Environmental Emergencies PDF

Emergencies PARA 3500 BLS v3.4  General Trauma Standard p 51  Burns (Thermal) Standard p119  Cold Standard p122  Electrocution Standard p124  Submersion Standard p132 Apply the General Trauma Standard  Ask to stay still  Move/extricate immediately if:  Safe to do s...

Emergencies PARA 3500 BLS v3.4  General Trauma Standard p 51  Burns (Thermal) Standard p119  Cold Standard p122  Electrocution Standard p124  Submersion Standard p132 Apply the General Trauma Standard  Ask to stay still  Move/extricate immediately if:  Safe to do so  Dangers identified during scene survey or primary survey  Perform rapid Primary Survey  Perform rapid trauma survey  Consider SMR  Attempt to estimate blood loss  Leave impaled objects in place unless interfering with airway or CPR  Assess injuries for CLAPS D TICS  Complete secondary survey if major or multiple trauma present/suspected  Remove clothing/jewellery that may compromise injury site. Temperature Regulation  Core temperature  The temperature of deep structures of the body, such as the liver, as compared to temperatures of peripheral tissues.  Core temperatures usually do not vary more than 1º – 2 º from the normal 98.6ºF or 37ºC, where the body functions best  The body maintains core temperatures through metabolism  Temperature Regulation  Metabolism  The combination of all chemical processes that take place in living organisms, resulting in growth, generation of energy, elimination of wastes & other bodily functions as they relate to the distribution of nutrients in the blood after digestion Metabolism = Generation of energy = Heat as a byproduct Temperature Regulation  Internal heat  Comes from routine cellular metabolism  Shivering can further generate heat through skeletal muscle contraction  Heat can be generated through strenuous exercise, greatly increasing metabolic rates  Environmental heat  We receive heat via the thermal gradient The difference in temperature between the environment & the body  If the environment is warmer than the body, heat flows from it to the body  Temperature Regulation  Controlled by hypothalamus  Locatedin the base of the brain, functions like a thermostat & controls many metabolic activities TOO HOT! TOO COLD! Vasodilates Vasoconstricts perspiration perspiration heat production heat production cardiac output cardiac output respiratory rate respiratory rate Temperature Regulation  Based on heat loss versus heat gained  Heat loss exceeds heat gain =hypothermia  Hypothermia A state of low body temperature, specifically low body core temperature below 35ºC  Heat loss occurs by 4 main mechanisms:  Radiation 55 – 65% even in dry conditions  Convection 15%, more depending on the wind  Windchill  Conduction 15%, more if wet  Water chill; immersion  Evaporation (of water vapour from our skin and respiratory tract) Exposure To Cold  Generalized hypothermia Overall reduction in body temperature  Local cold injury Damage to body tissues in a local part or parts of the body  Hypothermia  Mild hypothermia: 34ºC – 36 ºC  Shivering, not under voluntary control  Unable to do complex motor functions (i.e. skiing) but can still walk & talk  Periphery vasoconstricted  Moderate hypothermia: 30ºC – 34 ºC  ‘Dazed’ consciousness – “I don’t care…”  Loss of fine motor coordination, particularly hands  Slurred speech, violent shivering  Irrational behavior  Taking off clothes, unaware they are cold Hypothermia  Severe Hypothermia - < 30ºC  Shivering stops as the body attempts to preserve glucose  As the patient eventually collapses, assumes a fetal position to conserve heat  Muscle rigidity develops due to decreased peripheral blood flow & increased lactic acid & C02 buildup  Skin pale  Pupils dilated  Patient bradycardic Pathophysiology of Hypothermia  Immediate vasoconstriction  Catecholamine release  Increased HR, RR, BP and shivering until:  Depression of ADH  Increased urine output (Cold Diuresis)  Glucose stores depleted and shivering stops  Rapid cooling as