Download Final August 2009 CE Environmental

Environmental Emergencies
Condell Medical Center
EMS System CE
August 2009
Site Code #107200E-1209
Prepared by: Captain Tony Carraro
Greater Round Lake F.P.D.
Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P
1
Objectives
Upon successful completion of the this module,
the EMS provider will be able to:
•
•
•
•
•
Identify the various ways that the body loses and
gains heat.
Identify the differences of cold emergencies
(frostbite, mild hypothermia, severe hypothermia).
Identify the signs and symptoms of cold
emergencies
Identify the management for cold emergencies.
Identify the differences between the heat
emergencies heat cramps, heat exhaustion and
heat stroke.
2
Objectives cont’d
•
•
•
•
•
•
•
Identify the signs and symptoms of heat
emergencies.
Identify the management of heat emergencies.
Define drowning.
Identify the complications of drowning in fresh
water versus salt water.
Identify management of drowning cases.
Identify complications related to diving.
Identify the differences between allergic reactions
without airway involvement, with airway
involvement, and anaphylaxis.
3
Objectives cont’d
•
•
•
•
•
•
•
Identify signs and symptoms of allergic reactions.
Identify the emergency medical care of bites and
stings.
Identify management of allergic reactions.
Participate in case scenario presentations.
Return demonstrate use of an EpiPen®.
Demonstrate drawing up and administration of
Epinephrine 1:1000 IM and SQ.
Describe when to use CPAP and how to monitor
effectiveness.
4
Loss and Gain of Body Heat
• Conduction: Heat flows from warmer material
(body) to cooler one (environment).
• Convection: Currents of air or water pass over
the body, carrying away heat.
• Radiation: Sending out energy, such as heat, in
waves into space.
5
Loss and Gain of Body Heat cont’
• Evaporation: The change from a liquid to a
gas.
– When the body perspires or gets wet, evaporation
of the perspiration or liquid has a cooling effect on
the body
• Respiration: Breathing during respiration;
body heat is lost as warm air is exhaled from
the body
6
Water Chill
Water chill:
conducts
heat away 25
times faster
than still air
7
Wind Chill
• Wind Chill: Chilling caused by convection of
heat from the body in the presence of air
currents.
• The more wind, the greater the heat loss. At
10 degrees and a 20 mph wind the amount of
heat lost is the same as if it was minus 25
degrees.
8
Hypothermia
• Cooling that effects the entire body
• Causes a state of low body
temperature, specifically low core
temperature
• A core temperature dropping below
950F (35.50C) is considered
hypothermic
• FYI – 98.60F = 370C
9
Conversion Formula For Temperature
•
0F
0C
to
– 0C = 5/9 (0F – 32)
– Ex: 98.20F = ?0C
- 5/9 (98.2 – 32)
- 5/9 (66.2)
- 5 x 66.2 / 9
- 331/9
- 36.80C
• 0C to 0F
– 0F = 9/50C +32
– Ex: 28.40C = ?0F
• 9/5(28.4) + 32
• 9/5 x 28.4 + 32
• 9x28.4/5 + 32
• 255.6/5 + 32
• 51.12 + 32
• 83.10F
10
Degrees of Hypothermia
• Mild: A core temperature greater than 900F
(320C) with signs and symptoms of
hypothermia.
• Severe: A core temperature of less than 90 0F
(320C) with signs and symptoms of
hypothermia.
