First Responder Workshop 2010

1. First Responder Workshop 2010 Jim Holliman, M.D., F.A.C.E.P. Program Manager, Afghanistan Healthcare Sector Reconstruction Project Center for Disaster and Humanitarian Assistance Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland, U.S.A.

2. Goals of This Workshop • Using a case - based format for 20 of the common types of cases seen by first responders : • Present critical actions that should be done for each case • Review pitfalls to avoid on each case • Have a two - way discussion of other aspects of each case

3. Cases to be Presented in this Workshop • Precipitous childbirth • Heat illness • Acute psychosis • Obvious fatality • Snakebite • Coma • Shock • Near-drowning • Allergic reaction • Seizure • Cardiac arrest • Burns • Electrocution • Chest pain • Stroke • Dyspnea • Insecticide poisoning • Medication overdose • Multiple trauma • Pediatric trauma

4. Case 1 Cardiac Arrest • 65 year old male • Family called because he had chest pain • Lying in bed in home • Apneic, cyanotic, no pulse • Has history of "heart problems" and "colon cancer 12 years ago" according to the family

5. Cardiac Arrest Critical Actions • Verify presence of cardiac arrest • Quickly start CPR • Find out quickly if the patient has a "Do not attempt resuscitation status" certified by their doctor • Move quickly to ambulance • Contact advanced medical help (doctor or ambulance with defibrillator if available) • Rapid transport to closest hospital

6. Cardiac Arrest Pitfalls to Avoid • Not checking the resuscitation status of the patient • Taking a detailed history before starting resuscitation efforts • Not considering hypothermia • Not checking for signs of injury • Not notifying the receiving medical facility as early as possible • Expecting a high success rate

7. Case 2 Burns • 28 year old male • Was cleaning motor with gasoline when it exploded • The table and curtain in the room also caught fire ; the room is smoky • Second and third degree burns of face, neck, chest, and arms • Awake and alert but coughing frequently • Pulse 120, resps. 20, BP 136 / 88

8. Burns Critical Actions • Protect yourself if the fire is still burning • Remove patient from smoky environment quickly • Airway / breathing / circulation ("ABC") assessment • Get all burned clothes off the patient • Cover with clean dry sheets • Start oxygen if any potential airway problem or smoke inhalation • Copious irrigation with water if a chemical burn • Rapid transport to appropriate hospital

9. Burns Pitfalls to Avoid • Not removing all potentially smoldering clothes & stopping the burning process • Continued soaking of a large burn area thus making the patient hypothermic • Mis-estimating the extent of the burn • Not recognizing the potential for airway compromise • Not recognizing other associated traumatic injuries

10. Case 3 Electrocution • 24 year old male • Was working on a roof 4 meters high when he touched an overhead electric power line, was shocked, and fell off the roof • Was initially unconscious, now is awake but confused • Has entrance burns on one hand and his sandals are smoldering • Complains of limb and back pain • Pulse 96, resps. 20, BP 94 / 64

11. Electrocution Critical Actions • Turn off the electric power or push the patient off the electric source with an object that does not conduct electricity • ABC assessment • Determine if high voltage (> 1000 volts) • Assess for other associated injuries • Rapid transport to hospital (may require very large amounts of intravenous fluid) • Fairly good chance of success even if prolonged CPR required

12. Electrocution Pitfalls to Avoid • Not checking for associated trauma such as spinal injury, joint dislocations, etc., and not performing appropriate spinal immobilization or splinting • Not appreciating that there may be large amounts of muscle damage beneath unburned skin • Not checking for exit wounds

13. Case 4 Chest Pain • 48 year old female • Complains of anterior chest pain with radiation to the neck for 2 hours • No previous history of heart disease • Awake and alert, diaphoretic • Also complains of shortness of breath • No allergies • Husband is reluctant for her to go to hospital • Pulse 76, resps. 20, BP 130 / 90