internal temp drops  Eventual decrease in HR, RR, BP  Left shift of Oxyhemoglobin dissociation curve  Decreased 02 release to tissues  Depression of insulin release and it’s effectiveness  Hyperglycemia  Cardiac arrest at around 30 degrees C Changes according to Systems Metabolism Rate: decreases with decreasing temperature Cardiac Output: Decreases with decreasing temperature Respiratory effects: Initial increased rate, Decrease sensitivity to CO2 (decreases RR) eventual loss of respiratory drive Cardiovascular effects: initial tachycardiac moves to bradycardia (near 36 C) increasing risk of arrhythmias Hematological effects: Hb affinity for O2 increases (less delivery to tissues) Decreasing fibrinogen synthesis, increasing blood viscosity Other Effects: Shivering initially decreased carbohydrate metabolism hyperglycemia, cold diuresis Confusion Electrolyte imbalances Things to watch for:  Obvious exposure  Subtle exposure  Ethanol ingestion  Underlying illness  Overdose/poisoning  Major trauma  Outdoor resuscitation  Ambient temperature decreased  Home of the elderly patient Signs & Symptoms of Hypothermia  Cool/cold skin temperature  Abdomen  Decreasing mental status or motor function  Poor coordination  Memory disturbances  Reduced or loss of sensation to touch  Mood changes  Less communicative  Dizziness  Difficulty speaking Signs & Symptoms of Hypothermia  Stiff or rigid posture  Muscular rigidity  Shivering - present or lack of  Breathing  Early: rapid  Late: shallow, slow or absent  Slowly responding pupils  Pulse  Early: rapid  Late: slow, barely palpable; irregular or absent Signs & Symptoms of Hypothermia  Low to absent blood pressure  Poor judgment - i.e., removes clothing  Joint, muscle stiffness  Skin  Early: red  Late: pale, cyanotic, stiff or hard  ECG changes in Hypothermia  Mainly occurring late  Bradycardia – unresponsive to Atropine  Small or absent P waves  Abnormal ST segments, T waves  Development of Osborne or J waves Windchill Immersion in Cold Water BLS v3.4 Cold Injury Standard  Move as soon as possible after Primary  If trapped or delayed prevent additional heat loss  Consider life/limb/function threats  Attempt to determine: duration & type of exposure  Secondary Survey: expose only what assessing, attempt to remove wet, constrictive clothing, jewellery Emergency Medical Care - Generalized Hypothermia  SAFETY!  Remove the patient from the environment (after primary assessment)  Protect against further heat loss or wind chill  Remove wet clothing  Avoid rough handling-it may trigger arrhythmias  Do not let the patient exert themselves  Administer oxygen- warmed if possible  Monitor core temperature, if possible  Monitor cardiac rhythm, if possible Mild to Moderate  Shivering present  Wrap in blanket and then foil blanket  External re-warming as available  Hot packs to groin, axillary & cervical regions  Patient compartment temperature warm Severe Hypothermia  No shivering, unconscious, cold, stiff, slow vitals  Wrap body/area in blanket and foil blanket  Avoid vigorous suctioning or airway management Frostbite  Wrap affected area in blanket and foil blanket  Do NOT rub or massage the area  Leave blisters in tact  Dress digits separately  Generalized Hypothermia  Do not allow patient to eat  Do not allow them to smoke or drink alcohol  Do not massage extremities Note: most people will tolerate a mild hypothermia (32-35 degree C body temperature) without significant morbidity or mortality, but a recent study found a 21% mortality rate for moderate hypothermia (29-32 degree C body temperature)  The Hypothermic VSA pt  If VSA, initiate CPR  Analyze ONCE, than transport, they need to be re-warmed at a hospital The patient is not dead unless they are warm & dead Local Cold Injury  NON-FREEZING TYPE  Chilblains  Trench or Immersion Foot  FREEZING TYPE  Frostnip  Frostbite  Chilblains aka Pernio  Caused by chronic exposure to damp, non- freezing temperatures  Painful, inflammatory lesions on skin  Hands, ears, lower legs