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Warm Weather Emergencies Firework Injuries Legal Review of Intoxicated Person JUNE 2014 CME SILVER CROSS EMS SYSTEM SUBMERSION INJURIES: DROWNING & ASSOCIATED CAUTIONS Definition and description Immersion Submersion Drowning SUBMERSION INJURIES: DROWNING & ASSOCIATED CAUTIONS Immersion syndrome Sudden cardiac arrest caused by massive vagal stimulation after sudden exposure to cold water Postimmersion syndrome Delayed deterioration of a previous asymptomatic or minimally symptomatic patient SUBMERSION INJURIES: DROWNING & ASSOCIATED CAUTIONS Shallow water blackout Unconsciousness after submersion SUBMERSION INJURIES: DROWNING & ASSOCIATED CAUTIONS Epidemiology & demographics Second leading cause of accidental death in US Leading cause of accidental pediatric death Teenagers second major group Elderly third highest group SUBMERSION INJURIES: DROWNING & ASSOCIATED CAUTIONS Etiology Classic sequence starts with panic Victim can no longer hold breath, reflexively takes a breath, and water enters mouth Victim takes several violent intakes of air and water while flailing SUBMERSION INJURIES: DROWNING & ASSOCIATED CAUTIONS Etiology Water intake hits posterior oropharynx Laryngospasm Bronchospasm Severe hypoxia Acidosis Cardiac disturbances CNS anoxia Coma SUBMERSION INJURIES: DROWNING & ASSOCIATED CAUTIONS Physical findings Often accompanied by trauma Cardiac disturbances common Hypothermia common SUBMERSION INJURIES: DROWNING & ASSOCIATED CAUTIONS Differential diagnosis Trauma Spinal injury Cardiac disturbances Hypothermia Hypoglycemia CNS disturbances Metabolic abnormalities SUBMERSION INJURIES: DROWNING & ASSOCIATED CAUTIONS Therapeutic interventions Priority is reversing hypoxia If any resuscitation is required, patient must be transported SUBMERSION INJURIES: DROWNING & ASSOCIATED CAUTIONS Complications Sudden respiratory arrest ARDS Release of fluid into alveoli Inflammation of alveoli and lung tissue Loss of surfactant Atelectasis Aspiration pneumonia Pneumothorax ANATOMY & PHYSIOLOGY REVIEW Homeostasis State of equilibrium Homeotherm Body that strives to stay within 1° of norm ANATOMY & PHYSIOLOGY REVIEW Thermoregulation Thermoreceptors Brain Skin Spinal cord Abdominal viscera Great vessels Metabolism Increases to generate heat ANATOMY & PHYSIOLOGY REVIEW External mechanisms of heat and cold response Radiation Exchange heat with surroundings Convection Air movement moves heat being radiated Conduction Direct contact with an object Evaporation Heat transfer mechanisms in tandem ANATOMY & PHYSIOLOGY REVIEW External mechanisms of heat and cold response Involuntary responses Perspiration Blood vessels Metabolism Piloerection ANATOMY & PHYSIOLOGY REVIEW External mechanisms of heat and cold response Voluntary responses Seek shelter from cold or heat Add or remove insulation Outside Wind contributors velocity Humidity ANATOMY & PHYSIOLOGY REVIEW External mechanisms of heat and cold response Predisposing factors Age Health Medical history Shock CNS insult Burns Medications Skin conditions Mental history ANATOMY & PHYSIOLOGY REVIEW Measures to prevent heat and cold injury Cold Avoid long periods of exposure Cover exposed body surfaces Layer clothing Keep clothing and body dry ANATOMY & PHYSIOLOGY REVIEW Measures to prevent heat and cold injury Heat Avoid long periods of exposure Drink plenty of clear fluids Use shade to reduce heat Avoid using diuretics Avoid using amphetamines Limit alcohol intake HEAT EMERGENCIES Heat cramps Muscle spasms Poor fluid level Overexertion with fatigue Sodium and electrolyte loss Extended exertion in heat HEAT EMERGENCIES Heat cramps Physical findings Cramps in fingers Arms Legs Abdomen HEAT EMERGENCIES Heat cramps Differential diagnosis Tetany Other heat emergency Simple muscle cramps Therapeutic Remove interventions from heat Oral hydration of electrolytes IV solutions – nacl or LR HEAT EMERGENCIES Heat exhaustion Dehydration & compensated hypovolemia Sweating Sodium & electrolyte loss Vasodilation with venous pooling Extended exertion in heat HEAT EMERGENCIES Heat exhaustion Physical Rapid findings shallow