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Environmental Emergencies

Environmental Emergencies. Paramedic Program Chemeketa Community College. Describe the physiology of thermoregulation Discuss the risk factors, pathophysiology, assessment findings, and management of specific hypothermic conditions and frostbite. .

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Environmental Emergencies

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  1. Environmental Emergencies Paramedic Program Chemeketa Community College

  2. Describe the physiology of thermoregulation Discuss the risk factors, pathophysiology, assessment findings, and management of specific hypothermic conditions and frostbite. Discuss the risk factors, pathophysiology, assessment findings, and management of drowning and near-drowning Discuss the risk factors, pathophysiology, assessment findings, and management of diving emergencies and high-altitude illness Objectives

  3. Acute mountain sickness Afterdrop Boyle’s law Core body temperature Dalton’s law Decompression sickness Drowning Frostbite Frostnip Heat cramps Heat exhaustion Heat stroke Henry’s law High-altitude pulmonary edema High-altitude cerebral edema Homeostatis Near drowning Nitrogen narcosis Thermal gradient Thermogenesis Thermolysis Thermoregulation Trenchfoot Terms

  4. Environmental Emergencies • A medical condition caused or exacerbated by the weather, terrain, atmospheric pressure or other local factors

  5. Risk Factors • age • general health • fatigue • predisposing medical conditions • medications - Rx/OTC

  6. Environmental factors • Climate • Season • Weather • Atmospheric pressure • Terrain

  7. Types of environmental illnesses • Heat • Cold • Pressurization • Localized injuries

  8. General Pathophysiology, Assessment, Management • Homeostasis • Normal • Evaluation • Oral • Axillary • Tympanic • Rectal • Tactile

  9. Thermoregulation • Regulatory center – Posterior hypothalamus • Peripheral thermoreceptors • Central thermoreceptors • Metabolic rate • Basal • Exertional • Caloric requirements • Core temperature • 37 deg. Celsius • 98.6 deg. Fahrenheit

  10. Thermal gradient • The difference in temperature between environment and body • Ambient temperature • Infrared radiation • Relative humidity

  11. Thermogenesis • Muscular • Baseline • Exertion • Shivering • Metabolic • Sympathetic stimulation • Processing of food and nutrients • Endocrine • role of hormones in setting basal rate

  12. Thermolysis • Vasodilation • Perspiration • Ineffective if relative humidity is 75% or greater. • Decrease in heat production • Increased cardiac output • Increased respiratory rate • Conduction, Convection, Radiation, Evaporation, Respiration

  13. Heat controlling mechanisms • Nervous feedback mechanisms regulate body temperature • Hypothalamus • Skin • Mostly cold receptors • Mucous membranes • Selected deep tissues • Spinal cord • Abdominal viscera • Great veins

  14. Heat Illness • General signs and symptoms • diaphoresis • posture • increased skin temp. • flushing • altered mentation • altered level of consciousness

  15. Physiology of heat gain and loss • Heat gain • Metabolic heat production • increased metabolic activity • Environmental heat gain • Heat transfer from environment

  16. Heat Loss • Metabolic heat loss • increased thermolysis from vasodilation • Environmental heat loss • increased thermolysis from heat transfer

  17. Predisposing factors • Age • peds • elders

  18. General health and meds • Diabetes • autonomic neuropathy interferes with vasodilation and perspiration - may interfere with thermoregulatory input • Antihypertensive meds • Diuretics - predispose to dehydration • Beta blockers - interfere with vasodilation; reduce capacity to increase heart rate; may interfere with thermoregulatory input • Psychotropic medications and antihistamines • all interfere with central thermoregulation • antipsychotics • antihistamines • phenothiazines

  19. Length of exposure • Intensity of exposure • Environmental • Humidity • Wind • Preventative measures • adequate fluid intake • acclimatize; results in more perspiration with lower salt concentration; increases fluid volume in body.

  20. HyperthermiaHeat cramps Muscle cramps; 2ndary to rapid change in extracellular fluid osmolarity resulting from sodium and water losses. • Due to dehydration and overexertion • Presents with • cramps in fingers, arms, legs, abdominal muscles. • Generally good mentation, • hot sweaty skin, • tachycardia, • Normal BP • Normal core temperature

  21. Tx: • Remove from environment • Massage cramped muscle • Apply moist towels to forehead and over cramped muscles • Increase fluid and sodium intake • Consider IV with NS or LR, transport if s/s persist

  22. Heat exhaustion • Most common heat-related illness • History of exposure to hot weather necessary for accurate assessment • Person may lose 1 – 2 liters of water/hour. • Each liter lost contains 20-50 mEq of sodium

  23. Presents with: • increased CBT with some neuro deficit • Sweating • Decreased fluid intake • Decreased urine output • Tachycardia • N/V/D • Dizziness, transient syncope • H/A • Muscle cramps • dehydration • orthostatic hypotension

  24. Tx: • Rest • Remove enough clothing for cooling • Fan skin • 1 – 2 IV’s: IV Fluids; NS or LR • High-flow oxygen • supine position • Transport • S/s that don’t resolve are predictive of impending heatstroke

  25. Heat stroke • Increased CBT with significant neuro deficit • Organ damage • Brain, liver, kidneys • Predisposing conditions include age, diabetes, other medical conditions • increased CBT due to deficient thermoregulatory function

  26. Exertional • Commonly presents in people in good health • Increased CBT due to overwhelming heat stress • Excessive ambient temp. • Excessive exertion, prolonged exposure, poor acclimatization

