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First Responder Workshop 2010 Jim Holliman, M.D., F.A.C.E.P. Program Manager, Afghanistan Healthcare Sector Reconstruction Project Center for Disaster and Humanitarian Assistance Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland, U.S.A. Goals of This Workshop Using a case - based format for 20 of the common types of cases seen by first responders : Present critical actions that should be done for each case Review pitfalls to avoid on each case Have a two - way discussion of other aspects of each case Cases to be Presented in this Workshop Cardiac arrest Burns Electrocution Chest pain Stroke Dyspnea Insecticide poisoning Medication overdose Multiple trauma Pediatric trauma Precipitous Heat childbirth illness Acute psychosis Obvious fatality Snakebite Coma Shock Near-drowning Allergic reaction Seizure Case 1 Cardiac Arrest 65 year old male Family called because he had chest pain Lying in bed in home Apneic, cyanotic, no pulse Has history of "heart problems" and "colon cancer 12 years ago" according to the family Cardiac Arrest Critical Actions Verify presence of cardiac arrest Quickly start CPR Find out quickly if the patient has a "Do not attempt resuscitation status" certified by their doctor Move quickly to ambulance Contact advanced medical help (doctor or ambulance with defibrillator if available) Rapid transport to closest hospital Cardiac Arrest Pitfalls to Avoid Not checking the resuscitation status of the patient Taking a detailed history before starting resuscitation efforts Not considering hypothermia Not checking for signs of injury Not notifying the receiving medical facility as early as possible Expecting a high success rate Case 2 Burns 28 year old male Was cleaning motor with gasoline when it exploded The table and curtain in the room also caught fire ; the room is smoky Second and third degree burns of face, neck, chest, and arms Awake and alert but coughing frequently Pulse 120, resps. 20, BP 136 / 88 Burns Critical Actions Protect yourself if the fire is still burning Remove patient from smoky environment quickly Airway / breathing / circulation ("ABC") assessment Get all burned clothes off the patient Cover with clean dry sheets Start oxygen if any potential airway problem or smoke inhalation Copious irrigation with water if a chemical burn Rapid transport to appropriate hospital Burns Pitfalls to Avoid Not removing all potentially smoldering clothes & stopping the burning process Continued soaking of a large burn area thus making the patient hypothermic Mis-estimating the extent of the burn Not recognizing the potential for airway compromise Not recognizing other associated traumatic injuries Case 3 Electrocution 24 year old male Was working on a roof 4 meters high when he touched an overhead electric power line, was shocked, and fell off the roof Was initially unconscious, now is awake but confused Has entrance burns on one hand and his sandals are smoldering Complains of limb and back pain Pulse 96, resps. 20, BP 94 / 64 Electrocution Critical Actions Turn off the electric power or push the patient off the electric source with an object that does not conduct electricity ABC assessment Determine if high voltage (> 1000 volts) Assess for other associated injuries Rapid transport to hospital (may require very large amounts of intravenous fluid) Fairly good chance of success even if prolonged CPR required Electrocution Pitfalls to Avoid Not checking for associated trauma such as spinal injury, joint dislocations, etc., and not performing appropriate spinal immobilization or splinting Not appreciating that there may be large amounts of muscle damage beneath unburned skin Not checking for exit wounds Case 4 Chest Pain 48 year old female Complains of anterior chest pain with radiation to the neck for 2 hours No previous history of heart disease Awake and alert, diaphoretic Also complains of shortness of breath No allergies Husband is reluctant for her to go to hospital Pulse 76, resps. 20, BP 130 / 90 Chest Pain Critical Actions Assume a life - threatening cause is present until definitively proven otherwise ABC assessment Start oxygen if available Give an aspirin (80 to 500 milligrams) if not allergic to aspirin or nonsteroidals, and cardiac ischemia is suspected Rapid transport to a hospital with cardiology capabilities Chest Pain Pitfalls to Avoid Not suspecting cardiac ischemia in younger or female patients Not considering cardiac ischemia in elderly patients with vague symptoms (remember many elderly patients with acute myocardial infarction will NOT have chest pain) Taking the patient to a medical facility that does not have advanced cardiac care Not starting oxygen or giving aspirin Case 5 Stroke 60 year old male Suddenly developed weaknes of the left side and "garbled speech" according to the family 30 minutes ago The family does not know what medicines he takes He is sleepy but arousable, and his speech is difficult to understand Pulse 55, resps. 