Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Andrew Scordato • Pathophysiology, Assessment and management of: Submersion incidents Temperature-related illness Bites and envenomation Spiders Marine Animals Scorpions High altitude Diving injuries Lighting injury • Medical emergencies can result from exposure to heat or cold. • Certain populations are at higher risk for heat and cold emergencies. Children Older people People with chronic illnesses Young adults who overexert themselves • Water recreation can also create medical emergencies. Localized injuries Systemic injuries • Environmental emergencies require prompt treatment in the hospital. Physical condition Patients who are ill or in poor physical condition will not tolerate extreme temperatures wells. Age Infants have poor thermoregulation and are unable to shiver. Children may not think to put on layers. Older adults lose subcutaneous tissues and have poor circulation. • Environmental conditions – Conditions that can complicate or improve environmental situations: • Air temperature • Humidity level • Wind – Extremes in temperature and humidity are not needed to produce injuries. Environmental conditions (cont’d) Most hypothermia occurs at temperatures between 30°F and 50°F. Most heatstroke occurs when the temperature is 80°F and the humidity is 80%. Examine the environmental temperature of your patient. Cold exposure may cause injury to: Feet Hands Ears Nose Whole body (hypothermia) The five ways the body loses heat Conduction Radiation Respiration Convection Evaporation Lowering of the core temperature below 95°F (35°C) Body loses the ability to regulate its temperature and generate body heat Vital organs such as the heart slow down. Can lead to death Air temperature does not have to be below freezing for it to occur. People at risk: Those with out heat Homeless Lower income/ fixed income Outdoor enthusiast Geriatric/ill infants and children Factors in determining the severity of a local cold injury: Temperature and Duration of the exposure Wind velocity during exposure Exposure to wet conditions Inadequate insulation from cold or wind Restricted circulation from tight clothing or shoes, or circulatory disease Fatigue/Poor nutrition Alcohol or drug abuse Hypothermia Age and medical Hx i.e. Cardiovascular disease/Diabetes Mild Occurs when the core temperature is between 90°F and 95°F (32°C and 35°C) Patient is usually alert and shivering Increased HR/RR. Skin may appear red, pale, or cyanotic. Severe Occurs when the core temperature is less than 90 F or 32C Patient is usually alert but confused Initially Pulse rate and respirations are rapid Bradycardia develops V-Fib as the body falls below 86 Assess for Pulse and respiration Longer than normal Skin may appear red, pale, or cyanotic No shivering Loss of voluntary muscle control Ekg shows J-wave (osborn) Note the weather conditions (for You and for Pt.) ABC CPR, Resp./Pulse ? Perfusion will be compromised. Skin not a good indicator to determine shock. Bleeding may be difficult to find. Cardiac arrhythmias Rewarming V/S May be altered by the effects of hypothermia, an indicator of its severity Pulse OX ? If the patient is AOX3 shivering, and the core body temperature is between 90°F to 95°F, then the hypothermia is mild. Apply heat packs to the groin, axillary, and neck Increase ambient temperature Rewarm slowly. Warm IV fluids Warm humidified O2 When the Pt.has moderate or severe hypothermia, never try to actively rewarm Active rewarming should be reserved for an appropriate facility. Rewarming shock-reflex peripheral vasodilation Cold diuresis-Volume depletion/kidneys remove excess fluid from core The goal prevent further heat loss. Remove wet clothing, cover with a blanket, and transport BLS Start CPR immediately Longer pulse/respiration check One shock with AED until temp >86 ALS Start CPR immediately Longer pulse/respiration check Limit one defibrillation until temp is above 86 Limit one round of ACLS Rx until temp is above 86 Remember they are not Dead until they are Warm and Dead Frost bite Serious local cold injury tissues are actually frozen Gangrene requires surgical removal Frost nip Prolonged exposure to the cold, skin is freezing but deeper tissues are okay. Ear, nose, and fingers Usually not painful, Pt. often is unaware that a cold injury has occurred Immersion Foot Prolonged exposure to cold water Hikers and Hunters Assess the areas of the body affected by cold exposure. degree and extent of damage. attention to skin temperatures, textures, and turgor. Frost Nip and Immersion foot Skin= pale/cold to the touch Normal color does not return after palpation of the skin. The skin of the foot, wrinkled but remains soft. The