Environmental Issues

Cold vs warm water drowning

Cold water tends to be protective but increases risk of arrhythmia, especially in children

Most immediate threat in drowning

Dysfunction of CNS and cardiac systems

- during immersion, vital tissues may become hypoxic and acidotic, which may result in cardiac dysrhythmias

- highest morbidity and mortality are related to cerebral hypoxia

Laryngospasm (drowning)

Larynx closes so much that no water gets in

- occurs in about 20% of people

- no fluid in lungs

- said to have dry drowning

Freshwater drowning

- large amounts of hypotonic water causes hemodilution

- surfactant wash occurs, leading to atelectasis and formation of shunts

Saltwater drowning

- hypertonic solution draws fluid into pulmonary spaces

- shunts created and hypoxemia occurs

Mammalian Dive Reflex

Diminishes with age, but believed to aid in conservation of oxygen stores as protection against drowning

- bradycardia - decreases workload of heart to limit unnecessary oxygen consumption

- apnea - prevents aspiration

- increased peripheral vascular resistance - redistributes blood to vital organs and limits oxygen consumption

Thermoregulation occurs through...

- release of hormones

- vasodilation of blood vessels

- sweat production

- voluntary behavioural modifications

Who populations are at-risk of heat-related emergencies?

- pediatrics

- geriatrics (metabolic + medications)

- athletes (exertional)

Younger kids are at higher risk for developing heat-related injury due to...

- increased surface area to body mass ratio

- decreased blood volume

- immature thermoregulatory mechanisms

- higher set-point for sweat-inducing temperature compensation and less sweat volume

- slower ability to acclimatize to hotter environments

Differentiate between heat crampls, exhaustion, and stroke

Heat cramps - severe cramping of large muscle groups

Heat exhaustion - mild alterations in mental status, and non-specific complaints (headache, N/V, malaise) with excessive sweating in health adults

- hot, dry skin in elderly

Heat stroke - severely altered mental status, coma, seizures, hyperthermia >40

Common causes of heat stroke

- OD of TCAs, antihistamines, and beta blockers

- cocaine, ecstasy, amphetamine abuse

Management of Heat-Related Emergencies: Secondary Survey to assess...

- CNS

- mouth, for state of hydration

- skin for temperature, colour, condition, state of hydration

- extremities for circulation, sensation, movement

- temperature

Heat Cramps S/S

- severe muscular cramps

- typically in overworked/large groups of muscles

Heat Cramps Treatment

- remove patient from environment

- provide water or electrolyte-containing fluids in small quantities

- remove excess layers of clothing

Heat Syncope S/S

- fainting episode caused by rapid vasodilation causing a quick drop in patient's BP

- common complaint of patient in early stages of heat emergency

Heat Syncope Treatment

- remove patient from environment

- keep patient supine if hypotensive

- assess for other causes of syncope

Heat Exhaustion S/S

- vasodilation - hypotension and tachycardia

- heat cramps

- headache

- altered LOC

- hot flushed skin

- excessive sweating

Heat Exhaustion Treatment

- move patient to ambulance

- remove as much clothing as possible

- fluids in small quantities

Heat Stroke S/S

- seizures, unconsciousness, coma

- skin hot, flushed, dry

- combative or bizarre behaviour

Classic Heat Stroke Demographics and History

- older

- on medications

- very little activity

- little to no sweating

- hot, red, dry skin

- normal or high BGL

Exertional Heat Stroke Demographics and History

- younger

- healthy, often no medications

- strenuous activity

- sweating

- moist, pale skin

- hypoglycemic

Heat Stroke Treatment

- move patient to ambulance

- remove as much clothing as possible

- withhold oral fluids

- cover patient with wet sheets

- apply cold packs to axillae, groin, neck, head

Severity of Burn depends on...

- intensity of source

- length of exposure to source

- location of burn

- extent of burn

- patient's age

- patient's underlying medical conditions

Superficial Burns

- epidermis only

- present as pink to red with no blisters

- appear dry

- moderately painful

- heal without scarring within 5 to 10 days

Partial Thickness Burns

- epidermis and superficial dermis

- mostly red with blistering, edema, and severe pain

- healing typically occurs within 3 weeks with minimal scarring

- deeper partial thickness burns may begin to appear yellow

Full Thickness Burns

- full thickness of skin and subcutaneous structures

- appear white or black/brown, leathery and dry

- minimal to no pain because of decreased sensation

- heal by contracture and take greater than 8 weeks

- requires skin grafting

Rule of 9's Adult

Head = 9%

Front Torso/Abdomen = 18%

Back Torso/Abdomen = 18%

Right Leg (front and back) = 18%

Left Leg (front and back) = 18%

Right Arm (front and back) = 9%

Left Arm (front and back) = 9%

Groin = 1%

Rule of 9s Children (differences

Head = 18%

Legs = 14% each

Palmar method for burns

Patient's hand = 1% of their body

Cardiovascular Complications with Burns

- hypovolemic shock - damage to blood vessels causes fluid leaking and edema

- hypothermia - damage to skin and fat causes loss of insulation

- swelling - fluid leaking and edema

Respiratory Complications with Burns

- airway burns = swelling and edema

- dyspnea

- restricted movements - closing of airway due to edema and bronchoconstriction (mechanical obstruction - musculature of chest is impaired)