11
Predisposing Factors
 Age – Very Young
Larger skin surface area/less fat compared to
adults
Little or no shivering
Shivering mechanism immature so can’t
generate heat via shivering
Too immature in skills to independently put on
or take off clothing
12
Predisposing Factors
 Age – Very Old
Failing body systems
Chronic illness
Lack of exercise
Certain medications
13
Localized Cold Injuries
• Superficial Frostbite (frost nip)
– Some freezing of the epidermal tissue
– Redness followed by blanching
– Diminished sensation
– Skins remains soft
– As area is re-warmed it begins to tingle
14
Signs & Symptoms of
Deep (Late) Local Cold Injury
Severe frostbite
White, waxy skin
Firm or frozen on surface
Swelling and blisters may occur
Skin blotchy, mottled, or grayish yellow or
blue
15
Severe Frostbite
16
Partial Thickness
(2nd Degree) Burn
• It can be difficult to
tell the difference
between injuries
from heat versus
cold exposure
17
Localized Cold Injury
• Clear boundary
separates
injured/
uninjured areas
18
Emergency Care of
Superficial (Early) Local
Cold Injury
Remove patient from environment
Re-warm patient
Protect area from further injury
Splint and cover extremity
Do not rub or massage
Do not re-expose to cold
19
Trench Foot
• Trench Foot - immersion foot
– Similar to frostbite, but occurs in temperatures
above freezing
– Pain may be present
– Blisters form on spontaneous re-warming
• Treatment
– Early recognition
– Warm, dry, aerate, & elevate feet
• Prevention more effective
– Avoid prolonged exposure standing in water and
remove wet socks/shoes
20
Trench Foot
• Trench foot could also develop following prolonged
exposure to urine soaked clothing in contact with feet
– Consider a patient who lies undiscovered for several
days in their home
Core Body Temperature
Symptoms
99°F-96°F 37°C-35.5°C
Shivering.
95°F-91°F 35.5°C-32.7°C
Intense shivering, difficulty speaking.
90°F-86°F 32°C-30°C
Shivering decreases and is replaced by
strong muscular rigidity. Muscle
coordination is affected and erratic or jerky
movements are produced. Thinking is less
clear, general comprehension is dulled,
possible total amnesia. Patient generally is
able to maintain the appearance of
psychological contact with surroundings.
85°F-81°F 29.4°C-27.2°C
Patient becomes irrational, loses contact
with environment, and drifts into stuporous
state. Muscular rigidity continues. Pulse
and respirations are slow. Can appear
clinically dead at 80.60F
80°F-78°F 26.6°C-20.5°C
Patient loses consciousness and does not
respond to spoken words. Most reflexes
cease to function. Heartbeat slows further
before cardiac arrest occurs.
22
Signs and Symptoms
Mild Hypothermia
• Lethargy
• Shivering
• Lack of coordination
• Pale, cold, dry skin
• Early rise in blood
pressure, heart and
respiratory rate
Severe Hypothermia
• No Shivering
• Dysrhythmias,
asystole
• Loss of voluntary
muscle control
• Hypotension
• Undetectable pulse
and respirations
23
Treatment for Hypothermia
• Remove wet garments
• Prevent further heat loss
• Protect from further wind chill exposure
• Use passive external warming methods
• Blankets
• Maintain patient in horizontal position.
24
Treatment for Hypothermia
cont’
• Avoid rough handling, which can trigger
dysrhythmias
• Monitor temperature
• Monitor the cardiac rhythm
25
Passive vs. Active Re-warming
Passive
Allows body to rewarm itself
Remove wet clothing
Cover with blanket(s)
Active
Application of external
heat sources to
patient
26
Region X SOP – Hypothermia/Cold
Emergencies
Frostbite
Routine Medical Care
Move pt to warm environment as soon as
possible and prevent re-exposure
Rapidly re-warm frozen areas with tepid (warm)
water (if feasible)
Hot packs wrapped in a towel may be used
HANDLE SKIN LIKE A BURN
Protect with light, dry, sterile dressing
Do not let affected skin surfaces rub together
27
Hypothermia SOP cont’d
SYSTEMIC HYPOTHERMIA
Routine Medical Care
Avoid rough handling and excess activity
Apply heat packs to axilla, groin, neck and thorax
Assess pulse
Pulse present
Transport
Pulse Absent
(see next page)
28
Hypothermia SOP cont’d
Pulse absent
Can extremities be flexed?