14, BP 190 / 116 Stroke Critical Actions ABC assessment, may need airway management if level of consciousness is depressed Check fingerstick blood sugar Check pulse oximetry if available Start oxygen if available Determine time of onset of symptoms Rapid transport to a hospital with a computed tomography scanner Repeat the neurological exam at frequent intervals Stroke Pitfalls to Avoid Not checking for hypoxia or hypoglycemia early Not protecting the patient's airway if they have a depressed level of consciousness Not checking for associated injury (the patient may fall down from sudden weakness) Overtreating elevated blood pressure Not repeating the neurologic exam to see if there is worsening or improvement of the patient's symptoms and signs Case 6 Dyspnea 44 year old male Long history of smoking cigarettes Also history of asthma and pneumonia No allergies Uses salbutamol inhaler as needed Complains of progressive shortness of breath and frequent cough for the past several days ; no chest pain Pulse is 112, resp. rate 32, BP 155 / 100 Dyspnea Critical Actions ABC assessment ; check and record pulse oximetry if available Start oxygen If the patient is wheezing, have him use his metered dose inhaler meds if available (this is safe even if the dyspnea has a cardiac cause) If not hypotensive, don't force the patient to lie flat Rapid transport to an appropriate medical facility Dyspnea Pitfalls to Avoid Not starting oxygen for fear of "suppressing respiratory drive" Not considering a cardiac cause Dismissing hyperventilation as just due to anxiety Not providing aggressive airway management for patients with a depressed mental status Case 7 Insecticide (Organophosphate) Poisoning 30 year old female Ingested liquid insecticide in a suicide attempt Actively vomiting, diaphoretic, drooling, complaining of shortness of breath Vomitus all over the patient's clothes Pulse 90, resp. rate 36, BP 100 / 60 Insecticide Poisoning Critical Actions Protect yourself ; remember the patient's clothes may be contaminated and all the patient's body fluids (sputum, emesis, etc.) may contain the insecticide ; use universal precautions Make sure the ambulance is well ventilated (to prevent your exposure to "off-gassing") ABC assessment ; start oxygen Remove all the patient's clothes and footwear and bag these in plastic ; decontaminate the skin by irrigation with water if the skin was exposed to powder or liquid Rapid transport to appropriate medical facility Insecticide Poisoning Pitfalls to Avoid Getting yourself poisoned by skin exposure to contaminated clothes or vomitus or breathing offgassed vapors Failing to decontaminate the patient prior to entering the ambulance Not assessing for other exposures or ingestants Not providing supportive care (oxygen, suction of airway secretions, etc.) Not properly disposing of contaminated clothes or footwear Case 8 Medication Overdose 18 year old female History of depression and prior suicide attempts Taking several antidepressant meds but family does not know the names Took "a large number" of multiple pills about one hour ago Now drowsy but arousable Pulse 120, resp. rate 14, BP 104 / 55 Medication Overdose Critical Actions ABC assessment Try to identify what meds and how many the patient took and the time of ingestion ; collect all pill bottles in the home and bring these to the hospital Monitor the patient closely ; sudden deterioration may occur Try to determine if the ingestion was accidental or suicidal Medication Overdose Pitfalls to Avoid Trying to make the patient vomit (just predisposes to aspiration) Not identifying all co-ingestants Not preventing the patient from accessing other items to use in another suicide attempt ; not closely monitoring the patient at all times Not evaluating the airway or providing oxygen if the patient has a depressed mental status Case 9 Multiple Trauma 30 year old male truck driver Truck ran off road at high speed and rolled over Patient was thrown 5 meters from the vehicle Unconscious, several scalp lacerations actively bleeding, abrasions over chest and abdomen, deformity of left thigh and ankle Pulse 130, resp. rate 8, BP 80 / 40 Multiple Trauma Critical Actions If motor vehicle crash, assess scene for rescuer safety (is there need for water or foam to cover spilled gasoline or hot engine, etc.) ABC assessment ; start oxygen Control external bleeding with direct pressure Immobilize spine and apply limb splints Limit on-scene time as much as possible Make sure someone checks the scene for other "hidden" victims Rapid transport to trauma center Multiple Trauma Pitfalls to Avoid Not prioritizing the "ABC's" Being inefficient and taking too much time at the scene ; performing actions at the scene that could wait until the patient is in the ambulance Not having someone search the scene for other victims Not notifying the receiving medical facility early Not taking measures to prevent hypothermia Not frequently reassessing the patient Case 10 Pediatric Trauma 5 year old male Walking across road and hit by car at high speed Thrown 6 meters by the impact Reported initial loss of consciousness Now sceaming Bleeding lacerations of scalp, right arm, and left flank, deformity left thigh Pulse 145, resp. rate 