Pt. reports loss of feeling/sensation Frost Bite Hard and waxy with blisters and swelling Feels firm to frozen as you gently touch it. In light-skinned individuals with a deep injury, the skin may appear red with purple and white, or mottled and cyanotic. Depth of Injury (unknown) Superficial Deep Treatment Note the weather conditions (for you and for Pt.) ABC With frostnip, contact with a warm object may be all that is needed. With immersion foot, remove wet shoes, boots, and socks, and rewarm the foot gradually. With a late or deep cold injury, do not apply heat or rewarm the part. Move the patient from the cold environment. Do not allow the patient to walk. Remove any wet clothing. Place dry blankets over and under the patient. If available, give the patient warm, humidified oxygen. Handle the patient gently. Do not massage the extremities. Normal body temperature is 98.6°F. The body tries to rid itself of excess heat. Sweating Dilation of skin blood vessels Removal of clothing and relocation to a cooler environment Hyperthermia is a core temperature of 101°F (38.3°C) or higher. Risk factors of heat illness include: High air temperature/Humidity (reduces radiation/evaporation) Lack of acclimation to the heat Exercise (loss of fluid and electrolytes) Persons at risk for heat illnesses are: Children (especially newborns and infants) Geriatric patients Patients with heart disease, COPD, diabetes, dehydration, and obesity Patients with limited mobility Assess for: High temperature Red, dry skin Tachycardia Poor perfusion Absence of perspiration Confusion/Decreased level of consciousness Muscle cramping Nausea/Vomiting Three types of Heat Emergencies Heat Cramps Heat Exhaustion Heat Stroke Cramps Painful muscle spasms that occur after exercise , usually in the leg or abdominal muscles Do not occur only when it is hot outdoors Exhaustion Common illness Causes include: Heat exposure Stress/Fatigue Fluid replenishment Signs and symptoms Cold, Pale, Diaphoretic Dry tongue and thirst Normal vital signs/or slightly elevated body temperature Dizziness, weakness, Syncopal episode Change in LOC Muscle cramping, nausea, vomiting, or headache Onset =working hard or exercising in a hot, humid, or poorly ventilated area, sweating heavily Least common but most serious The body is subjected to more heat than it can handle and normal mechanisms are overwhelmed Typical situations Physical activity Outdoors or in a closed, poorly ventilated, humid space During heat waves Elderly/Homeless/Fixed income Child left unattended in a car on a hot day Untreated heatstroke always results in death. Signs and symptoms Hot, dry, flushed skin/Early on, skin may be moist or wet. Rising body temperature Changes in LOC/behavior Unresponsiveness Seizures Strong, rapid pulse at first, becoming weaker with falling blood pressure (signs of Shock) Increasing respiratory rate Note: Inadequate oral intake Diuretics Certain psychiatric medications Cramps/Exhaustion Remove the patient from the hot environment. O2,IV fluids (cool), EKG Rest cramping muscles. Cool the patient (remove clothing, turn on air conditioning) Stroke All the above plus apply cold packs to neck, groin and axillary Avoid Vasopressors and Anticholinergic RXs Rapid transport Process of experiencing respiratory impairment from submersion/immersion in liquid Prevention Drowning VS. Near drowning. D=Patient dies with in 24 hours after suffocation in water ND=Refers to a patient who survives at least temporarily (24 hours) after suffocation in water Drowning's may be complicated by spinal fractures and spinal cord injuries. Suspect Spinal Injury if: Diving or long fall. ALOC/Unconscious. Complaints of weakness, paralysis, or numbness. Never give up on resuscitating a cold-water drowning victim. Hypothermia can protect vital organs from the lack of oxygen. The diving reflex may cause immediate bradycardia. Always transport near-drowning patients to the hospital. Inhalation of any amount of fluid can lead to delayed complications. Drowning patients may deteriorate rapidly due to: Pulmonary injury Fluid shifts in the body Cerebral hypoxia Hypothermia Dry Vs. Wet drowning Dry-Lungs don’t fill with water because of Laryngospasm Salt Vs. Fresh Fresh water causes the alveoli to collapse from a lack of surfactant. Salt water causes pulmonary edema and eventual hypoxemia due to its hypertonic nature. Factors affecting survival Cleanliness of Water Length of Time Submerged Victim’s Age and Health Water Temperature Cold-water drowning. Mammalian diving reflex. Scene Never drive through moving water; be cautious driving through still water. Never attempt a water rescue without proper training and equipment. Consider trauma (MOI) and spinal