Yes
Follow appropriate
cardiac protocol but
extend times between
meds – repeat defib
as core temp rises
Transport
No
Follow appropriate cardiac
protocol, but limit shocks
to 1 and withhold IV
medications
Transport
29
Region X SOP – Hypothermia/Cold
Emergencies
Pediatric Considerations
Assess for severe cardiorespiratory compromise:
Shivering, decreased LOC, cyanosis despite
oxygen administration, increased/decreased
respiratory rate, dysrhythmias, dilated
sluggish pupils, decreased reflexes, or
weak/thready pulses
30
Heat Emergencies
• Hyperthermia: a state of unusually high body
temperature, specifically the core
temperature
• A fever (pyrexia) is the elevation of the body
temperature above normal for that person
• A person’s normal temperature may be one or
two degrees above or below 98.6 degrees
FYI: 98.60F = 370C
31
Types of Heat Emergencies
• Heat cramps
– Muscle cramps from over exertion and
dehydration
• Heat exhaustion
– Mild heat illness; acute reaction to heat
exposure
• Heat stroke
– True environmental emergency occurring
when the body’s hypothalamic temperature
regulation is lost
32
Predisposing Factors to Consider
Preexisting Illness
Heart disease
Dehydration
Obesity
Infections/fever
Fatigue
Diabetes
Drugs/medications
Age
33
Predisposing Factors
Young age – Newborns/Infants
Poor thermoregulation system (under
developed)
Can’t remove own clothing (skills immature)
Older age – Elderly
Poor thermoregulation system
Don’t sense the heat level
Interference with prescribed medication
Limited ability to escape heat
Often wear multiple layers of clothing
Lack of air conditioned environment
34
Symptoms of Heat Exposure
• Diaphoresis (sweating as a compensation to
cool down)
• Increased skin temperature
• Flushing
• As heat symptoms progress additional signs
and symptoms may develop
– Altered mental status
– Altered level of consciousness
– Altered vital signs
35
Signs and Symptoms Heat Cramps
Alert
Normal body temperature
Normal vital signs
Sweating, pale
Skeletal muscle cramps
c/o weakness, dizziness, faintness
Signs & Symptoms Heat Exhaustion
Anxiety to possible loss of consciousness
Body temperature slightly elevated (>1000F)
Normal B/P
Pulse weak
Respirations rapid, shallow
Skin normal to cool; clammy; heavy sweating
Occasional muscle cramps
CNS symptoms: Headache, paresthesia, diarrhea
Signs & Symptoms of Heat Stroke
Confusion, disorientation, loss of
consciousness
Hot skin, can be dry or moist, with high temp
Low blood pressure
Rapid, weak pulse that later slows
Deep respirations that eventually slow and
become shallow
Possible seizures
38
It’s All Relative!!!
• Polar bears are
collapsing from heat
exhaustion as the
normal temperature in
polar regions has risen
from 20 degrees below
zero to 15 degrees
below zero
39
Emergency Care of Heat Exposure
Patient with Normal to Cool Skin
Remove from hot environment.
Administer high-concentration
oxygen.
Loosen or remove clothing.
Cool by fanning.
Patient supine, legs elevated.
Avoid drinking plain water to rehydrate.
40
Emergency Care of Heat Exposure
Patient with Hot Skin
Remove patient from hot environment.
Remove clothing.
Administer high-concentration oxygen.
Apply cool packs to neck, groin, armpits.
Keep skin wet (aids in evaporation).
Fan aggressively (aids in convection).
Transport immediately.
41
Region X SOPHeat Emergencies, Adult & Pediatric
Heat Cramps
Move patient to a cooler environment
Do not massage cramped muscles
Transport
42
Region X SOPHeat Emergencies, Adult (Peds)
Heat Exhaustion
Adults - IV fluid challenge in 200 ml increments
(Peds: IV fluid challenge 20 ml/kg; may repeat to max
60 ml/kg)
Gradual cooling procedure
Move patient to cool environment
Remove as much clothing as possible to facilitate cooling
Place in supine position with feet elevated
43
Region X SOPHeat Emergencies, Adult
Heat Stroke
IV fluid challenge in 200 ml increments
Rapid cooling procedure
Follow gradual procedure along with:
Douse towels or sheets with cool water, place on
patient, and fan body
Cold packs to lateral chest wall, groin, axilla, carotid
arteries, temples, and behind knees
If actively seizing, follow seizure protocol
Transport
44
Region X SOPHeat Emergencies, Pediatrics
Heat Stroke – Peds
IV fluid challenge 20 ml/kg; may repeat to max 60
ml/kg
Rapid cooling procedure
Douse towels/sheets with cool water & place on patient, fan
body; cold packs to lateral chest, groin , axilla, carotid arteries,
temples, behind knees
Stop cooling if shivering begins
Consider Valium 0.2mg/kg IVP/IO over 2 min every 15
min til shivering stops (or 0.5 mg/kg rectal)
If actively seizing, follow seizure protocol
45
Definition Drowning
• Submersion or immersion in a liquid
– prevents the person from breathing air
– patient has a primary respiratory impairment
• 4,500 people die of drowning every year in the
U.S.