28, BP 94 / 56 Pediatric Trauma Critical Actions Scene safety and ABC assessment ; oxygen Stop external bleeding with direct pressure dressings Try to notify the parents if they are not at the scene and find out the patient's medical history, allergies, and current meds Limit on-scene time as much as possible however Reassure and try to verbally calm the child Rapid transport to (pediatric) trauma center Pediatric Trauma Pitfalls to Avoid Not prioritizing the "ABC's" Focusing on one obvious injury and not performing a complete assessment Not taking measures to prevent hypothermia Not providing reassurance to the child Using terminology the child does not understand Taking the child to a facility not capable of pediatric care Case 11 Precipitous Childbirth 30 year old female 5 prior pregnancies with vaginal deliveries Started having strong contractions 2 hours ago, now every 2 minutes "Water broke" one hour ago Pulse 110, resp. rate 24, BP 110 / 60 Now says she feels as if she must use the toilet Precipitous Childbirth Critical Actions ABC assessment Start oxygen if possible fetal distress (prolapsed cord, breech crowning, etc.) Position mother so if baby is suddenly delivered, the baby will not fall or be injured Don't insert anything in the vagina (could stir up bleeding) Expose the perineum if any possibility of crowning Rapid transport to obstetric facility Precipitous Childbirth Pitfalls to Avoid Not safely positioning the mother Not recognizing urge to void or defecate as a sign of imminent delivery Not starting oxygen if any possibility of fetal distress Not providing reassurance to the mother and family Not notifying the receiving facility early Case 12 Heat Illness 68 year old male Found unconscious in very hot poorly ventilated upstairs room in an apartment buliding Outside air temperature > 40 degrees Centigrade for the past 5 days Responds only to painful stimuli Skin dry and very warm Pulse 112, Resps. 22, BP 90 / 60 Heat Illness Critical Actions Recognition ABC assessment Measure temperature if thermometer available Check fingerstick blood sugar if abnormal mental status Start cooling measures early Scalp, axillary, and groin ice packs Water mist and fan Try to avoid causing shivering Rapid transport to medical facility Heat Illness Pitfalls to Avoid Attributing altered mental status from hyperthermia to something else such as alcohol intoxication Not starting cooling measures as part of initial resuscitation Excessive fluid treatment for classic heatstroke Not anticipating multiorgan dysfunction Causing excess shivering from cooling measures (shivering may make the patient's temperature go even higher) Case 13 Acute Psychosis 32 year old male Found running in circles in the street Yelling loudly "the spiders are after me ! " Previous history of "psychiatric problems" No allergies according to family Stopped taking his haloperidol recently Pulse 120, Resps. 24, BP 160 / 100 Acute Psychosis Critical Actions Protect yourself from injury if the patient is potentially combative ABC assessment May require physical restraints for both patient safety and rescuer safety Check for hypoxia and hypoglycemia Determine if alcohol or illicit drug ingestion may be contributing Make sure the patient is not hyperthermic (this can accompany amphetamine or cocaine use) Acute Psychosis Pitfalls to Avoid Not assessing for "reversible" or medical causes of the psychosis Not restraining the patient safely Safest approach to the combative patient is to wait until 4 or 5 first responders are available before closely approaching the patient Trying to verbally reason with the patient Not searching the restrained patient for weapons Case 14 Obvious Fatality 85 year old male Last seen by family over 12 hours ago Found by family unresponsive in bed History of metastatic cancer and advanced cardiac disease No pulse or resps. Dependent lividity noted Obvious Fatality Critical Actions Don't start any resuscitation if death criteria clearly present (dependent lividity, rigor mortis, initial decomposition, major dismemberment or open head injury incompatible with life, etc.) Notify appropriate local authorities Counsel the family Cover the body from public view and treat the body with cultural respect Don't leave the family until responsibilty for the body has been transferred to local authorities or a funeral director Obvious Fatality Pitfalls to Avoid Overlooking resuscitatable hypothermia Moving the body or altering the scene if any possibility of homicide Leaving the family before arrangements for management of the body are verified Not notifying the local authorities or the patient's regular doctor Continuing resuscitation attempts when started by others but when clearly inappropriate Case 15 Snakebite 18 year old male Was walking through tall grass when bitten by a large black snake on the right leg about one half hour ago Did not see what kind of snake it was Now complaining of nausea and vomiting and feeling weak Pulse 120, resps. 