Other Complications with Burns

- infection/sepsis

- renal failure

- clotting disorder

General Burn Management

- remove patient from environment - use allied agencies

- stop burning process (saline on burn)

- remove any clothing or jewelry that is not fused into injury

- perform assessment and determine burned area, burn depth, and percentage of body surface burned

- assess CSM in injured extremities

- determine if smoke inhalation occurred

Burn Management of Eyes

If burns involve an eye, eye is swollen shut, leave eye shut

- cover both eyes

Burn Management & Oxygen Administration

- if administering oxygen where facial burns are present, place gauze pads under edges of the mask to decrease pain and irritation

- administer high concentration of oxygen to known or suspected cases of CO or cyanide poisoning (both are potential concerns for any incident involving combustible materials)

Burn Dressings

- cover all 1st degree burns with moist sterile dressing and then cover with dry sheet or blanket

- cover all 2nd degree burns estimated to involve <15% of body surface area with moist sterile dressing, and dry sheet or blanket

- cover all 2nd degree burns estimated to involve >15% of body surface area with dry, sterile dressing or sheet

- cover all 3rd degree burns with dry, sterile dressing or sheet

- dress digits individually

Burns & Hypothermia

- for burn sites estimated to involve <15% of body surface area, cool burns and limit cooling to <30 minutes to prevent hypothermia

- if signs of hypothermia are noted, stop all cooling efforts

Burns & FTT

Not FTT eligible unless burns were caused by a traumatic mechanism

What is the Parkland Formula for?

Burn formula used to estimate amount of replacement fluid required for first 24 hours in a burn patient so as to ensure patient is hemodynamically stable

- first half administered over 8 hours, and second half over next 16 hours

Parkland Formula (Burns)

Total fluid over first 24 hours = 4ml x % of TBSA burned x body weight (kg)

In children, formula is 3ml x % TBSA burned x kg

Airway Burns S/S

- SOB - shallow respirations and decreased air entry

- audible wheezing

- burns to lips or mouth

- cough and drooling

- stridor or hoarse voice

- burned or singed nasal hairs or eyebrows

Eschar Formation

- circumferential burns can severely inhibit bodily functions, most problematic around chest

- appear as thick leathery scars

- increased pressure around area of burn

- decreased blood flow to area due to increased pressure

Management of Chemical burns

- brush off or manually remove solid, powdered hazardous materials

- irrigate exposure site using large volumes of cool, not cold water

- avoid irrigation if chemical is known to be reactive to water

Management of Chemical Burns: How long to irrigate acids, bases, and unknown substances

Acids = 10 minutes

Bases = 20 minutes

Unknown substances = 20 minutes

How is Heat Lost?

1) Evaporation - body heat lost by evaporation of perspiration

2) Convection - body heat lost to air

3) Conduction - body heat lost to nearby objects through touch

4) Radiation - body heat lost to nearby objects without touching them

What is Frostnip

- redness with blanching and diminished sensation

- fully reversible

- cold, sore, painful

What is Frostbite

Superficial:

- white, waxy frozen appearance

- pins and needles

- patches of peeling skin

Deep:

- cold, hard, wooden skin

- very hard on palpation of affected areas

- numbness

Management of Frostbite

- wrap patient's body/affected parts in blanket or foil blanket, cover and protect part

- don't rub or massage skin

- leave blisters intact

- if dressing digits, dress separately

Mild to Moderate Hypothermia Management

- remove patient from cold

- wrap patient's body/affected parts in blanket or foil rescue blanket

- provide external re-warming as available to axillae, groin, neck, and head

Severe Hypothermia Management

- remove patient from cold

- wrap patient's body/affected parts in blanket or foil rescue blanket

- when suction required, do not perform vigorous suctioning or airway manipulation as it may trigger VF

- no external re-warming

Hypothermia: ECG Change

Common finding with hypothermic patients is J (Osborn) waves

- if present, patient is more likely to go into VF if not gently handled

Crush Injuries: Rhabdomyolysis

Characterized by leakage of muscle cell contents into extracellular fluid

- results in acute renal impairment

Rhabdomyolysis S/S

- muscle weakness

- pain

- local swelling

- dark red urine

Crush Injuries: Compartment Syndrome

Condition in which there is increased pressure within a closed compartment, resulting in impaired circulation

- local ischemia results from swelling and compression of blood vessels

- long-term ischemia can lead to tissue death and further swelling

Crush Injuries: Compartment Syndrome S/S

- tense 'wood-like' feeling of compartment

5Ps

- pain

- pallor

- paresthesia

- pulselessness

- pressure

Crush Injuries: Management

- consider SMR

- consider air ambulance

- attempt to get all information from patient before removing object

- consider FTT

- consider trauma TOR