and feet are a common site  Itchy, burning feeling that tends to reoccur with any exposure to cold  Trench or Immersion Foot  Caused by prolonged exposure or immersion of the extremity in water  Skin becomes pale, mottled, no sensation  Sloughing of skin, gangrene may develop  Frostnip  Local freezing of tissues, but no ice crystal formation  Extremities; exposed ears, nose, face appear pale  Risk factors include:  Inadequate clothing, poor nutrition, Diabetes, Decreased tissue perfusion (tobacco use, tight clothing), Increased vasodilatation (alcohol, medications)  Frostbite  Superficial frostbite  Affects the dermis & shallow subcutaneous layers  Deep frostbite  Affects the dermal & subdermal layers of tissue Pathophysiology of Frostbite Phase 1  Prolonged exposure to cold  Peripheral vasoconstriction of tissues  Decreased blood flow to periphery  Ice crystal formation in extracellular fluid  Ischemia of tissue  Cellular dehydration, hyperosmolarity  Local edema  Increased pressure, increased ischemia, necrosis begins at cellular level Pathophysiology of Frostbite Phase 2  Tissue is rewarmed and crystals break  Blood flow returns to damaged area  Damaged capillaries now leak fluid  Increased local edema  Sludging of cold, thick blood causes thrombus to form  Increased necrosis  Frostbite Signs and Symptoms  1st Degree – partial skin freezing, redness, mild edema, no blisters  2nd Degree – full thickness, substantial edema, formation of clear, fluid filled blisters  3rd Degree – Full thickness skin and underlying tissues, hemorrhagic blisters, skin necrosis, blue/gray discoloration  4th Degree – full thickness affecting skin, muscles, bone, little edema, area initially mottled or cyanotic, eventually dry, black mummified Frostbite Local Cold Injury  General: SAFETY! Remove the patient from the environment Protect the extremity from further injury Remove wet or restrictive clothing Frostbite- Management If short transport time:  ABC’s  Protect the affected area (bandage, splint)  Avoid rewarming  Consider analgesia for pain (NSAIDS) if you can patch to the BHP and get permission Frostbite  If late or deep cold injury:  Remove jewelry  Cover with loose dry clothing or dressings Do not:  Break blisters  Rub or massage area  Apply heat  Rewarm  Allow patient to use affected extremity  Allow patient to smoke or drink alcohol Ok Now Lets Talk HEAT  Temperature Regulation  If heat gain exceeds heat loss = hyperthermia  Hyperthermia  Abnormal excess in body temperature  Co-morbid factors  Climate  Highambient temperatures reduces the body’s ability to lose heat by radiation  Highrelative humidity reduces the body’s ability to lose heat through evaporation  Exercise and activity  Can lose more than 1L of fluid per hour through sweat  Loss of electrolytes (sodium, chloride and fluid) The Combination of Heat & Humidity Signs & Symptoms of Hyperthermia Three major categories: Heat cramps Heat exhaustion Heat stroke  Heat Cramps  Most common  Least serious  Muscular spasms that occur when the body loses too much salt during sweating, not enough salt is taken in, when calcium levels are low or when too much water is consumed Heat Cramps  Treatment  Remove from environment  Transport  Heat Exhaustion  Occurs when volume and electrolytes lost through perspiration isn’t replaced, & remaining volume pools in vessels attempting to lose heat  Most critical problem - dehydration  Signs & symptoms  Headache  Extreme weakness, fatigue  Dizziness, faint  Decreased appetite, nausea, vomiting  Normal - slightly elevated body temperature Heat Exhaustion  Treatment  Remove the patient from the environment  Cool the patient  Assess vitals & transport Heat Stroke  An acute, dangerous reaction to heat exposure  Results when the body fails to cool itself sufficiently – perspiration stops!  