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Summer Emergencies Dan O’Donnell 8/8/06 Indiana University School of Medicine Department of Emergency Medicine Case #1 • 34 y/o roofer calls EMS for severe cramping of right arm • Denies any trauma • Patient is new roofer and has never had a cramp this bad before • PMHx and Medications: None • Diagnosis? Heat Cramps • Brief, intermittent muscular cramps that occur most commonly in the muscles that are fatigued by work • More common during the first few days on the job • Due to an overall salt deficiency – Patients drinking copious amounts of hypotonic solution (aka water) Treatment • #1: Get patient out of environment • Salt solutions (i.e. Gatorade, all sport) • If patient unable to take po it may be a sign of a more serious condition • Consider starting IV • Transport as needed Case #2 • 35 y/o WF jogging in park during Mid July (temp 98 °F). EMS called for patient c/o Headache, lightheadedness, nausea and vomiting. • • • • • • • PMHx: Depression Meds: Elavil NKDA VS: 120; 100/50; 28; 100.4 F Neuro: GCS 15; A&O x 3; no focal deficits Skin: hot and diaphoretic Rest of exam normal Dx and TX • Heat Exhaustion • TX: – – – – Remove from warm environment .9% NS IV until hemodynamically stable PO fluids Get that Accu-check Heat Exhaustion • Clinical syndrome characterized by volume depletion that occurs under conditions of heat stress Heat Exhaustion • • • • Fatigue, HA, N/V, myalgias Core temp < 104 degrees F/ 40 deg C Mental status normal Tachycardia, orthostatic hypotension, clinical dehydration Medications that Predispose to Heat Illness • • • • • • • • Phenothiazines Anticholinergics Sympathomimetics MAO inhibitors Cyclic antidepressants Lithium Diuretics Beta Blockers Predisposition to Heat illness • Coronary artery disease • Atherosclerosis: inability to vasodilator in periphery • Skin or sweat gland disorders • Hyperthyroidism • Psychiatric disorders Case #3 • 19 y/o WM first day of football practice in full uniform. Mid July. EMS called because patient collapses in the showers. Questions?? • • • • • • Pmhx: ?? Meds: ?? Allergies:?? VS: 130; 90/55; 40; 106.8 deg F GCS 7: posturing then seizing Skin: hot and dry Heat Stroke • Heat stress resulting in Hyperpyrexia and Neurologic symptoms. • Life Threatening Emergency Heat Stoke Classic Heat Stroke: sedentary, elderly persons with compromised homeostatic mechanisms; living in poorly ventilated, hot conditions. Exert ional Heat Stroke: previously healthy person. Strenuous activity in hot, humid weather. Both resulting in the failure of thermoregulatory homeostasis. Heat Stroke • Exposure to heat stress • Signs of severe CNS dysfunction (seizure, coma, delirium) • Core temp usually greater than 104 deg F/ 41 deg C • Dry, hot skin frequent, but sweating may persist Complications • • • • • • • Seizure Liver Failure Hypo/Hyperglycemia Cerebral Edema Renal Failure/Rhabdo Shock DIC Treatment • • • • • ABC’s Remove Clothing Cooling: Cornerstone of therapy Accucheck: hypoglycemia Fluid replacement: 1-2 Liters Types of Cooling • Evaporative Cooling – Use mist and fans to promote rapid cooling – Can decrease the temperature to less than 39 degrees in as little as 10-30 minutes • Ice packs – Apply to high blood flow areas Case #2 Addendum • As you begin to cool the patient, she begins to start shivering…….. • Diazepam(Benzo) for shivering to prevent increase in temp. Case #4 • You are called for a person “found down” • Upon arrival you find a 30ish year old man unresponsive in the middle of a field • Patient is pulse less and apneic • As you are placing him on the monitor you notice… Lightning Injuries • 5 types • Direct Injury – person is directly struck • Contact – person touching an object in the pathway of the lightning current • Side Flash (aka “Splash”) – Lightning jumps from primary strike object to a nearby person on the way to the ground Lightning Injuries Cont… • Ground Current or Step Voltage – Current travels through an individuals feet rather than the ground – We are good conductors • Blunt Trauma (2 mechanisms) – Person is thrown from the contraction caused by current passing through body – An explosion occurs from the rapid heating and cooling of the lightning pathway What Kind of Injuries Can it Cause? • Head and Neck-Burns, cataracts, skull fractures, c-spine fractures • CV-Cardiac arrest (asystole or v-fib) – Can cause a-fib, AMI, prolonged QT, Hypertension • Skin-Burns – Usually not deep (<5%) – Feathering Burns – Kissing Burns Injuries Cont… • Extremities – Muscular damage – Transient vasospasm • Usually resolves quickly • CNS – + LOC, amnesia – Keraunoparalysis-temporary paralysis of blue extremities – Due to severe vasospasm – Usually resolves EMS Care • #1-Secure the scene – Don’t be the next one struck • #2-ABCs – Lightning is a DC counter shock which can cause asystole with return of cardiac activity – If there is profound respiratory arrest than their may be a secondary cardiac arrest EMS Care Cont… • #3. Treat this patient as both a trauma and cardiac/medical patient – C-spine – Place on monitor and follow protocols (v-fib is v-fib is v-fib) • Report any dysrhthmias to hospital personnel – IVF-remember burn component Case #4 • 16 y/o male dove into pond, pulled out by friends who performed “CPR” • Alert upon EMS arrival, c/o mild dyspnea • VS: RR 35 SaO2 92% RA • Lungs with bibasilar crackles • Parents do not want him to be transported, WHAT DO YOU DO??? Drowning vs. Near Drowning • Drowning – Death from suffocation by submersion in water • Near-drowning – Submersion that results, at least, temporarily in survival of the victim Near Drowning • Peak incidence in toddlers and teens • Occurs in bathtubs, buckets, toilets in toddlers • Swimming pools, lakes in teens – Associated with ETOH What if They Look Fine • At risk for late deterioration – Intubation – ARDS – Death • Even asymptomatic patients should be transported Management • C-spine precautions • Airway – Supplemental O2 • Breathing • Circulation • All patients should be transported Key Historical Factors • Submersion time • Events surrounding accident – Do the police need to be involved – Is there a higher suspicion of trauma • Type of liquid the patient was submerged in – Pool vs. lake vs. puddle Take Home Points • Remember the spectrum of heat illness • IVF are great but no substitute for active cooling of the patient • There are many ways to sustain a lightning injury • Lightning injuries are a combination of trauma and medical cases • Transport all near-drowning patients • Remember C-spine precautions