Environmental emergencies JCCC EMT (EMS 132)

what part ofthe brain controls temp? What are the tow types of sensors?

hypothalamus

–Central sensors

•On or near anterior hypothalamus

–Peripheral sensors

•In skin & mucous membranes

body response to cold vs heat

cold- increased metabolic rate/ shivering, vasoconstriction

heat-vasodilation, sweat, increased respiration, increased blood flow to skin

the different types of heat transfer (5 types)

convection- transfered through air or liquid

radiation- heat lost to atmosphere and other objects without touching them

respiration- heat lost through breathing

evaporation- sweat evaporates causing heat loss

conduction- transfer of heat from physical contact

a few examples of risk factors for hypothermia

drugs/poisons

extremes of age

medical conditions

measurement of severity of hypothermia

Mild: 32.1°–35°C/89.8°–95°F

Moderate: 28.1°–32°C/82.5°–89.7°F

Severe: 24°–28°C/75.2°–82.4°F

Profound: less than 24°C (75.2°F)

about every 4-5 degrees it gets worse

look at signs and symptoms

thermoregulation ability is lost when temperature drops below 95. Shivering usually stops around 90

s/s of hypothermia/how they progress

body tries to compensate then slows down

faster hr, rr, and shivering but then that all stops

AMS develops

skin goes from red to pale and waxy

pupils get dilated 

how soon can death occur with hypothermia

2 hours

hypothermia happens ____ times faster in water

25-35

what is a local cold injury/what causes it.

–Local cold injury occurs when ice crystals form between the cells of the skin.

local cold injury risk factors

trauma, tight footwear, alcohol (a vasodilator), arteriosclerosis

external hypothermia

inadequate access to shelter

internal hypothermia

no heat in home

hypothermia assessment considerations

check pulse for 30-60 seconds carefully

move pt to warm enviornment early.

Get PMH for possible risk factors

look for signs of hypothermia and trauma

look for bradycardia, bradypnea, hypotension, poor perfusion, dilated pupils

hypothermia treatment

remove from cold enviornment

remove wet clothes

humidified and warmed (to max of 104-108) o2 if needed

warm food and drink if patient is able and awake

shivering is good

get a BGL

blankets

warmers/heat packs around core (no direct contact on skin)

hand pt carefully and keep them supine if possible (cut clothes off so you dont move arms) dont let them exert themselves

cardiac monitor on and AED ready

local cold injury s/s

numbness involving the affected body part

along with a "clumsy" feeling along with areas of blanched skin — later findings

include a "woody" sensation, decreased or loss of sensation, bruising or blister

formation, or a white and waxy appearance to affected tissue

hypothermia exp ?s

Attention to any associated injury or illness

Duration of cold exposure

Ambient temperature

Treatments initiated before EMS arrival

local cold injury treatment

avoid rewarming of extremities until definitive treatment

is possible.

If rewarming is feasible and refreezing can be prevented use

circulating warm water (37°–39°C/98.6°–102°F) to affected body

part, thaw injury completely. If warm water is not available, rewarm

frostbitten parts by contact with non-affected body surfaces. Do not

rub or cause physical trauma.

After rewarming, cover injured parts with loose sterile dressing.

keep doing CPR on hypothermic pt unless

Obvious fatal injuries (such as decapitation)

1.9.1.2 The patient exhibits signs of being frozen (such as ice formation in the airway)

1.9.1.3 Chest wall rigidity such that compressions are impossible

1.9.1.4 Danger to rescuers or rescuer exhaustion

1.9.1.5 Avalanche victims buried for 35 minutes or longer with airway obstruction by ice

or snow

note:

1.9.2 Fixed and dilated pupils, apparent rigor mortis, and dependent lividity may not be a contraindication for resuscitation in the severely hypothermic patient

hypothermia airway management considerations

In the absence of advanced airways, ventilate the patient at the same rate as a

normothermic patient

If the patient has an advanced airway, ventilate at half the rate recommended

for a normothermic patient to prevent hyperventilation. If EtCO2 is available,

ventilate to maintain normal EtCO2 levels (1:12 for adult and 1:4-6 for pediatric)

heat cramps

•Painful muscle spasms following strenuous activity in hot environment.

•Usually caused by electrolyte imbalance.

•Patient fully alert & sweaty with normal to warm skin temperature.

•Move to cool environment; replenish fluids.

heat exaustion

–Mild state of shock

•Pooling of blood in vessels below skin with increased vasodilation

•In extreme cases, organs are not well perfused.

•Prolonged – profuse fluid loss from sweating

heat exaustion s/s

–Mild to moderate perspiration

–Warm or cool skin temperature

–Skin color may be normal to pale

–Weakness, exhaustion, dizziness

–Nausea and vomiting

–Muscle cramps (usually in legs, abdomen)

–Rapid, weak pulse

–Rapid, shallow breathing

–Altered mental status (extreme cases)

temp greater than 100

heat stroke

–Body’s heat-regulating mechanisms breaks down & are unable to keep the body cool

–High body temperature damages brain cells.