stabilization. Check for additional patients. Assess and Treat: Determine the length of time the patient was underwater or the start symptoms Remove patient from water. If needed start ventilations in the water Suspect head and neck injuries Protect the patient form heat loss ABC/CPR It may be difficult to find a pulse. When in doubt start CPR EKG/Capnography? Normal temp follow normal ACLS guidelines Hypothermic treat with one defib and one round of drugs until temp >86 degrees The cold-water drowning patient is not dead until he is warm and dead. Divided into Injuries on the surface, Descent, injuries at the bottom and Ascent Injuries at the Surface Lines or kelp fields Panic/fatigued Drown Boats Cold water Shivering and pass-out Descent (barotrauma) Caused by the increase in pressure Typical areas affected Lungs Sinus cavities Middle ear Teeth The pain forces the diver to return to the surface to equalize the pressures, and the problem clears up by itself. Perforated tympanic membrane Cold water may enter the middle ear through a ruptured eardrum. The diver may lose his or her balance and orientation and run into ascent problems. Emergencies at the Bottom Rare=Commercial divers/Oil Rig Caused by faulty connections in the diving gear Inadequate mixing of oxygen and carbon dioxide Accidental feeding of poisonous carbon monoxide into the breathing apparatus Can cause drowning or rapid ascent Nitrogen Narcosis Occurs During a Dive Can contribute to accidents during the dive. Signs and Symptoms Altered levels of consciousness and impaired judgment. Diver misjudges amount of air left for dive Ascent Sudden decrease in pressure/Not enough “off Gassing” Several big Problems Air Embolism Dangerous and common Bubbles of air in the blood vessels Air pressure in the lungs remains at a high level while pressure on the chest decreases Signs-Sharp tearing pain, mimics stroke with confusion, vertigo, visual disturbances and LOC Treatment Hyperbaric O2,Iv,EKG Steriods? Decompression sickness (the bends) Bubbles of gas, especially nitrogen, obstruct the blood vessels. Conditions (dive charts) Rapid ascent Too long of a dive at too great of a depth Repeated dives on the same day Complications Blockage of tiny blood vessels deprives the body of nutrients Severe pain in certain tissues or spaces Decompression Occur within 36 hours Fatigue, paresthesias, and CNS disturbances Abdominal/joint pain so severe that the patient doubles up May find it difficult to distinguish between air embolism and decompression sickness. Air embolism generally occurs immediately on return to the surface. Symptoms of decompression sickness may not occur for hours. Tx-Hyperbaric chamber Pulmonary Overpressure Accidents Air becomes trapped on ascent Trapped by Mucus Bronchospasm Holding breath Ambient pressure drops, trapped air expands in the lungs Alveoli Rupture Hemorrhage Decreased 02 c02 trans Air escaping Treatment-tx for possible pneumothorax Pneumomediastinum Caused by Pulmonary Overpressure Release of air into the mediastinium and the pericardial sac Signs Chest pain Irregular pulse Decreased BP Narrow pulse pressure Changes in the Voice Treatment ABC O2,IV,EKG Rapid transport Determine the dive parameters Depth Time Previous dives Rate of Ascent Experience of the diver Equipment Use of medication or alcohol Assess for: Peripheral pulses Skin color and discoloration Pain Paresthesia (numbness and tingling). General Treatment ABC O2 (NRB or BVM prn),IV,EKG Unconscious should be intubated Supine or Left lateral recumbent Pulse OX/Capnnogrpahy Protect from excessive cold or heat Monitor for neurological symptoms Valium Send patients dive equipment if possible Assess for Decompression illness Reverse of dive injuries/Lack of Pressure (Dsybarims injuries) Altitude illness Caused by diminished oxygen at high altitudes Effects CNS PULMONARY Three Altitude illness (progressive) Acute Mountain Sickness HAPE HACE AMS (Acute Mountain Sickness) diminished oxygen pressure at altitudes above 8,000′ Ascending too high too fast or not being acclimatized to high altitudes HAPE (High Altitude Pulmonary Edema) Fluid collects in the lungs, blocks passage of oxygen into the bloodstream. Altitudes of 10,000 HACE (High Altitude Cerebral Edema) Occurs above 12,000 Follows HAPE AMS Fatigue Loss of appetite/N&V Shortness of breath during physical exertion Swollen face Headache/Lightheadedness Tx Mild-high flow 02 use of antiemtics Severe- Dissent, hyperbaric chamber PRN HAPE Shortness of breath/Cyanosis Dry cough with pink sputum Rapid pulse Crackles in the lungs Tx Earlier recognition High flow 02 Dissent Hyperbaric Bag (pressure bag simulates a dissent of 5,000 ft) Meds-Morphine, Procardia, and Lasix HACE Severe