12, BP 88 / 50 Snakebite Critical Actions Move patient a safe distance from the snake if it is still in the vicinity ABC assessment Try to identify the snake type but don't take any risk to do so Apply "lymphatic" tourniquet above the bite site (snug but not too tight) Rapid transport to a medical facility that has antivenin Snakebite Pitfalls to Avoid Trying to capture the snake and bring it also to the hospital Excessive ice treatment of the bite site Can cause tissue damage like frostbite Incising the bite site to try to release venom Not recognizing signs of systemic envenomation Case 16 Coma 35 year old male Found by coworkers lying on the floor in a garage, last seen by them two hours ago No histroy of alcohol or illicit drug use Unconscious, responds to pain only by limb withdrawl Pulse 60, resps. 12 and snoring, BP 166 / 100 Coma Critical Actions ABC assessment May benefit from nasal airway Start oxygen routinely Neck and spine immobilization if any possibility of trauma Check for hypoxia and hypoglycemia Consider also carbon monoxide intoxication, and hypothermia or hyperthermia Rapid transport to medical facility Coma Pitfalls to Avoid Failure to consider possibility of spine injury and provide spine immobilization Failure to check for hypoxia or hypoglycemia Attributing coma just to alcohol intoxication Taking the patient to a medical facility without a computed tomography (CT) scanner Case 17 Shock 20 year old female Called ambulance because of severe lower abdominal pain Last menstrual period 7 weeks ago No prior abdominal problems No current meds or allergies Pulse 92, resps. 22, BP 60 / 30 Skin pale and diaphoretic Shock Critical Actions ABC assessment Start oxygen routinely Stop any external blood loss with pressure dressings Elevate legs Rapid transport to medical facility Shock Pitfalls to Avoid Not diagnosing shock just because the patient has a near normal blood pressure or pulse Not starting oxygen Not rechecking the patient's vital signs frequently Not notifying the receiving facility early Case 18 Near-drowning 12 year old male Fell off bridge into lake Was submerged 5 to 10 minutes Was unconscious when pulled from the water Now drowsy but arousable, coughing frequently Pulse 70, resps. 20, BP 100 / 64 Near-drowning Critical Actions ABC assessment May need to suction upper airway Even prolonged CPR may be successful (particularly in cold water near-drownings) Start oxygen if patient still symptomatic Don't induce vomiting Assess for associated trauma Check for hypoxia and hypoglycemia if altered mental status Rapid transport to medical facility Near-drowning Pitfalls to Avoid Doing CPR with the patient's head higher than the chest (after rescue from the water, position patient parallel to shore line so head and heart are at same level) Not checking for associated trauma (such as neck injury from diving) Performing the Heimlich maneuver routinely (it just predisposes to vomiting and aspiration ; most patients do not have any removable fluid in their airway) Case 19 Allergic Reaction 29 year old male Stung by wasp on left hand 15 minutes ago Now complaining of throat tightness, difficulty breathing, and diffuse itchy rash Skin shows diffuse hives Left hand is very swollen and red Pulse 124, resps. 22, BP 92 / 64 Allergic Reaction Critical Actions ABC assessment Start oxygen if in shock Remove stinger or insect if still imbedded Administer injectable epinephrine if patient has a self-treatment kit Administer oral antihistamine med if available Administer aerosol treatment if wheezing Ice pack to sting site Rapid transport to medical facility Allergic Reaction Pitfalls to Avoid Not recognizing risk for airway obstruction Not stopping further exposure of the patient to the allergen Not rechecking the patient's vital signs frequently Case 20 Seizure 18 year old male Was in a store when he was seen to fall to the floor and started having a tonicclonic gran mal seizure which lasted about 5 minutes No other history available Now very drowsy with snoring respirations Pulse 110, resps. 14, BP 140 / 78 Seizure Critical Actions ABC assessment May benefit from nasal airway Assess for associated trauma (such as tongue lacerations) and immobilize neck and spine if possible injury from fall Check for hypoxia and hypoglycemia Position the patient to prevent injury if seizure recurs Determine if any prior history of seizures or drug or alcohol use Transport to medical facility if patient not quickly back to normal mental status or if new onset seizure Seizure Pitfalls to Avoid Not checking for associated trauma Not starting oxygen if potentially hypoxic Not determining what medications or drugs the patient may have taken Failing to position the patient so he will not injure himself if the seizure recurs Overly aggressive use of a bite block thus damaging the teeth First Responder Workshop Summary Always consider scene safety first Then always perform an "ABC" pattern patient assessment Try to quickly gather all relevant information about the patient at the scene ; consider searching the scene for medication bottles to bring along Decide on the medical facility destination based on its capabilities to manage the patient Notify the receiving facility early