–Temperature rises – inability to sweat

–Patient has altered mental status & may present with hot skin that is either dry or moist.\

the brain is cooking

heat stroke s/s

–Altered mental status

–Skin hot-to-touch

–Skin slightly moist-to-dry

–Rapid, shallow breathing

–Rapid pulse

–Weakness, exhaustion, dizziness

–Nausea & vomiting

–Convulsions

temp greater than 104

•

hyperthermia exp ?s

what were you doing

fluid intake

 Diuretics?

how is heat exaustion indentified in compasrison to stroke

stroke is distinguished from heat exhaustion

by altered level of consciousness, seizures, or coma

• stopping sweating

hyperthermia treatment

ABCs

get out of heat

remove clothing

if A&O give small sips of cool liquid

check BGL

cardiac monitor

if AMS or core temp of greater than 104

begin active cooling by:

1.4.2.7.1 Ice bath immersion provides the most rapid cooling mechanism

1.4.2.7.2 If ice bath immersion is not available, consider the following:

Tarp-assisted cooling with oscillation

1.4.2.7.2.2 1.4.2.7.2.3 Rotating ice water-soaked towels or sheets

Continually misting the exposed skin with tepid water while fanning

the victim

1.4.2.7.2.4 Truncal ice packs may be used, but are less effective than

evaporation

1.4.2.7.2.5 DO NOT apply wet cloths or wet clothing, as they may trap heat and

prevent evaporative cooling

if shivering occurs, call ALS for meds

keep doing active cooling until…

Cooling efforts should continue until the patient's temperature is less than

102.2°F (39°C) or, if continuous temperature monitoring is not available, until

the patient demonstrates improvement in mental status

drowning s/s

•Airway-patent? Obstructed? Fluids?

•Resp distress

•Resp Failure

•Cold to touch?

•Cyanotic?

Cardiac Arrest?

important s/s and concerns drowning

•Persistent cough

•Dyspnea/apnea

•AMS or LOC

•Vomiting

•Drug/ETOH

•Pertinent past medical hx

•Hypothermia

•Duration of CA/RA

•Age of patient

•Spinal Injury?

•Water temp

•Duration of submersion

mammalian diving reflex

•Drastically slows down metabolism and may prolong possibility of resuscitation

•Larynx spasms (inhibits breathing), slowed heart rate, vasoconstriction (except to heart and brain)

•The colder the water, the more pronounced the effects

does “secondary or dry drowning” really exist? if so what do we do

not exactly

it is possible that water enters the lungs and damages the alveoli. This can cause the alveoli to leak and cause non cardiogenic pulmonary edema (just like normal pulmonary edema). This can happen 12-48 hours later so its important to watch someone even if they are not showing symptoms.

pulmonary edema= CPAP

Barotrauma

(pressure-induced trauma)

•Dysbarism 

a medical condition that results from changes to ambient pressure

Boyles law

Volume/pressure inversely related

 if a diver takes a lungful of air while he is underwater, that air will expand in his lungs as he rises to the surface. If he holds his breath or ascends too rapidly (like a cork) the expanding air can rupture his lungs (air embolisms).

some gases become toxic or cause mental impairment when their partial pressure in the blood rises above a particular level.

•Henry’s Law

-- dissolving of gases (nitrogen) are faster at high pressures

•Ascent can cause bubbles in blood and tissue

•Charles Law 

- gas will expand when heated

•Ascension can again cause trauma to airway structures and lungs

can also make bubbles

Barotrauma -- EENT and other considerations

•The “squeeze”-- pressure in cavities is too great, and eardrums or sinuses may rupture

•May see blood from ears/nose, pain to affected areas, dizziness/disorientation, & nausea (N/V)

pneumothorax

pneumomediastinum

Arterial Gas Embolism

•Ascend to rapidly causing trauma to alveoli & surrounding blood vessels which allows air to escape into circulation

•An “air clot” (air embolism)

S/S -- rapid onset of S/S of allergic reaction, deep pain in muscles, joints, tendons, distortion of senses, frothy blood in airway, coma, CA, behavioral changes

Decompression Sickness AKA ”the bends”

•Expansion of Nitrogen within tissues and joints

•Act as air emboli (air clots) and obstruct circulation

•Compress and stretch blood vessels and nerves

•Can mimic an allergic reaction

•May occur hours after a dive (versus air emboli that happens immediately upon ascent – if you are trying to delineate which is which)

diving exp ?s

•Where?

•Depths and how long?

•Rate of ascent

•Been on a plane?

•Air supply content?

•Work or problems underwater?

