1 Environmental Emergencies Prepared by: Captain Tony Carraro Greater Round Lake F.P.D....

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Environmental Emergencies

Prepared by: Captain Tony CarraroGreater Round Lake F.P.D.

Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P

Condell Medical CenterEMS System CE

August 2009Site Code #107200E-1209

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ObjectivesUpon 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.

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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.

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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.

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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.

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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

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Water Chill

Water chill: conducts heat away 25 times faster than still air

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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.

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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

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Conversion Formula For Temperature

• 0F to 0C– 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

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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.

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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

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Predisposing Factors

Age – Very OldFailing body systems

Chronic illness

Lack of exercise

Certain medications

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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

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Signs & Symptoms ofDeep (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

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Severe Frostbite

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Partial Thickness (2nd Degree) Burn

• It can be difficult to tell the difference between injuries from heat versus cold exposure

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Localized Cold Injury

• Clear boundaryClear boundaryseparates separates injured/ injured/ uninjured areasuninjured areas

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Emergency Care ofSuperficial (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

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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

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

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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.

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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

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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.

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Treatment for Hypothermia cont’

• Avoid rough handling, which can trigger dysrhythmias

• Monitor temperature• Monitor the cardiac rhythm

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Passive vs. Active Re-warming

Passive

Allows body to re-warm itself

Remove wet clothing

Cover with blanket(s)

Active

Application of external heat sources to patient

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Region X SOP – Hypothermia/Cold Emergencies

FrostbiteRoutine 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 usedHANDLE SKIN LIKE A BURN

Protect with light, dry, sterile dressingDo not let affected skin surfaces rub together

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Hypothermia SOP cont’d

SYSTEMIC HYPOTHERMIARoutine Medical Care

Avoid rough handling and excess activityApply heat packs to axilla, groin, neck and thorax

Assess pulse

Pulse present Pulse Absent Transport (see next page)

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Hypothermia SOP cont’d

YesFollow appropriate cardiac protocol but

extend times betweenmeds – repeat defibas core temp rises

Transport

NoFollow appropriate

cardiacprotocol, but limit shocks

to 1 and withhold IV medications

Transport

Pulse absentCan extremities be flexed?

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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

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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

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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

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Predisposing Factors to Consider

Preexisting Illness

Heart disease

Dehydration

Obesity

Infections/fever

Fatigue

Diabetes

Drugs/medications

Age

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Predisposing FactorsYoung age – Newborns/Infants

Poor thermoregulation system (under developed)Can’t remove own clothing (skills immature)

Older age – ElderlyPoor thermoregulation system

Don’t sense the heat levelInterference with prescribed medication Limited ability to escape heat

Often wear multiple layers of clothingLack of air conditioned environment

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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

Signs and Symptoms Heat Cramps

AlertNormal body temperature

Normal vital signs Sweating, pale

Skeletal muscle crampsc/o weakness, dizziness, faintness

Signs & Symptoms Heat Exhaustion

Anxiety to possible loss of consciousnessBody temperature slightly elevated (>1000F)

Normal B/PPulse weak

Respirations rapid, shallowSkin normal to cool; clammy; heavy sweating

Occasional muscle crampsCNS symptoms: Headache, paresthesia, diarrhea

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Signs & Symptoms of Heat StrokeConfusion, 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

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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

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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.

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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.

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Region X SOP- Heat Emergencies, Adult & Pediatric

Heat Cramps

Move patient to a cooler environment

Do not massage cramped muscles

Transport

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Region X SOP- Heat 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 environmentRemove as much clothing as possible to facilitate cooling

Place in supine position with feet elevated

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Region X SOP- Heat Emergencies, Adult

Heat Stroke

IV fluid challenge in 200 ml incrementsRapid cooling procedure

Follow gradual procedure along with:Douse towels or sheets with cool water, place on

patient, and fan bodyCold packs to lateral chest wall, groin, axilla, carotid

arteries, temples, and behind kneesIf actively seizing, follow seizure protocol

Transport

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Region X SOP- Heat Emergencies, Pediatrics

Heat Stroke – PedsIV fluid challenge 20 ml/kg; may repeat to max 60

ml/kgRapid 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 beginsConsider 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

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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

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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”

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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.

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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

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Pathophysiology of Drowningcont’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

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Pathophysiology of Drowningcont’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

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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.

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Predisposing Factors & Drowning

• Use of alcohol• Lack of ability to swim• Swimming in unprotected,

non-monitored areas• Not following posted

warnings

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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

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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

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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

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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.