breathing Weak rapid pulse Flushed or pale skin Cool clammy skin Heavily sweating Normal core temp which can rise to 100-105° F May present with dehydration HEAT EMERGENCIES Heat exhaustion Differential diagnosis Uncomplicated Hypoglycemia Infection Intoxication Fatigue dehydration HEAT EMERGENCIES Heat exhaustion Therapeutic Similar interventions to heat cramps Remove from heat Supine Oral hydration of fluids/electrolytes IV solutions – nacl of LR Manage core temp HEAT EMERGENCIES Heat stroke Increase in core temp over 105°F with decreased LOC Hypothalamic temperature regulation lost Chain reaction within tissue Cellular death of brain, kidneys, liver Hallmark is altered mental status Metabolic acidosis Hyperkalemia HEAT EMERGENCIES Heat stroke Classic Long heat stroke periods of heat and humidity exposure Affects very young, very old, diabetics, alcoholism and cardiac history Risks from diuretics, psychotropics, anticholinergics Late sign – hot red dry skin HEAT EMERGENCIES Heat stroke Exertional Sudden heat stroke rise in core temp during exertion All age groups susceptible Patient not fluid deprived Skin may be sweaty HEAT EMERGENCIES Heat stroke Physical findings Altered LOC – disorientation, combative Unconsciousness Hallucinations Seizures Core temp above 40.6°C or 105°F Ataxia Tachycardia that slows near death Tachypnea progressing to bradypnea Hypotension often lacking diastolic HEAT EMERGENCIES Heat stroke Differential diagnosis CVA Hypoglycemia Infection Uncomplicated dehydration Intoxication Neuroleptic malignant syndrome HEAT EMERGENCIES Heat stroke Therapeutic Goal interventions -cooling core temperature Goal –replenish fluid Airway management Cardiac monitoring FIREWORK INJURIES NFPA Statistics In 2011, 9600 firework related injuries treated in emergency rooms 8 out of 9 (89%) of injuries involved “consumer use” fireworks In 2011, 17,800 reported fires were started by fireworks STATS CONT’D 26% of victims were under 15 years old Injury rates apply to a range of ages; the greatest being 5-19 years old and 25-44 years old Males account for 68% of firework related injuries AREAS OF FIREWORK INJURIES 61% to extremities 46% to the hands or finger 11% to the legs 4% to the wrist 34% to parts of the head including the eye (17% of the total) Sparklers, fountains, and novelties accounted for one-third (34%) of ER visits INJURY TYPES More than half are thermal (burn) related One quarter resulted in bruises or lacerations 3% of injuries occur as people are trying to escape an area of danger; sustaining a fracture or sprain IN PERSPECTIVE… TREATMENT FOR FIREWORKS INJURIES SCENE SAFETY is always the priority Assess trauma triage criteria Burns >10% BSA of 2nd or 3rd degree should be considered Burns with involvement to head, neck, or airway are high priority patients Impaled objects through the abdomen or airway Amputation of digits or extremities Spinal cord injuries associated with blunt trauma or falls TREATMENT, CONT’D Establish level of responsiveness Immobilize c-spine if indicated check the neck prior to placing c-collar Airway assessment for patency Get good lung sounds if risk of inhalation, assess work of breathing Identify and treat any life threatening hemorrhages Check for neurological deficits AVPU Motor & Sensory Pupils BURNS SMO’s Code 22 (Thermal) Initial trauma care 100% Oxygen for stridor, hoarseness, or wheezing (accelerated transport) Check for distal pulses in extremity burns Burn wound care Use sterile gloves and mask if available Cool burns with sterile water or saline (<20% BSA) Dry sterile dressing or burn sheets for >20% BSA Consider pain management Nitrous Oxide inhalation Morphine Sulfate 5-10mg IVP in 5mg increments every 5 minutes, if SBP>90. Do not give Morphine IM. IMPALED OBJECTS Secure object in place using whatever you can, however you can! NEVER remove an impaled object unless it interferes with the patients airway, or EMS airway management Think of “what lies below” to determine potential internal injuries, risk of hemorrhagic shock LEGAL REVIEW OF THE INTOXICATED PERSON “Intoxicated” may include Alcohol (ethanol) Illicit drugs (LSD, heroin, cocaine, GHB, ecstasy, methamphetamine, etc.) Legally prescribed medications(Hydrocodone, Oxycontin, Valium, etc.) Mind altering substances such as inhaled chemicals, etc. (720 ILCS 690/ Use of Intoxicating Compounds Act) LEGAL VS. MEDICAL Legal definition “The state of being poisoned; the condition produced by the administration or introduction into the human system of a poison. But in its popular use this term is restricted to alcoholic intoxication, that is, drunkenness or inebriety, or the mental and physical condition induced by drinking excessive quantities of alcoholic liquors, and this is its meaning as used in statutes, indictments, etc.” Black’s Law Dictionary Medical definition Substance intoxication: “Reversible, substancespecific, maladaptive behavioral or psychological changes directly resulting from physiologic effects on the central nervous system of recent ingestion of or exposure to a psychoactive substance, particularly alcohol” http://medical-dictionary.thefreedictionary.com/intoxication COMMONALITIES? Both definitions refer to “alcohol” as a primary substance leading to intoxication Both refer to a diminishment in psychomotor and cognitive function Neither refer to any risk of harm CRITICAL DETERMINATIONS Assumption: There is some degree of Altered Mental Status 1. 2. 3. 4. Is there a non-alcohol cause for Altered Mental Status? Is there risk of harm? Does the individual have capacity to refuse care? Is there someone who can take responsibility for the patient? ESSENTIAL H&P ELEMENTS Thorough history and physical examination Blood glucose level Pulse oximetry EtCO2 if available CRITICAL HISTORY CONCERNS ANY history of trauma ANY suicidal threats or depression ANY significant co-ingestants ANY alcohol ingestion in the last hour ANY significant medical complaints ANY combative behavior ANY involvement of less-than-lethal devices CRITICAL PHYSICAL EXAM CONCERNS ANY evidence of trauma beyond minor extremity ANY significant derangement of blood glucose ANY evidence of airway compromise ANY significant hypoxia/hypercarbia ANY abnormal vital signs RISK OF HARM Is there a responsible caretaker? Is there an inherent danger in refusal? Is there a possibility of worsening BAL? Alcohol consumption history What was consumed? What was the time period of consumption? Trauma Rage (combative) RISK OF HARM, CONT’D Airway compromise Narcotics/Co-ingestants Suicidal/Depression/Psychotic Pain (chest/abdomen/other medical complaints) Oxygen low or CO2 high Risk of harm to self or others TASER (other less-than-lethal devices) RISK OF HARM, CONT’D Ingestion recent/Extremely large (EtOH) Not normal vital signs Glucose low or high DETERMINING CAPACITY Adult or qualified minor Alert and oriented GCS 15 Must appreciate the situation Must understand the medical concern/diagnosid Must understand the consequences of refusing care HARD DECISION? EMS and the Hippocratic Oath •We are not bound by Oath to “DO NO HARM” •As licensed agents through the Illinois Department of Public Health, and our EMS System Physicians, we are required to be competent in action and decision •Medical Control is NOT in place to defer provider risk •Regardless of Medical Control’s advice, ALL parties involved in patient care are responsible for outcome THE “ART OF THE REFUSAL” •Using the combination of “Determining Capacity” and “Risk of Harm” will lead you to the right decision. •This is the most subjective decision any EMS professional has to determine •If there is ever any doubt, your best defense is to act in the best interest of the patient WHAT WOULD YOU DO? You are summoned to a possible overdose. You assess and treat a 25 yr old male that is unresponsive with gasping respirations at 6/min. After administration of Narcan, the patient regains full sensorium; is alert and oriented to person, place, time, and events; admits to overdosing on heroin; and is refusing further care or transportation to a medical facility. ??? What lasts longer, the effects of Narcan or heroin? What is his Determining Capacity? Are there any Risks of Harm to the patient if he is allowed to refuse care? Discussion…… THANK YOU! Any Questions???