14. Chest Pain Critical Actions • Assume a life - threatening cause is present until definitively proven otherwise • ABC assessment • Start oxygen if available • Give an aspirin (80 to 500 milligrams) if not allergic to aspirin or nonsteroidals, and cardiac ischemia is suspected • Rapid transport to a hospital with cardiology capabilities

15. Chest Pain Pitfalls to Avoid • Not suspecting cardiac ischemia in younger or female patients • Not considering cardiac ischemia in elderly patients with vague symptoms (remember many elderly patients with acute myocardial infarction will NOT have chest pain) • Taking the patient to a medical facility that does not have advanced cardiac care • Not starting oxygen or giving aspirin

16. Case 5 Stroke • 60 year old male • Suddenly developed weaknes of the left side and "garbled speech" according to the family 30 minutes ago • The family does not know what medicines he takes • He is sleepy but arousable, and his speech is difficult to understand • Pulse 55, resps. 14, BP 190 / 116

17. Stroke Critical Actions • ABC assessment, may need airway management if level of consciousness is depressed • Check fingerstick blood sugar • Check pulse oximetry if available • Start oxygen if available • Determine time of onset of symptoms • Rapid transport to a hospital with a computed tomography scanner • Repeat the neurological exam at frequent intervals

18. Stroke Pitfalls to Avoid • Not checking for hypoxia or hypoglycemia early • Not protecting the patient's airway if they have a depressed level of consciousness • Not checking for associated injury (the patient may fall down from sudden weakness) • Overtreating elevated blood pressure • Not repeating the neurologic exam to see if there is worsening or improvement of the patient's symptoms and signs

19. Case 6 Dyspnea • 44 year old male • Long history of smoking cigarettes • Also history of asthma and pneumonia • No allergies • Uses salbutamol inhaler as needed • Complains of progressive shortness of breath and frequent cough for the past several days ; no chest pain • Pulse is 112, resp. rate 32, BP 155 / 100

20. Dyspnea Critical Actions • ABC assessment ; check and record pulse oximetry if available • Start oxygen • If the patient is wheezing, have him use his metered dose inhaler meds if available (this is safe even if the dyspnea has a cardiac cause) • If not hypotensive, don't force the patient to lie flat • Rapid transport to an appropriate medical facility

21. Dyspnea Pitfalls to Avoid • Not starting oxygen for fear of "suppressing respiratory drive" • Not considering a cardiac cause • Dismissing hyperventilation as just due to anxiety • Not providing aggressive airway management for patients with a depressed mental status

22. Case 7 Insecticide (Organophosphate) Poisoning • 30 year old female • Ingested liquid insecticide in a suicide attempt • Actively vomiting, diaphoretic, drooling, complaining of shortness of breath • Vomitus all over the patient's clothes • Pulse 90, resp. rate 36, BP 100 / 60

23. Insecticide Poisoning Critical Actions • Protect yourself ; remember the patient's clothes may be contaminated and all the patient's body fluids (sputum, emesis, etc.) may contain the insecticide ; use universal precautions • Make sure the ambulance is well ventilated (to prevent your exposure to "off-gassing") • ABC assessment ; start oxygen • Remove all the patient's clothes and footwear and bag these in plastic ; decontaminate the skin by irrigation with water if the skin was exposed to powder or liquid • Rapid transport to appropriate medical facility

24. Insecticide Poisoning Pitfalls to Avoid • Getting yourself poisoned by skin exposure to contaminated clothes or vomitus or breathing off-gassed vapors • Failing to decontaminate the patient prior to entering the ambulance • Not assessing for other exposures or ingestants • Not providing supportive care (oxygen, suction of airway secretions, etc.) • Not properly disposing of contaminated clothes or footwear

25. Case 8 Medication Overdose • 18 year old female • History of depression and prior suicide attempts • Taking several antidepressant meds but family does not know the names • Took "a large number" of multiple pills about one hour ago • Now drowsy but arousable • Pulse 120, resp. rate 14, BP 104 / 55

