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HypothermiaFebruary 2013 CECondell Medical CenterEMS SystemSite Code: 107200E-1213
Prepared by: Sharon Hopkins, RN, BSN, EMT-PRev: 2.11.13
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ObjectivesUpon successful completion of the program the EMS
provider will be able to:
Describe the thermoregulatory mechanism. Describe the mechanisms of heat transfer. Identify risk factors that predispose a patient to an
environmental emergency. Discuss the pathophysiology of cold emergencies. Identify the normal and critically low body
temperatures.
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Objectives cont’d List and describe the various cold disorders. Describe signs and symptoms, and management of
cold disorders. Describe differences of treatment of the arrested
patient with a normal body temperature versus a cold presentation.
Actively participate in case scenario discussion. Review use of a saline lock with and without IV
tubing. Successfully complete the post quiz with a score of
80% or better.
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Background Hypothermia Body’s job is to maintain homeostasis
A constant and suitable condition in which the body functions
Normal body temperature is 98.60F (370C) Hypothermia considered a core temperature
less than 950F Unable to generate sufficient heat production to
return to a normal core temperature
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Thermoregulatory Mechanisms Body attempts to maintain/regulate the body
temperature Core temperature
Temperature of deep body tissues Varies minimally from 98.60F (370C) Can be measured via tympanic or rectal
thermometers (additional routes used in hospital) Tympanic and rectal can reflect core temperatures Peripheral body temperature measured via oral or
axillary temperatures
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Thermoregulatory Mechanisms cont’d Production and loss of heat maintained via a balance
between the nervous system and negative feedback mechanisms (an action is stopped or negated)
Hypothalamus at base of brain regulates temperature When heat is sensed, heat generating mechanisms shut off
(i.e.: stop shivering) When decrease in body temperature sensed, heat losing
mechanisms shut off (i.e.: stop sweating) Thermoreceptors located peripherally (i.e.: skin and
certain mucous membranes) and centrally (deeper tissues of body)
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Hypothalamus – Thermoregulatory Center
Sits deep in brain
Thermo-stat for body
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Thermoregulatory Mechanisms cont’d Basal metabolic rate – BMR
Metabolism that occurs when body completely at rest
Continually adjusting based on the need of the body Blood vessels constrict or dilate based on need to
conserve heat or dissipate heat Can develop a difference between peripheral and core
body temperatures Core temperature is the crucial measurement with
major organs Rectal temperatures will reflect core temperatures
9
Mechanisms of Heat Transfer
Heat flows from warmer to colder substances Conduction
Direct contact Convection
Heat loss to air currents passing over body Radiation
Heat loss via infrared rays Evaporation
Change of liquid to vapor; sweat evaporation Respiration
Via convection, radiation, and evaporation via lungs
10
Conduction Transfer of heat away from the warmer
surface to the cooler surface Air is poor conductor of heat
Still air is good insulator Water conducts better than dry air Example: Sitting on a cold bench at the
stadium you warm it up by your body temperature conducting to the colder bench
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Convection Heat lost to air currents passing over the body Amount of heat lost depends on temperature
difference between your body and environment plus speed which the air or water currents are moving Air in motion takes away a lot of heat
Body heat is first conducted to the air before convection occurs
Example: Blowing on your food to cool it down
12
Radiation Direct emission of heat Heat radiates from the warmer body and
clothing to the cooler environment The greater the difference between the body
and environmental temperature, the greater the heat loss
Example: On a hot summer day you can see the heat radiating off the hot pavement
13
Evaporation Responsible for 20-30% of heat loss Wet clothing enhances heat loss Exhaled respiratory vapors add to the heat
loss Notice how you see your breath in cold weather?
Example: Stepping out of a shower on a cold winter morning, you warm up immediately after drying off
14
Review Question??? When a person is exposed to cold
temperatures and strong winds for extended period of time, heat is lost mainly through: A. Radiation B. Convection C. Conduction D. Evaporation
15
Answer: B - Convection Convection occurs when heat is transferred to
circulating air (cool air moves across body surface). If person is wearing light clothing and standing in the cold, windy weather, lose heat mostly by convection.