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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

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Treatment

If patient responsive and spine injury

not ruled out

- Immobilize head manually

- Use backboard to remove from water

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Region X SOP – Near Drowning

Routine Trauma CareC-spine precautions

Oxygen 100%Consider CPAP if patient condition indicates

Stable UnstableAwake, alert, normal respirations Transport

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SOP Near Drowning cont’d

UnstableAbnormal respirations; altered mental status

Evaluate for gag reflexNegative Positive

Intubate & assist Assist ventilations viaventilations via BVM BVM

Asses for hypothermiaNormothermic HypothermicTreat dysrhythmias per Refer to hypothermia protocol protocol

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Region X SOP – Near Drowning

Pediatric Consideration

Aggressive airway managementBe aware of potential for C-spine injury and

hypothermia

Studies indicate potential for survival after prolonged submersion especially in cooler

water

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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

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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

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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

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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

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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

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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

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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

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!!!

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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)

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Pathophysiology of Anaphylaxis

Antigen exposureRelease of chemicals including histamine

Capillarypermeability

Peripheralvasodilation

Constriction ofextravascular smooth

muscle

3rd spacingintravascular

fluid

Peripheralvascular resistance

Abdominal cramps,diarrhea, vomiting

bronchoconstriction,laryngeal edema

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Pathophysiology cont’d3rd spacing (fluid leakingfrom intravascular space

Edema Relative hypovolemia

Decreased cardiac output

Decreased tissue perfusion

Impaired cellular function

Cellular death

Systemic Reactions

HIVES

HIVES

3RD SPACING

Laryngealedema

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Body Systems Affected

• Immune system– Principle system affected

• Cardiovascular system• Respiratory system• Nervous system• Gastrointestinal system

(Note: this list is not all inclusive)

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Effects on Body Systems

• Skin– Flushing– Itching– Hives– Swelling– Cyanosis

• Cardiovascular system– Vasodilation– Increased heart rate– Decreased blood pressure

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Effects cont’d

• Respiratory system– Respiratory difficulty– Sneezing, coughing– Wheezing, stridor– Laryngeal edema– Laryngospasm– Bronchospasm

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Effects cont’d

• Gastrointestinal system– Nausea and vomiting– Abdominal cramping– Diarrhea

• Nervous system– Dizziness– Headache– Convulsions– Tearing

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Allergic Response – Helpful or Killer?

• Cascade of events after exposure to an antigen – To remove antigen from the body & prevent

further ones from enteringBronchospasm – prevents entrance into the

respiratory systemCoughing – removes antigen from the respiratory

system3rd spacing (leaky capillaries) – shifts antigen from

vascular space into interstitial space for removal via the lymph system

Vomiting & diarrhea – removes antigen from GI system

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Severe Allergic Response

Bronchospasm Respiratory compromise

3rd spacing Cardiovascular collapse Decreased cardiac output from vasodilation Fluid shift Relative hypovolemia

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

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Generalized Signs & Symptoms Bites and Stings

Dizziness and chills

Fever

Nausea and vomiting

Respiratory distress

Bite marks or stinger

Localized pain or itchingNumbness body partBurning sensation

followed by painRedness and swellingWeaknessMuscle cramps, chest

tightening and joint pain

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Brown Recluse Spider

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Early Bite of Brown Recluse

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Recluse Bite One Day Old

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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

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

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Tick (Lyme Disease)• Tweezers are used to remove the deer tick• Grasp the tick as close to the skin and pull

upward

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Region X SOP Adult Allergic Reaction

Hives, itching, and rashGI distress

Patient alertSkin warm and dry

Systolic B/P > 100 mmHg

Routine medical careBenadryl 25 mg IVP slowly over 2 minutes or IM

Transport

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Region X SOP Pediatric Allergic Reaction

Hives, itching, and rashGI distress

Patient alertSkin warm and dry

Apply ice/cold pack to site

Benadryl 1 mg/kg IVP slowly over 2 minutes or IMMaximum 25 mg

Transport

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Region X SOP Adult Allergic Reaction with Airway

InvolvementPatient alert

Skin warm and drySystolic B/P > 100 mmHg

Epinephrine 1:1000 0.3 mg SQBenadryl 50 mg IVP slowly over 2 minutes or IMIf wheezing, Albuterol 2.5 mg/3ml; may repeat

Transport

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Region X SOP Pediatric Allergic Reaction with Airway

InvolvementPatient 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

Anaphylaxis – Life Threatening

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Region X SOP - Adult AnaphylaxisUnstable; altered mental status; B/P <100 mmHg

Maintain and support airway; intubate as indicatedIV 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

TransportIf worsening condition, contact Medical Control

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Region X SOP - Pediatric AnaphylaxisUnstable, 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 repeatIf 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

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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

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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

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EpiPen®

• EpiPen®

• EpiPen® Jr

Firm grip

Jab intoouter thigh

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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

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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

Whisperflow CPAP Device

Generator and 1 way filter

Mask, head straps,CPAP valve

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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