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Chapter 22 Environmental Emergencies Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 1 Environmental Emergencies Cold emergencies Hypothermia Local cold injuries Heat emergencies Heat cramps Heat exhaustion Heat stroke Submersion incidents Bites and stings Insects Snakebites Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2 Body Temperature Under Different Conditions Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3 Skin Circulation and Heat Regulation Skin is “heat radiator system.” Blood flow to skin provides means for heat transfer. High blood flow to the skin would promote heat loss. Low blood flow would conserve heat. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4 Range of Temperature A – Under warm conditions patient is comfortable. B – Cold conditions lead to shivering. Note difference for deeper structures compared to skin. Difference can contribute to frostbite. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5 Heat Loss Radiation Conduction Convection Evaporation Breathing Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6 Wind Chill Factor Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7 Heat Regulation – Mechanisms of Control Normal body temperature: 37° C (98.6° F) Direct cardiovascular effects Maintained through heat production vs. loss Changes directed by brain (hypothalamus). Heat production affected by metabolic rate. Vasodilation Vasoconstriction Skin Primary site for heat loss Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8 Hypothermia Acute immersion hypothermia Example – Man falls through ice on lake Nonimmersion Subacute exposure – cold environment • Example – Lost in snowy wilderness Chronic exposure • Elderly woman falls and lies on cool bedroom floor for 2 days Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9 Predisposing Factors – Age Very old Difficult to flee cold environment Diminished muscular activity to generate heat Body’s thermostat (hypothalamus) may be altered Very young (infants and young children) Small body with large body surface area Small muscle mass • Children – poor ability to shiver • Infants – no shivering capability at all Less body fat Cannot put on or take off clothes independently Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10 Predisposing Factors – Medical Conditions Shock (hypoperfusion) Head injury Burns Generalized infection Injuries to the spinal cord Diabetes and hypoglycemia Drugs/poisons Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11 Predisposing Factors – Alcohol and Drugs Alcohol Vasodilator Drugs Benzodiazepines Antidepressants Narcotics Organophosphates Narcotics Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12 Mild Hypothermia – Signs and Symptoms Cool/cold skin temperature Check by placing the back of your hand between the clothing and abdomen. Generalized hypothermia will present with cool abdomen. Shivering Difficulty in speech and movement Memory disturbances Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13 Moderate Hypothermia – Signs and Symptoms Skin – pale or cyanotic Stupor Shivering stops Muscle rigidity develops Decreased pulse (irregular) and respirations Pupils dilate VF possible Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14 Severe Hypothermia – Signs and Symptoms Unresponsive to pain Hypotension VF cardiac arrest likely Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15 Summary of Levels of Hypothermia Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16 General Care for Hypothermia Remove the patient from the environment. Protect the patient from further heat loss. Handle the patient extremely gently. Remove wet clothing and cover with blanket. Rough handling could precipitate VF. Do not allow the patient to walk or exert himself or herself. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17 Resuscitation of Hypothermia Patient Assess pulses for 30-45 seconds before starting CPR. If pulses not present, perform CPR Use AED up to 3 shocks. After 3 shocks, perform CPR until patient can be rewarmed. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18 Local Cold Injuries Freezing of superficial, then deep tissues Most common sites Formation of ice crystals Extremities Exposed areas • Ears • Nose • Face Vasoconstriction Prevents hypothermia Contributes to localized cold injuries Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19 Frostnip – Signs and Symptoms Local injury Loss of sensation Clear demarcation Blanching of the skin If rewarmed, tingling sensation Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20 Early or Superficial Frostbite – Signs and Symptoms Feeling and sensation in affected body parts are lost. Outer skin is hard. Deep tissue remains soft. If rewarmed Appears flushed or mottled Possible blister formation Usually painful Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21 Surperficial Frostbite Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22 Deep Frostbite – Signs and Symptoms White, waxy skin Firm to frozen feeling on palpation Resists depression If thawed or partially thawed Mottled, blue, gray Areas of demarcation separating injured and healthy tissues Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23 Deep Frostbite Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24 Emergency Medical Care – Local Cold Injuries Remove the patient from the environment. Administer oxygen. Remove wet or restrictive clothing. Remove jewelry. Protect injured extremity from further injury. Splint extremity. Cover the extremity. Do not rub or massage. Do not reexpose to the cold. Do not apply heat. Do not allow patient to walk on frostbitten extremity. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25 Emergency Medical Care – Late or Deep Cold Injury Not usually done in prehospital setting For extremely long or delayed transport Active rapid rewarming • Immerse affected part in warm water bath (105° F) • Monitor the water to ensure that it does not cool the frozen part (104 ° to 108 ° F) • Continuously stir water. • Continue until the part is soft and color and sensation return. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26 Heat-Related Illnesses Heat cramps Heat exhaustion Heat stroke Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27 Predisposing Factors Climate Temperature, humidity, wind velocity Exercise and activity Age Elderly • Poor thermoregulation • Medications • Lack mobility Newborn/infants • Poor thermoregulation • Cannot remove own clothing Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28 Predisposing Factors – Illness and Conditions Heart disease Dehydration Obesity Fever Fatigue Diabetes Drugs/medications Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29 Heat Cramps Signs and symptoms Muscular cramps of heavily exercised muscles Excessive loss of sodium Heavy sweating Treatment Move to cool environment Have patient drink fluids • Water, dilute salt solution, electrolyte-balanced drinks Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30 Case History You respond to a marathon race on a very hot (98 ° F) and humid day and find a 23-year-old male who collapsed in the 21st mile of the race. Physical exam reveals the patient is lethargic and has pale, cool, and sweaty skin. His vital signs are pulse 90 and regular, respirations 20 and shallow, and blood pressure 120/80. However, the blood pressure drops to 90/70 when the patient sits up. What is the problem? What is the treatment? Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31 Heat Exhaustion Signs and symptoms Skin • Moist, pale (or pink), normal to cool temperature Weakness or exhaustion Vital signs normal (pulse may be rapid) Dizziness when sitting up Treatment Move patient to cool environment. Lay patient supine with legs elevated. Fan patient. Have patient drink fluids. • Water, dilute salt solution, electrolyte-balanced drinks Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32 Case History You respond to the home of a 83-year-old female who has been bedridden for 3 days with a fever. Her daughter states that she was unable to awaken her this morning. The temperature in the room is in the high 90s and it is very humid. The patient is covered with blankets. Physical exam reveals the patient is unresponsive to pain and has hot and dry skin. Her vital signs are pulse 120 and regular, respirations 26 and shallow, and blood pressure 80/60. She takes several medications, including Valium and antidepressants. What is the problem? What is the treatment? Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33 Case History You respond to a 5K race on a very hot (95 ° F) and humid day and find a 48-year-old male who collapsed in the third mile of the race. His friend states that he has never raced before and rarely exercised. Physical exam reveals the patient is unresponsive to pain and has pale, hot, and sweaty skin. His vital signs are pulse 130 and regular, respirations 28 and shallow, and blood pressure 74/60. A nurse on the scene took the patient’s temperature, which was 105 ° F. What is the problem? What is the treatment? Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34 Heat Stroke – Assessment Loss of heat-regulatory ability Very high body temperatures (>104° F) Brain death likely without immediate cooling Signs and symptoms Altered mental status Hot and dry (or moist) skin Very high body temperature Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35 Heat Stroke – Treatment Apply cool packs to neck, groin, and armpits. Keep the skin wet by applying water with sponge or wet towels. Fan aggressively. Transport immediately. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36 Drowning and Submersion Episodes Drowning Near drowning Submersion incident victim who dies within 24 hours Submersion incident victim who survived longer than 24 hours Submersion incident Incident where submersion victim required prehospital care and hospital transport Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37 Submersion Incident – Safety Ensure the safety of the rescue personnel. When possible, throw flotation device or rescue equipment in boat. Heroic rescuers who swim toward the victim may become victims. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 38 Submersion Incident Suspect possible spine injury if diving accident is involved or unknown. Consider length of time in cold water incidents. Cardiac arrest patients submerged in cold water – attempt resuscitation Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 39 Submersion Victim – Unresponsive and Breathing Spine injury suspected In-line immobilization Removal from water with backboard Spine injury not suspected Place patient in recovery position. Allow water, vomitus, and secretions to drain. Suction as needed. Administer oxygen. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 40 Submersion Victim – Cardiac Arrest Management Emphasis on ABCs Spinal immobilization as needed CPR Suction as needed Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41 Submersion Victim – Cardiac Arrest Management Heimlich maneuver Not routinely used to clear water from lungs Used when airway obstruction detected Use AED after moving patient to dry surface and drying chest. If patient is hypothermic, provide up to 3 shocks, then begin CPR. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 42 Submersion Victim – Cardiac Arrest Management If gastric distention interferes with artificial ventilation Place patient on left side. Suction immediately. Provide firm pressure to epigastrium. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 43 General Care – Bites and Stings Be alert for anaphylaxis. If stinger present Remove or scrape stinger out. Wash area gently. Remove jewelry from injured area. Place ice pack over area. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 44 Brown Recluse Spider Black “violin-shaped” band on back Red spot with central blister after bite Few serious systemic reactions Treatment is hospital based. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 45 Black Widow Spider Black, shiny body with red hourglass shape on abdomen Stinger contains neurotoxins. Serious symptoms are rare. Abdominal pain and rigidity Fever, chills, and spasms of large muscles Respiratory depression Weakness Treatment Immobilize affected part. Avoid unnecessary movement. Transport Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 46 Snakebites – Pit Vipers Pit vipers Rattlesnake Copperhead Triangular head Elliptical eyes Fangs Fang marks at bite site Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 47 Eastern Diamondback Rattlesnake Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 48 Cottonmouth Water Moccasin Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 49 Copperhead Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 50 Swelling and Necrosis from Pit Viper Swelling and early necrosis Necrosis 7 weeks later Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 51 Snakebites – Coral Snakes Color “Red on black, venom lack” (top) “Red on yellow, kill a fellow” (bottom) Holds on and chews victim Minimal pain and swelling at bite site Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 52 Australian Compression Technique for Coral Snake Bites Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 53 Snakebites – Emergency Medical Care Remove jewelry. Have victim rest. Immobilize affected part. Do not apply cold to snakebites. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 54 Snakebites – Emergency Medical Care Consult medical direction regarding constricting band for snakebite. For coral snakes, apply elastic bandage (per local protocol) Observe for development of signs and symptoms of an allergic reaction. Do not cut the wound. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 55 Summary History is a key aspect of medical patients. Responsive patients require a focused exam. Unresponsive patients require a rapid assessment. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 56