•Physical condition prior?

decomp sickness s/s

mild

Respiratory distress

•Pain

•Pruritis, skin bends (bruising or mottled skin)

•Skin rash

•Pain (severe) usually localized to abdomen, joints, tendons – makes patient bend over, hence “the bends”

•severe

S/S vary wildly

•Respiratory distress

•Nervous -- low back pain that progresses to paralysis, deafness, vertigo

•The “chokes”-- dyspnea, pain on inspiration, cough

•S/S of shock

care for drowning

ABCs

hypothermia treatment if needed

identify cause if possible

C-spine precautions if suspected

in water ventilations only if delayed extrication

Start CPR with 5 rescue breathes

care for diving incident

ABCs

treat other injuries

 If air embolism suspected, place in left lateral recumbent position- helps trap air from traveling into cerebral circulation

 Patients with symptoms suspicious for decompression illness, should be placed

on supplemental oxygen regardless of saturations to enhance washout of inert

gasses

transport to hyperbaric facility

Acute mountain sickness s/s

Headache plus one or more of the following: anorexia, nausea

or vomiting, fatigue or weakness, dizziness or lightheadedness or difficulty sleeping. (In

infants and young children, symptoms include pallor, fussiness, vomiting, decreased

appetite, poor sleep, decreased playfulness.) These symptoms must occur in the setting

of recent arrival to high altitude (generally considered greater than 5000 – 7000 feet)

High altitude pulmonary edema (HAPE): s/s

Progressive dyspnea, cough, hypoxia, and

weakness in high altitude environments (considered greater than 8000 feet). (In infants

and young children, symptoms again include pallor, fussiness, vomiting, decreased

appetite, poor sleep, decreased playfulness.) Patients may or may not exhibit new

symptoms if acute mountain sickness precedes symptoms of HAPE

High altitude cerebral edema (HACE):

 Identified by mental status changes in patients with

symptoms of acute mountain sickness including altered mentation, ataxia, or stupor and

progressing to coma. Typically seen in high altitude environments (greater than 8000 feet)

altitude sickness treatment

ABCs

descend 

pulmonary edema=CPAP

Acute mountain sickness

• Ibuprofen or acetaminophen for pain

brown recluse- toxin type, s/s

•Bite injects a cytotoxin

•Cytotoxin -- toxic to cells

•Breaks down cell membranes leading to necrosis of the tissue

Not very painful when bite happens

may lead to amputation of bite area

•Not deadly

•Localized swelling (initially), tenderness

•Pale, mottled, cyanotic center w/possible blister formation

•Open sore & necrosis (2 - 8 hrs)

black widow- toxin type and s/s

•Inject a neurotoxin

•Neurotoxins affect the nervous system

•Black widow toxin causes affected nerve cells to dump neurotransmitters

•Very painful, but rarely deadly in healthy adults

•Painful bite

•Localized swelling initially

•Dizziness, sweating, N/V, rashes

cramping- abdomen, back, chest, shoulders

rigid abdomen

•Chest tightness, difficulty breathing, or abdominal pain (depending on bite site)

•Occur within 24 hours of bite & subside within 48 hours (usually)

•Antivenin exists – saved for those who are most at risk for adverse outcomes

Muscle pain****

spider bite care

monitor ABCs

clean wound with mild soap and water

cover with dry sterile dressing 

cardiac monitor 

BGL test

•Remove any watches / rings / constricting jewelry

keep them still- splint…

draw circle around swelling

take pic of spider if possible

the venomous snakes in kansas

cotton mouth

rattle snake

copperhead

rattle snake toxin

•Hemotoxic & neurotoxic:

•Hemotoxin -- break down blood & tissue causing necrosis & hemorrhaging, can also cause clotting issues

neuro- weakness, spasm, paralysis, etc

•Toxins affect blood & nervous system both at the bite site & systemically

•Patient age & size cause different effects (same with perpetrator)

copperhead toxin

hemotoxin

cottonmouth toxin

hemotoxin

snake bite care

ABCs

clean it

cover it

take pic of snake if possible

••Note time of bite

•Remove any constricting jewelry

•Keep patient calm

•Notify receiving facility immediately to ensure antivenin capabilities

•Rapid Transport to appropriate facility

draw circle around swelling

keep them still- splint…

what should you watch for with any bite or sting

anaphylaxis

marine stings

scrape of tentacles or carefully pull out tooth or barb

hot water immersion of effected part (113°F/45°C).

types of lightning strike

direct

contact-they were touching something that got struck

splash

ground current

body systems lightning strike can effect

cardiac

resp.

skin

nervous

musko.

care for lightning strike

ABCs

cspine

care for other trauma (fractures or burns)

drowning exp ?s

length of submersion

what lead up to it

alcohol involved?

Bee sting care

Remove stinger

Cool compress/not ice

clean it