26. Medication Overdose Critical Actions • ABC assessment • Try to identify what meds and how many the patient took and the time of ingestion ; collect all pill bottles in the home and bring these to the hospital • Monitor the patient closely ; sudden deterioration may occur • Try to determine if the ingestion was accidental or suicidal

27. Medication Overdose Pitfalls to Avoid • Trying to make the patient vomit (just predisposes to aspiration) • Not identifying all co-ingestants • Not preventing the patient from accessing other items to use in another suicide attempt ; not closely monitoring the patient at all times • Not evaluating the airway or providing oxygen if the patient has a depressed mental status

28. Case 9 Multiple Trauma • 30 year old male truck driver • Truck ran off road at high speed and rolled over • Patient was thrown 5 meters from the vehicle • Unconscious, several scalp lacerations actively bleeding, abrasions over chest and abdomen, deformity of left thigh and ankle • Pulse 130, resp. rate 8, BP 80 / 40

29. Multiple Trauma Critical Actions • If motor vehicle crash, assess scene for rescuer safety (is there need for water or foam to cover spilled gasoline or hot engine, etc.) • ABC assessment ; start oxygen • Control external bleeding with direct pressure • Immobilize spine and apply limb splints • Limit on-scene time as much as possible • Make sure someone checks the scene for other "hidden" victims • Rapid transport to trauma center

30. Multiple Trauma Pitfalls to Avoid • Not prioritizing the "ABC's" • Being inefficient and taking too much time at the scene ; performing actions at the scene that could wait until the patient is in the ambulance • Not having someone search the scene for other victims • Not notifying the receiving medical facility early • Not taking measures to prevent hypothermia • Not frequently reassessing the patient

31. Case 10 Pediatric Trauma • 5 year old male • Walking across road and hit by car at high speed • Thrown 6 meters by the impact • Reported initial loss of consciousness • Now sceaming • Bleeding lacerations of scalp, right arm, and left flank, deformity left thigh • Pulse 145, resp. rate 28, BP 94 / 56

32. Pediatric Trauma Critical Actions • Scene safety and ABC assessment ; oxygen • Stop external bleeding with direct pressure dressings • Try to notify the parents if they are not at the scene and find out the patient's medical history, allergies, and current meds • Limit on-scene time as much as possible however • Reassure and try to verbally calm the child • Rapid transport to (pediatric) trauma center

33. Pediatric Trauma Pitfalls to Avoid • Not prioritizing the "ABC's" • Focusing on one obvious injury and not performing a complete assessment • Not taking measures to prevent hypothermia • Not providing reassurance to the child • Using terminology the child does not understand • Taking the child to a facility not capable of pediatric care

34. Case 11 Precipitous Childbirth • 30 year old female • 5 prior pregnancies with vaginal deliveries • Started having strong contractions 2 hours ago, now every 2 minutes • "Water broke" one hour ago • Pulse 110, resp. rate 24, BP 110 / 60 • Now says she feels as if she must use the toilet

35. Precipitous Childbirth Critical Actions • ABC assessment • Start oxygen if possible fetal distress (prolapsed cord, breech crowning, etc.) • Position mother so if baby is suddenly delivered, the baby will not fall or be injured • Don't insert anything in the vagina (could stir up bleeding) • Expose the perineum if any possibility of crowning • Rapid transport to obstetric facility

36. Precipitous Childbirth Pitfalls to Avoid • Not safely positioning the mother • Not recognizing urge to void or defecate as a sign of imminent delivery • Not starting oxygen if any possibility of fetal distress • Not providing reassurance to the mother and family • Not notifying the receiving facility early

37. Case 12 Heat Illness • 68 year old male • Found unconscious in very hot poorly ventilated upstairs room in an apartment buliding • Outside air temperature > 40 degrees Centigrade for the past 5 days • Responds only to painful stimuli • Skin dry and very warm • Pulse 112, Resps. 22, BP 90 / 60