– 3rd leading cause of accidental death in the USA
• 40 % of deaths are children under 5 years old
• Deaths again peak in teenagers
• Third peak is in elderly who drown in bath tubs
46
Near-Drowning
• This term is not used anymore due to the
confusion regarding the terms “drowning” and
“near-drowning”
• All incidents are referred
to as “drowning”
47
Pathophysiology of Drowning
• Following submersion, if conscious, victim will
experience up to three minutes of apnea
(involuntary reflex)
• Blood is shunted to heart and brain due to
mammalian dive reflex
• While apneic the PaCO2 in blood rises and the
PaO2 falls.
48
Mammalian Dive Reflex
• A complex cardiovascular reflex
– Stimulated by submersion of face and nose
• Breathing inhibited
• Bradycardia develops
• Protective function of vasoconstriction
– Almost all areas sacrificed with decreased blood
flow
• Cerebral & cardiac blood flow is maintained
– Heart and brain receive blood flow
49
Pathophysiology of Drowning
cont’d
• The stimulus from hypoxia (low oxygen)
overrides the sedative effects of hypercarbia
(excess carbon dioxide)
• Central nervous system (CNS) stimulated
• Until unconscious, the victim will panic
– Patient makes violent inspiratory and
swallowing efforts
50
Pathophysiology of Drowning
cont’d
• Copious amounts of water enter into mouth,
pharynx and stomach
– laryngospasm and bronchospasm result in
deeper coma
• Reflex swallowing continues
– gastric distention, vomiting and aspiration
• If untreated:
– hypoxia, hypotension, bradycardia and then
death develops
51
Dry Versus Wet Drowning
• Dry drowning
– Significant amount of water does not enter
the lungs due to laryngospasm
• Wet drowning
– Laryngospasm does not occur and a
significant quantity of water enters the
lungs.
52
Predisposing Factors & Drowning
• Use of alcohol
• Lack of ability to swim
• Swimming in unprotected,
non-monitored areas
• Not following posted
warnings
53
Factors Affecting Survival
•
•
•
•
Cleanliness of the water
Length of time submerged
Age and health of victim
Temperature of water (cold water = under 68
degrees.)
• Children have a longer survival time and
greater probability of successful resuscitation
54
Fresh Water vs Salt Water
• Fresh Water
– Water diffuses across the alveoli into
bloodstream
• Blood is diluted
• O2 carrying capacity decreased
• Bleeding lung inflammation develops
• Surfactant is destroyed
–Substance that keeps alveoli open
• Alveoli collapses
– Ventricular fibrillation often occurs
55
Fresh Water VS Salt Water
• Salt Water
– Salt water is 3 to 4
times more hypertonic
than plasma
– Water drawn from the
bloodstream into alveoli
– Pulmonary edema
develops
– Blood volume decreases
causing shock
56
Treatment
Primary concerns:
Everyone’s safety
Assume cervical spine injury and treat for spine
injury
If cervical injury cannot be ruled out:
Attempt resuscitation of submerged
cardiac arrest patient unless medical
direction rules it out.