  27. Presents with: • Hot, Red, Dry skin • Irrational or unconscious • Rectal temperature 105 deg. F or higher • Tachycardia • Bradycardia • Hypotension with low or absent diastolic • Rapid, shallow respirations • Airway compromise • Seizures • Cardiac arrest

  28. Tx with: • Cool rapidly; pack in ice and/or wrap in wet sheets • Apply cold packs to armpits, groin, behind knees, on wrists, ankles, behind neck • High flow oxygen with airway management • 1 – 2 IV’s: NS or LR, wide open • Diazepam or Versed to control seizures • Transport rapidly

  29. Dehydration in heat disorders • Common syndrome • leads to orthostatic hypotension • N/V/D • Vision disturbances • Decreased urine output • Poor skin turgor • Signs of hypovolemic shock • May occur with s/s of heatstroke

  30. Tx with: • High-flow oxygen • 1 – 2 IV’s: NS or LR titrated to B/P, if BS clear, dry

  31. Water intoxication • Occurs when pt. In hot environment drinks water at a rate that exceeds fluid loss from sweating and fails to replace sodium losses.

  32. Presents with: • Normal vitals with negative orthostatics • Chills • Loss of coordination • N/V • H/A • Altered mentation • Hx: greater than one liter/hour • Urinary frequency, dilute urine

  33. Tx with: • Encourage pt. To eat foods high in sodium • Restrict further fluid intake • Unresponsive pt’s: follow protocol for unconscious, unresponsive pt., IV tko.

  34. Pyrexia (Fever) • Body temperature above normal • Hx of infection or illness • Neuro sx may present • If unsure, tx for heatstroke • Tx; • remove from environment • active cooling • Watch for reflex hypothermia • Use tepid water • Fluid therapy • Oral: Add some salt • IV: 0.9% NaCl

  35. Hyperpyrexia • Core body temperature above 106 deg. F. • Causes: • Hot baths • Hot air • Reaction to infection • Some develop hyperpyrexia within 24 hours after surgery • Rare cause: Administration of succinylcholine

  36. Hypothermia - Body core temperature < 97.0 deg. F • Environmental causes • Other causes: • Hypothyroidism • Brain tumors, head trauma • MI, Diabetes, Hypoglycemia, Drugs, Poor nutrition, Sepsis. Geriatrics also contribute • Meds that interfere with thermogenesis • Narcotics, alcohol, barbiturates • Antiseizure meds • Antihistamines, other allergy meds • Antipsychotics, sedatives, antidepressants • Aspirin, acetaminophen, NSAIDs

  37. Fatigue, exhaustion • Length of exposure • Intensity of exposure • Environmental • Humidity • Wind • Temperature

  38. Onset • Acute (immersion) • Subacute (exposure) • Chronic (urban)

  39. Mild hypothermia: Body core temp. 94 – 97 deg. F. • Presents with: • Peripheral vasoconstriction • Increase in sympathetic nervous discharge, catecholamine release, basal metabolism. •  HR •  BP • RR • Shivering until CBT about 86 deg. F, Glucose depleted • Mood changes

  40. Tx with: • Protect against heat loss and wind chill • Add heat to head, neck, chest, groin • Blankets • Skin-skin contact • NO alcoholic or caffeine beverages or nicotine • Warm oral fluids and sugar

  41. Moderate hypothermia: Body core temp. 86 – 94 deg. F • Presents with: • Peripheral vasoconstriction • Increase in sympathetic nervous discharge, catecholamine release, basal metabolism. •  HR •  BP • RR

  42. Significant ECG changes • Prolonged PR, QRS, QT intervals • Absent P waves • ST-segment, T-wave abnormalities • J waves (Osborn waves) • Shivering until CBT about 86 deg. F, Glucose depleted • Mood changes

  43. Tx with: • Remove all wet clothing; Rewarm • Add heat to head, neck, chest, groin • Consider respiratory rewarming • Do not give alcohol, caffine, nicotine • Protect against heat loss and wind chill • Maintain horizontal position • Avoid rough movement and excess activity • Monitor cardiac rhythm • Provide warm oral fluids and sugar AFTER uncontrolled shivering stops and pt. Is rewarming

  44. Severe hypothermia: Body core temp. less than 86 deg. F • Presents with: • Disorientation, confusion, irrational behavior • May become comatose • Shivering usually stops • May appear pulseless, apneic

  45. Tx with: • Assess pulse, respirations for at least 30 seconds q 1-2 minutes • Begin CPR if pulseless, apneic; follow ACLS guidelines • Provide warmed, humidified oxygen • Warm IV fluids only • <84 deg. F CBT; do not give IV meds • >84 deg. F CBT; give IV meds at longer intervals • GENTLE handling, especially when rewarming

  46. Continue resuscitation efforts until pt. Is rewarmed to at least 86 deg. F. CBT • Do not attempt warming in the field unless the patient is more than 15 minutes from a medical facility • If rewarming, use water 103-105 deg. • A patient is not considered dead until warm!

  47. Rewarming shock - Afterdrop • reflex vasodilation • Resuscitation considerations • BLS • take vitals longer • CPR • Oxygen • AED

  48. ACLS • effects of cold on meds • orotracheal intubation • Risks of Vf related to depth and duration of hypothermia • Be gentle • Impossible to defibrillate a heart colder than 86 degrees • Lidocaine and procainamide paradoxically lower fibrillatory threshold and increase resistance to defibrillation • Bretylium and Mag. Sulfate may be effective

  49. Transport considerations • Gentle • Transport with head level or slightly down • Destination considerations

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