age – Elderly • Poor thermoregulation system • Don’t sense the heat level • Interference with prescribed medication • Limited ability to escape heat • Often wear multiple layers of clothing • Lack of air conditioned environment

35. Symptoms of Heat Exposure • Diaphoresis (sweating as a compensation to cool down) • Increased skin temperature • Flushing • As heat symptoms progress additional signs and symptoms may develop • Altered mental status • Altered level of consciousness • Altered vital signs

36. Signs and Symptoms Heat Cramps Alert Normal body temperature Normal vital signs Sweating, pale Skeletal muscle cramps c/o weakness, dizziness, faintness

37. Signs & Symptoms Heat Exhaustion Anxiety to possible loss of consciousness Body temperature slightly elevated (>1000F) Normal B/P Pulse weak Respirations rapid, shallow Skin normal to cool; clammy; heavy sweating Occasional muscle cramps CNS symptoms: Headache, paresthesia, diarrhea

38. Signs & Symptoms of Heat Stroke Confusion, disorientation, loss of consciousness Hot skin, can be dry or moist, with high temp Low blood pressure Rapid, weak pulse that later slows Deep respirations that eventually slow and become shallow Possible seizures

39. It’s All Relative!!! • Polar bears are collapsing from heat exhaustion as the normal temperature in polar regions has risen from 20 degrees below zero to 15 degrees below zero

40. Emergency Care of Heat Exposure Patient with Normal to Cool Skin Remove from hot environment. Administer high-concentration oxygen. Loosen or remove clothing. Cool by fanning. Patient supine, legs elevated. Avoid drinking plain water to rehydrate.

41. Emergency Care of Heat Exposure Patient with Hot Skin Remove patient from hot environment. Remove clothing. Administer high-concentration oxygen. Apply cool packs to neck, groin, armpits. Keep skin wet (aids in evaporation). Fan aggressively (aids in convection). Transport immediately.

42. Region X SOP- Heat Emergencies, Adult & Pediatric Heat Cramps Move patient to a cooler environment Do not massage cramped muscles Transport

43. Region X SOP- Heat Emergencies, Adult (Peds) Heat Exhaustion Adults - IV fluid challenge in 200 ml increments (Peds: IV fluid challenge 20 ml/kg; may repeat to max 60 ml/kg) Gradual cooling procedure Move patient to cool environment Remove as much clothing as possible to facilitate cooling Place in supine position with feet elevated

44. Region X SOP- Heat Emergencies, Adult Heat Stroke IV fluid challenge in 200 ml increments Rapid cooling procedure Follow gradual procedure along with: Douse towels or sheets with cool water, place on patient, and fan body Cold packs to lateral chest wall, groin, axilla, carotid arteries, temples, and behind knees If actively seizing, follow seizure protocol Transport

45. Region X SOP- Heat Emergencies, Pediatrics Heat Stroke – Peds IV fluid challenge 20 ml/kg; may repeat to max 60 ml/kg Rapid cooling procedure Douse towels/sheets with cool water & place on patient, fan body; cold packs to lateral chest, groin , axilla, carotid arteries, temples, behind knees Stop cooling if shivering begins Consider Valium 0.2mg/kg IVP/IO over 2 min every 15 min til shivering stops (or 0.5 mg/kg rectal) If actively seizing, follow seizure protocol

46. Definition Drowning • Submersion or immersion in a liquid • prevents the person from breathing air • patient has a primary respiratory impairment • 4,500 people die of drowning every year in the U.S. • 3rd leading cause of accidental death in the USA • 40 % of deaths are children under 5 years old • Deaths again peak in teenagers • Third peak is in elderly who drown in bath tubs

47. Near-Drowning • This term is not used anymore due to the confusion regarding the terms “drowning” and “near-drowning” • All incidents are referred to as “drowning”

48. Pathophysiology of Drowning • Following submersion, if conscious, victim will experience up to three minutes of apnea (involuntary reflex) • Blood is shunted to heart and brain due to mammalian dive reflex • While apneic the PaCO2 in blood rises and the PaO2 falls.

49. Mammalian Dive Reflex • A complex cardiovascular reflex • Stimulated by submersion of face and nose • Breathing inhibited • Bradycardia develops • Protective function of vasoconstriction • Almost all areas sacrificed with decreased blood flow • Cerebral & cardiac blood flow is maintained • Heart and brain receive blood flow

50. Pathophysiology of Drowningcont’d • The stimulus from hypoxia (low oxygen) overrides the sedative effects of hypercarbia (excess carbon dioxide) • Central nervous system (CNS) stimulated • Until unconscious, the victim will panic • Patient makes violent inspiratory and swallowing efforts