57
Treatment
• Protect the patient from heat loss
• Avoid laying the patient on a cold surface
– Would continue to lose body heat via conduction
• Remove wet clothing and cover the body with
dry warm linen
– Want to prevent evaporation of body heat
• Assess airway, breathing and circulation, need
for CPR and defibrillation
58
Treatment
If patient responsive and spine injury
not ruled out
- Immobilize head manually
- Use backboard to remove from water
59
Region X SOP – Near Drowning
Routine Trauma Care
C-spine precautions
Oxygen 100%
Consider CPAP if patient condition indicates
Stable
Unstable
Awake, alert, normal
respirations
Transport
60
SOP Near Drowning cont’d
Unstable
Abnormal respirations; altered mental status
Evaluate for gag reflex
Negative
Positive
Intubate & assist
Assist ventilations via
ventilations via BVM
BVM
Asses for hypothermia
Normothermic
Hypothermic
Treat dysrhythmias per
Refer to hypothermia
protocol
protocol
61
Region X SOP – Near Drowning
Pediatric Consideration
Aggressive airway management
Be aware of potential for C-spine injury and
hypothermia
Studies indicate potential for survival after
prolonged submersion especially in cooler
water
62
Dive Injuries (Descent)
• Barotrauma: Injuries caused by changes in
pressure
• The “squeeze”
– Injury to the inner ear
• Signs and symptoms
– Middle ear PAIN
– Ringing in the ears
– Dizziness
– Hearing loss
– In severe cases rupture of the eardrum
63
Dive Injuries At the Bottom
• Nitrogen narcosis (raptures of the deep)
– Breathing compressed air under pressure
– Nitrogen becomes toxic to cerebral function
– Diver appears intoxicated and may take
unnecessary risks
– Panic will worsen the situation
– Disorientation, confusion
• Problems disappear on surfacing
64
Dive Injuries During Ascent
• Decompression sickness (the bends)
– Dives below 33 feet require staged ascent
to prevent the bends
– Rapid reduction of air pressure while
ascending after exposure to compressed air
• Dissolved nitrogen does not leave blood
– Nitrogen bubbles form, especially in the
abdomen and joints, obstructing blood
vessels causing severe pain
65
Ascent Injuries cont’d
• Pulmonary overpressure
– Can occur with deep or shallow dive (as little as 3
feet)
– Occurs if the breath is held during the ascent
• Compressed air in the lungs now expands
• Alveoli rupture if air is not exhaled
• An air embolism may enter the circulatory
system from the damaged lung
• Pneumothorax will occur if the alveoli ruptures
into the pleural cavity
66
Assessment of Dive Emergencies
•
•
•
•
•
•
•
•
Time signs and symptoms began
Type of breathing apparatus and suit worn
Depth, number of dives, duration of dives
Rate of ascent
Experience of diver
Aircraft travel following a dive
Medication and alcohol use
Medical history and previous events
67
Treatment
•
•
•
•
•
•
ABC’s
CPR (if required) and high flow O2
Secure airway (if required)
Keep patient supine
Protect from excessive heat or cold
Evaluate and transport
68
Allergic Reactions
• Allergic Reaction
– An exaggerated response by the immune
system to a foreign substance
• Anaphylaxis
– A biochemical chain of events following
exposure to a particular substance that
leads to shock and possible death
– Life threatening emergency that requires
prompt recognition and specific treatment
69
What is the Difference???
• Anaphylaxis is life-threatening
– Blood pressure is low
– Patient is in shock
– Patient will die from respiratory compromise and
shock
• Allergic reaction
– Annoying, bothersome with systemic reaction but
patient not in shock
CHECK THE BLOOD PRESSURE TO DETERMINE
THE DIFFERENCES!!!
Agents that May Cause Anaphylaxis
•
•
•
•
•
•
•
•
•
•
Antibiotics and other drugs
Foreign proteins (horse serum, Streptokinase)
Foods (nuts, eggs, shrimp)
Allergen extracts (allergy shots)
Hymenoptera stings (bees, wasps)
Hormones (insulin)
Blood products
Aspirin and Non-steroidal anti-inflammatory (NSAIDs)
Preservatives
X-ray contrast media (ie: iodine)
71
Pathophysiology of Anaphylaxis
Antigen exposure
Release of chemicals including histamine
Capillary
permeability
Peripheral
vasodilation
3rd spacing
intravascular
fluid
Peripheral
vascular
resistance
Constriction of
extravascular smooth
muscle
Abdominal cramps,
diarrhea, vomiting
bronchoconstriction,
laryngeal edema
72
Pathophysiology cont’d
3rd spacing (fluid leaking
from intravascular space
Edema
Relative hypovolemia
Decreased cardiac output
Decreased tissue perfusion
Impaired cellular function
Cellular death
73
Systemic Reactions
HIVES
3RD SPACING
Laryngeal
edema
HIVES
Body Systems Affected
• Immune system
– Principle system affected
•
•
•
•
Cardiovascular system
Respiratory system
Nervous system
Gastrointestinal system
(Note: this list is not all inclusive)
75
Effects on Body Systems
• Skin
– Flushing
– Itching
– Hives
– Swelling
– Cyanosis
• Cardiovascular system
– Vasodilation
– Increased heart rate
– Decreased blood pressure
76
Effects cont’d
• Respiratory system
– Respiratory difficulty
– Sneezing, coughing
– Wheezing, stridor
– Laryngeal edema
– Laryngospasm
– Bronchospasm
77
Effects cont’d
• Gastrointestinal system
– Nausea and vomiting
– Abdominal cramping
– Diarrhea
• Nervous system
– Dizziness
– Headache
– Convulsions
– Tearing
78
Allergic Response – Helpful or Killer?