headache Ataxia Fatigue Vomiting ALOC/Changes in Bx/Unconscious Tx Dissent High flow 02 steroids Hyperbaric Bag Common targets outdoor activities (boaters, swimmers, golfers) Anyone in a large, open area Individuals are indirectly struck when standing near an object that has been struck by lightning. Cardio and Nervous System injury Cardiac arrest Injuries range from mild to severe S/SX assessment Tx Move patient quickly ABC O2, IV, EKG (monitor for EKG changes) Reverse triage Signs and Symptoms Localized pain, redness, swelling, skin wheal. Idiosyncratic reactions Observe for signs of an allergic reaction. Localized pain, redness, swelling, skin wheal Generalized flushing of the skin or itching Tachycardia, hypotension, bronchospasm, laryngeal edema, facial edema, uvular swelling Wash the area. Remove stingers, if present. Use care not to disturb the venom sac. Apply cool compresses to the injection site. Observe for and treat allergic reactions and/or anaphylaxis. Numerous spider and spiders species Two to worry about Black Widow Brown Recluse Black Widow Black with a, bright red-orange marking in the shape of an hourglass on its abdomen Every state except Alaska Prefers dry, dark places Venom is Neurotoxic Brown Recluse Dull brown in color and 1″ long and has a violin-shaped mark on its back Lives mostly in the southern and central parts of the country but can be found throughout the U. S. Venom is Cytotoxic Like dark areas Black Widow bite is sometimes overlooked. Localized pain and symptoms, including muscle spasms Dizziness Sweating Nausea/Vomiting Rashes Chest tightness/Difficulty breathing Symptoms end after 48 hours Brown Recluse Local tissue damage The skin is swollen and tender, with pale, mottled, cyanotic center The bite is not painful at first Chills, fever, nausea, vomiting, joint pain may also develop. Black Widow ABC O2,IV,EKG monitor for dysthymias Treat signs and symptoms Consider using muscle relaxants to relieve severe muscle spasms. Diazepam 2.5–10 mg IV calcium gluconate solution 0.1–0.2 mg/kg of a 10% IV Brown Recluse ABC O2,IV,EKG Note area and extent of damage BEE, ANTS,WASP ABC monitor for Allergic reaction O2,IV,EKG EPI PRN Remove stinger Scorpions Eight-legged arachnids/ venom gland/stinger at the end of their tail. Rare and live southwest Usually not very dangerous One exception Centruroides sculpturatus Circulatory collapse Severe muscle contractions Excessive salivation Hypertension Convulsions and cardiac failure (Sludge mm) Tx ABC O2,IV,EKG Rapid transport Apply a constricting band? Ticks Burrow under skin Mostly during summer months Less than an inch long, found in wooded areas/beaches Saliva carries disease/Transmission 12 hours Rocky Mountain Spotted Fever Mechanism 7 to 10 days after the bite S/Sx Petechial Rash-Palms to feet Nausea/Vomiting Headache Weakness/Paralysis Cardiorespiratory collapse Ticks cont. Lyme disease Mechanism Rash to bull-eyes pattern Disease of the joints/Pain and Swelling Ohio reports Tx Do not attempt to suffocate or burn the tick. KY Jelly? Use tweezers, grab the tick by the body and pull it straight out of the skin. Disinfect the area Ohio exotic animal problem Over a hundred different species in US Most are defensive not aggressive 19 are venomous Rattlesnakes, copperheads, cottonmouths or water moccasins, and coral snakes PitVipers Small pits that contain poison located just behind each nostril and in front of each eye. Triangular heads Rattlesnakes Copperheads Cottonmouths Most Common in Ohio? Burning or pain at the site of injury Swelling and bluish discoloration Weakness Nausea and vomiting Sweating Seizures/Fainting Blurred Vision or changes in vision Altered level of consciousness “Red on Black venom lack, Red on Yellow kill a fellow” King Sakes Vs. Coral Snakes Venom causes paralysis of the nervous system. Within a few hours of being bitten Bizarre behavior Paralysis of eye movements Paralysis of respiratory system Other S/SX Numbness, weakness, drowsiness, ataxia, slurred speech, excessive salivation, Drooping of the eyelids, double vision, dilated pupils, abdo pain, N&V, LOC, SZR hypotension Antivenin is available, but most hospitals do not stock it. King Coral ABC O2,IV,EKG Note injury area Flush it and Splint it Keep Pt. Calm and as still as possible DO NOT apply constricting bands, ice, cold packs, tourniquets Hospitals with Antivenom? Include: Jelly Fish, Portuguese Man O War, sea Anemones Nematocysts Acids (Vinegar, Urine?) S/Sx Painful, reddish lesions Man O War extremely painful Headache/Dizziness Muscle cramps Fainting Establish and maintain the airway. Apply a constricting band above the site. Apply heat or hot water. Inactivate or remove any stingers. Vinegar PMOW Sting