38. Heat Illness Critical Actions • Recognition • ABC assessment • Measure temperature if thermometer available • Check fingerstick blood sugar if abnormal mental status • Start cooling measures early • Scalp, axillary, and groin ice packs • Water mist and fan • Try to avoid causing shivering • Rapid transport to medical facility

39. Heat Illness Pitfalls to Avoid • Attributing altered mental status from hyperthermia to something else such as alcohol intoxication • Not starting cooling measures as part of initial resuscitation • Excessive fluid treatment for classic heatstroke • Not anticipating multiorgan dysfunction • Causing excess shivering from cooling measures (shivering may make the patient's temperature go even higher)

40. Case 13 Acute Psychosis • 32 year old male • Found running in circles in the street • Yelling loudly "the spiders are after me ! " • Previous history of "psychiatric problems" • No allergies according to family • Stopped taking his haloperidol recently • Pulse 120, Resps. 24, BP 160 / 100

41. Acute Psychosis Critical Actions • Protect yourself from injury if the patient is potentially combative • ABC assessment • May require physical restraints for both patient safety and rescuer safety • Check for hypoxia and hypoglycemia • Determine if alcohol or illicit drug ingestion may be contributing • Make sure the patient is not hyperthermic (this can accompany amphetamine or cocaine use)

42. Acute Psychosis Pitfalls to Avoid • Not assessing for "reversible" or medical causes of the psychosis • Not restraining the patient safely • Safest approach to the combative patient is to wait until 4 or 5 first responders are available before closely approaching the patient • Trying to verbally reason with the patient • Not searching the restrained patient for weapons

43. Case 14 Obvious Fatality • 85 year old male • Last seen by family over 12 hours ago • Found by family unresponsive in bed • History of metastatic cancer and advanced cardiac disease • No pulse or resps. • Dependent lividity noted

44. Obvious Fatality Critical Actions • Don't start any resuscitation if death criteria clearly present (dependent lividity, rigor mortis, initial decomposition, major dismemberment or open head injury incompatible with life, etc.) • Notify appropriate local authorities • Counsel the family • Cover the body from public view and treat the body with cultural respect • Don't leave the family until responsibilty for the body has been transferred to local authorities or a funeral director

45. Obvious Fatality Pitfalls to Avoid • Overlooking resuscitatable hypothermia • Moving the body or altering the scene if any possibility of homicide • Leaving the family before arrangements for management of the body are verified • Not notifying the local authorities or the patient's regular doctor • Continuing resuscitation attempts when started by others but when clearly inappropriate

46. Case 15 Snakebite • 18 year old male • Was walking through tall grass when bitten by a large black snake on the right leg about one half hour ago • Did not see what kind of snake it was • Now complaining of nausea and vomiting and feeling weak • Pulse 120, resps. 12, BP 88 / 50

47. Snakebite Critical Actions • Move patient a safe distance from the snake if it is still in the vicinity • ABC assessment • Try to identify the snake type but don't take any risk to do so • Apply "lymphatic" tourniquet above the bite site (snug but not too tight) • Rapid transport to a medical facility that has antivenin

48. Snakebite Pitfalls to Avoid • Trying to capture the snake and bring it also to the hospital • Excessive ice treatment of the bite site • Can cause tissue damage like frostbite • Incising the bite site to try to release venom • Not recognizing signs of systemic envenomation

49. Case 16 Coma • 35 year old male • Found by coworkers lying on the floor in a garage, last seen by them two hours ago • No histroy of alcohol or illicit drug use • Unconscious, responds to pain only by limb withdrawl • Pulse 60, resps. 12 and snoring, BP 166 / 100

50. Coma Critical Actions • ABC assessment • May benefit from nasal airway • Start oxygen routinely • Neck and spine immobilization if any possibility of trauma • Check for hypoxia and hypoglycemia • Consider also carbon monoxide intoxication, and hypothermia or hyperthermia • Rapid transport to medical facility