• Cascade of events after exposure to an antigen
– To remove antigen from the body & prevent
further ones from entering
 Bronchospasm – prevents entrance into the
respiratory system
 Coughing – removes antigen from the respiratory
system
 3rd spacing (leaky capillaries) – shifts antigen from
vascular space into interstitial space for removal via
the lymph system
 Vomiting & diarrhea – removes antigen from GI
system
79
Severe Allergic Response
Bronchospasm
 Respiratory compromise
3rd spacing
Cardiovascular collapse
Decreased cardiac output from vasodilation
Fluid shift
Relative hypovolemia
80
Bites and Stings
• Often patient unaware of offending agent
• May have delayed response in calling/seeking
medical care
• Obtain a detailed history
– Was patient in any activity putting them at
risk for exposure
• Treat the signs and symptoms
Generalized Signs & Symptoms
Bites and Stings
Dizziness and chills
Fever
Nausea and vomiting
Respiratory distress
Bite marks or stinger
Localized pain or itching
Numbness body part
Burning sensation
followed by pain
Redness and swelling
Weakness
Muscle cramps, chest
tightening and joint
pain
82
Brown Recluse Spider
83
Early Bite of Brown Recluse
84
85
Recluse Bite One Day Old
86
Treatment of Bites and Stings
Treat for shock
Contact medical control
Immobilize affected limb
slightly below heart level
Prevent exertion of patient
Wash area gently – use sterile normal saline
Remove jewelry distal to affected area
Observe for allergic reaction
Apply ice indirectly to the wound
87
Removing
Stingers
• The faster the
stinger is
removed, the less
venom enters
and the smaller
the reaction
• Lesson – get the
stinger out
anyway possible
as soon as
possible
Tick (Lyme Disease)
• Tweezers are used to remove the deer tick
• Grasp the tick as close to the skin and pull
upward
89
Region X SOP
Adult Allergic Reaction
Hives, itching, and rash
GI distress
Patient alert
Skin warm and dry
Systolic B/P > 100 mmHg
Routine medical care
Benadryl 25 mg IVP slowly over 2 minutes or IM
Transport
90
Region X SOP
Pediatric Allergic Reaction
Hives, itching, and rash
GI distress
Patient alert
Skin warm and dry
Apply ice/cold pack to site
Benadryl 1 mg/kg IVP slowly over 2 minutes or IM
Maximum 25 mg
Transport
91
Region X SOP
Adult Allergic Reaction with Airway
Involvement
Patient alert
Skin warm and dry
Systolic B/P > 100 mmHg
Epinephrine 1:1000 0.3 mg SQ
Benadryl 50 mg IVP slowly over 2 minutes or IM
If wheezing, Albuterol 2.5 mg/3ml; may repeat
Transport
92
Region X SOP
Pediatric Allergic Reaction with Airway
Involvement
Patient alert; skin warm & dry
Epinephrine 1:1000 SQ 0.01 mg/kg Maximum 0.3 ml
per single dose; May repeat every 15 minutes
Benadryl 1 mg/kg IVP slowly over 2 minutes Maximum
50 mg
Albuterol 2.5 mg/3ml; may repeat
Transport
93
Anaphylaxis – Life Threatening
Region X SOP - Adult Anaphylaxis
Unstable; altered mental status; B/P <100 mmHg
Maintain and support airway; intubate as indicated
IV wide open
Epinephrine 1:1000 0.5 mg IM
Benadryl 50 mg IVP slowly over 2 minutes or IM
If wheezing, Albuterol 2.5 mg/3ml; may repeat
Transport
If worsening condition, contact Medical Control
95
Region X SOP - Pediatric Anaphylaxis
Unstable, altered mental status
Epinephrine 1:1000 IM 0.01 mg/kg Maximum 0.3 ml
per single dose; may repeat every 15 minutes
Benadryl 1 mg/kg IVP slowly over 2 minutes; maximum
50 mg
IV fluid challenge 20 ml/kg; repeat as indicated;
maximum 60 ml/kg
Albuterol 2.5 mg/3ml; may repeat
If no response and continued deterioration, contact
Medical Control to consider Epinephrine 1:10,000
IV/IO 0.01 mg/kg; repeated every 5 min as indicated
96
Epipen
• An auto injection device prescribed for
patients susceptible to anaphylaxis
• Patient can initiate immediate care while
waiting for EMS response
• 2 doses
– EpiPen ® - Adult dose 0.3 mg