Body temperature can reach in excess of 105ºF / 40.5ºC  The body loses hypothalamic temperature regulation  Heat stroke can cause brain damage  Heat Stroke  Signs & symptoms  Deep, rapid breathing that becomes shallow  Dilated pupils  Rapid, strong pulse  Decreased BP  Altered LOC (dizziness, weakness to combativeness)  Hot, red skin  Initially can be very wet, followed by very dry skin  Seizures  Coma Heat Stroke  Treatment  SAFETY!  Remove the patient from the source of the heat  ABC’s  Patient compartment temperature to low  Begin cooling with irrigation saline and cold packs to axillae, groin, neck  Monitor temperature, if possible  Monitor cardiac rhythm  Drowning & Near Drowning  Drowning is the second leading cause of accidental death among Ontario children under five years old, according to new data released today by the Canadian Institute for Health Information (CIHI). Children under the age of 5 are involved in more drowning or near- drowning incidents than those in any other age group. The second most at-risk age group is that of children aged 5 to 9 years old, with a rate of 4.12 per 100,000 population.  Most drowning incidents do not actually involve people swimming. In fact, 76% of children involved in a drowning incident were playing or walking near water when drowning or near-drowning occurred.  Overall, more than 1,000 (1,166) people visited an Ontario emergency department (ED) in 2002-2003 because of injuries sustained in a water-related incident, and 68% of these were drownings or near- drownings. Drowning & Near Drowning  Drowning  "Drowning"is death by suffocation after submersion in a liquid medium.  Near Drowning  "Near drowning" occurs when a patient recovers, at least temporarily, from a drowning episode. Patients who initially recover but then die within 24 hours are classified as drowning victims.  "Secondary drowning" refers to death from complications of submersion at least 24 hours after the episode. Drowning & Near Drowning  Causes:  Exhaustion  Losing control, getting swept into deeper water  Losing a support  Getting entangled in water  Concurrent drug or alcohol ingestion  Poor judgement  Hypothermia  Suffering trauma  Diving accident  Drowning & Near Drowning  Certain factors will impact survival rates:  Cleanliness of the water  Length of time submerged  Age & general health (co-morbid factors) of the victim  Water temperature Drowning & Near Drowning  Treatment  SAFETY!  Always suspect a spinal injury in a diving accident  Hypothermia?  Full assessment  DO NOT use Heimlich maneuver to remove water from lungs  CPR & AED as required Drowning & Near Drowning Never go out into the water to attempt a rescue unless you:  Are a good swimmer, and;  Are specially trained in water rescue techniques, and;  Are wearing a PFD, and;  Are accompanied by other rescuers  Drowning & Near Drowning  “Wet” and “dry” drowning  Wet: occurs when fluid is aspirated into the lungs  Dry: occurs when laryngospasm cuts off respiration but does not allow aspiration of a significant amount of water into the lungs  Fresh vs. salt water drowning - water follows salt  Fresh water: less salt in the water than body fluids so water leaves the lungs & enters the blood  Salt water: more salt in the water than body fluids so water leaves the blood & enters the lungs  “Secondary” drowning  Refersto complications (inflammatory & immune response) that arise minutes to days post-incident Drowning Types Dry Wet  15% of cases  85% of cases  Small amount of H20 aspirated  Large amounts of water enter  Laryngospasm occurs, closes lungs airway  Fluid, electrolyte imbalances  Patient asphyxiates occur  Cardiac Arrest  Cardiac arrest Wet Lung: Fresh Water  Water moves from alveoli to bloodstream  Hemodilution occurs  O2 carrying capacity  Water moves into red cells  Red cells swell, rupture  Potassium in bloodstream Arrhythmias Release of Hgb into bloodstream Renal failure  Loss of surfactant Collapse of alveoli Wet Lung: Salt Water  Water moves from bloodstream to alveoli  Hemoconcentration occurs  Pulmonary edema occurs  Shock, Death Near Drowning  If possible, begin pulmonary resuscitation in water  Resuscitate all cold water drowning (