– EpiPen® Jr - Pediatric dose 0.15 mg
• Stored at room temperature
• Trainer pen received with device
97
Using the EpiPen
• Remove the yellow or green cap from the carrying case
• Slide the pen out and remove the gray safety cap
• With a firm grip, jab the black tip into the outer thigh
(designed to work through clothing)
• Listen for the click and hold for 10 seconds
• Needle stays exposed after use
• Red plunger visible in window when med is
administered
• Dose wears off in approximately 15 – 20 minutes
98
EpiPen®
• EpiPen®
• EpiPen® Jr
Firm
grip
Jab into
outer
thigh
99
Benadryl
• Antihistamine
– Blocks histamine release in allergic reactions
• Max effects in 1-3 hours with a duration of
6-12 hours
• Side effects include drowsiness and drying of
bronchial secretions
• Elderly are particularly sensitive to Benadryl
– Watch for hypotension
100
Administering Epinephrine SQ or IM
•
•
•
•
•
•
•
•
•
•
Check the medication 3 times prior to admin
If from a vial, cleanse off the rubber stopper
If from an ampule, break open
Draw up specified amount of medication
Clear syringe of all bubbles
Draw up 0.1 ml of air in the prepared syringe
IM – pull skin taut and inject at 900 angle
SQ – pinch up skin and inject at 450 angle
Aspirate and if no blood return, inject
Remove needle and massage site
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Epinephrine
• Sympathomimetic mimicking the sympathetic
nervous system (flight or fight) response
• Most useful for 2 desired responses
– Vasoconstriction
– Bronchodilation
• Use with caution in the elderly & presence of
heart disease
– Increases heart rate and strength of contractions
which may not be well tolerated by these populations
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Is There Airway Involvement?
• In some patients airway involvement is clear
– Wheezing
– Swelling of tongue
• In some cases the airway involvement is unclear
– Throat feels scratchy but breath sounds are clear
• If doubtful of airway involvement, contact Medical
Control for guidance regarding use of Epinephrine
1:1000
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Albuterol
• Sympathomimetic (mimicking the sympathetic
nervous system)
• Bronchodilator
• Onset 5-15 minutes
• Watch for tachycardia – usually dose related
• To be effective, the patient must be coached while
inhaling the medication
– Slow down the breathing
– Begin to take deeper breathes
– Hold the breath in to enhance medication absorption
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CPAP
• Useful to expand the alveoli space to allow more
surface space for oxygen exchange
• To be used simultaneously with drug therapy
• Watch for vasodilation and drop in blood
pressure
– Occurs with all therapies used for pulmonary edema
(Nitroglycerin, Lasix, Morphine)
• If indicated in pulmonary edema, use it
• Call for Medical Control orders in symptomatic
COPD (wheezing)
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CPAP
• Patient will need coaching to get use to the
tight fitting mask
• Patient will need encouragement at least the
first few minutes to tolerate the mask
– CPAP is effective within a few minutes and the
symptoms dramatically begin to improve quickly
• CPAP will use up portable O2 cylinders quickly
– Be prepared to switch portable tanks when not
using the fixed unit in the ambulance
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Whisperflow CPAP Device
Generator and
1 way filter
Mask, head straps,
CPAP valve
Case Scenario #1
• It is a cold January morning and 911 is called
for a “woman down”.
• Wind chill 20 degrees below zero
• Patient is 89 y/o female who apparently
slipped on the ice while retrieving mail
• Unconscious and unresponsive
• Extremities cold to the touch; skin pale
• VS: B/P unobtainable; P – 50 & weak; R – 8
• How do you handle this call?
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Case Scenario #1 - Discussion
• Scene is not safe; EMS in danger due to the
elements
• Use C-spine immobilization
• Move patient into ambulance
• Assist ventilations with BVM
• Remove wet clothing, cover with blanket, turn
up rig heat
• Transport for re-warming from the body’s core
outward
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Case Scenario #2
• Your patient is a 28 y/o female running in a
race.
• The temp is 960F and the humidity is 70%
• The patient complains of leg cramps and
abdominal pain.
• Assessment: diaphoretic, skin cool & pale
• VS: B/P 100/66; P – 128 weak; R – 26 regular
• What do you think and what is your action
plan?
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Case Scenario #2 Discussion
• Patient most likely has heat cramps
– Excessive loss of salt and water from sweating
• Move to a cool environment
• Acceptable practices:
– Placing cool towels on patient
– Fanning the patient to increase air currents
– Allowing the patient to drink an electrolyte drink
(ie: sports drink)
• Drinking water without salt worsens the cramps
• Transport
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Case Scenario #3
• You are on the scene of a 16 y/o male who fell
into the water while canoeing. He was found
45 minutes later lying face down. The water
temperature is approximately 500F. He is
pulseless and apneic. Friends have started
CPR.
• What do you think and what interventions are
appropriate?
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Case Scenario #3 Discussion
• Cold water drowning
• Continue CPR
– Resuscitation may be possible after extended
periods of time in cold water
• After placing the patient on a monitor, follow
the appropriate protocol
• Follow c-spine precautions restricting motion
of the spine
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Case Scenario #4
• A 28 y/o male was diving with friends. He was
found floating face up in the water.
• Patient complains of tightness in his chest and
weakness in his right arm and leg
• VS: B/P 110-78; P – 82 regular and strong;
R – 22 and labored
• What do you think and what interventions are
appropriate?
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Case Scenario #4 Discussion
• This patient most likely is suffering from an air
embolism
• Arterial air embolism occurs when a diver
holds their breath while ascending
– Air in the alveoli expand and tear the alveolar
walls
– Air enters the pulmonary circulation
– Air is returned to the heart and pumped into the
systemic circulation where emboli obstruct blood
flow
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Case Scenario #4 Discussion cont’d
• Administer O2 via non-rebreather mask
• Transport supine
– Do not place the patient in any form of a sitting
position – air rises
– Need to prevent air from traveling to the brain
• IV as precaution
– Fluid rate at keep open
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Case Scenario #5
• You are dispatched to a parking lot at 1530
and find a 2 y/o male unresponsive in the
father’s arms
• The child was left sleeping in the car with the
windows rolled up
• Temperature is 850F with 88% humidity
• Patient is unresponsive; skin hot, dry, and red
• Lips are a bluish gray color
• Extremities mottled with a cap refill > 2 sec
• VS: P - > 200; R – 70 and shallow
• What do you think, what is your action?
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Case Scenario #5 Discussion
• Heat stroke
– Hot, dry, red skin; unresponsive with history of being in a
closed car
• This is a life threatening condition
• Resp rate of 70 indicates respiratory failure
– Inadequate tidal volume at this rate
– Patient will tire before long
• Cardiac rate >200 too fast for an adequate cardiac
output
• Extreme body temp increases the metabolic demand
in the body on all organ systems
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Case Scenario #5 cont’d
• Begin to assist ventilations with supplemental O2
• Strip off clothing, turn up the air conditioner, place
wet towels and cold packs on the patient
• IV access
– Consider IO
– Fluid challenge 20 ml/kg
• If peds patient begins to shiver, administer Valium
– 0.2 mg/kg IVP/IO over 2 minutes every 15 minutes or
until shivering stops
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References
• Bledsoe, B. Porter, R., Cherry, R. Paramedic Care
Principles and Practices. Volume 3
• Dalton, A., Walker, R. Mosby’s Paramedic Refresher
and Review. Elsevier Mosby. 2006.
• Limmer, D., O’Keefe, M. Brady Emergency Care 10th
Edition
• Nagel, K., Coker, N. EMT-Basic Review – A Case Based
Approach. Elsevier Mosby. 2005.
• Region X SOP’s. March 2007, Amended January 1,
2008
• www.epipen.com
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