16
Respiration As you breathe, you inhale ambient air
In cold climates, this can cool the core When you exhale you lose moisture and with it goes
heat Heat is lost with ventilations via the processes of
convection, radiation, and evaporation via lungs Expired air usually 98.60F (370C) and 100%
humidified
17
Heat Conserving Mechanisms Vasoconstriction
Via sympathetic nervous system Skin pale, cool
Piloerection – goose bumps Evolutionary remnant
Increased heat production Shivering Chemical thermogenesis (heat generation by body) Increased thyroxine release
rate of cell metabolism
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Predisposing Risk Factors Age
Especially young children and older adults Less developed heat-generating mechanisms
General health/ predisposing medical conditions Hypothyroidism, diabetes, Parkinson’s, malnutrition
Presence of fatigue Increases poor decision making skills
Duration of exposure Coexisting weather conditions
Wind chill Altitude Humidity level
19
Risk Factors cont’d Certain medications that interfere with heat-
generating mechanisms Narcotics Alcohol Phenothiazines Barbiturates Antiseizure meds Antihistamines Antipsychotics Sedatives antidepressants, Pain meds like aspirin, acetaminophen, NSAIDS
20
Body Temperature Levels
Normal 96 – 1000F (37.80C) Mild hypothermia 90 (320C) – 950F (350C) Severe hypothermia – below 900F (<320C) Below 860F cardiac resuscitation possible;
more favorable above 860F (300C)
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Complications Anticipated Dehydration from cold diuresis Hypoglycemia Decreased CNS electrical activity Coagulopathy disorders – clotting problems Non-cardiogenic pulmonary edema Cardiac dysrhythmias
Atrial fibrillation common VF at 820F (<280C) Asystole at 680F (<200C)
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Fluid Balance Cold induced vasoconstriction increases fluid thru
kidneys Respond with diuresis Tubules reabsorb less water increasing more diuresis
Fluid shifts intravascular space extravascular space intracellular space
Reverses on rewarming so intravascular volume may increase 30% above normal volume
23
Cold or Heat Emergencies Difficult to determine mechanism of injury by
appearance of wounds– cold or heat exposure? Obtaining history very important Field treatment does not differ for wound care
24
Pathophysiology In response to exposure to cold and wet
environments, blood vessels vasoconstrict Vasoconstriction results in a decreased blood flow to
tissues especially in the periphery Ears, nose, fingers, toes
Cellular waste is not cleared and builds up Dehydration occurs easily in the cold especially if
physically active Injuries can occur at freezing AND non-freezing
temperatures
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Stages of Hypothermia Shivering
Body’s attempt to generate heat Begins around 94-970F (34.4 -360C) Does not function around 84-880F (29-310C)
Mild hypothermia – 93-970F Conscious but displaying poor judgment and irrational
behavior B/P, HR, RR to retain & generate heat
Cools more by inhaling cold air and exhaling moisture and heat with ventilations
Skin may be red, pale, or cyanotic
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Stages of Hypothermia cont’d Moderate hypothermia – 86-92.90F
Cognitive abilities declined; does not respond to painful stimuli
Progressive muscular rigidity B/P, HR, RR leading to cardiac dysrhythmias
Severe hypothermia – core below 860F Unconscious; no response to pain VS barely or non-detectable
27
Review Question??? What does shivering in the presence of
hypothermia indicate? A. Musculoskeletal system damaged B. Nerve endings are damaged causing loss of
muscle control C. Body is trying to generate more heat thru
muscular activity D. Thermoregulatory system has failed and body
temperature is falling
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Answer: C – Generating more heat Shivering in presence of hypothermia
indicates that body is trying to generate more heat (thermogenesis) through muscular activity
In early hypothermia, shivering is voluntary attempt to produce heat
As hypothermia progresses, shivering is involuntary
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Frostnip Skin freezing but deeper tissues unaffected Usually affects ears, nose, fingers Usually not painful until rewarming Skin pale, cold to touch May report loss of feeling and sensation to
injured areas.
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2 weeks
Initial insult
4 weeks
Progression of Frostbite Damage
31
Trench Foot 1st noted in Napoleon’s army 1812 Particular problem in trench warfare during
winters WW I, WWII, Vietnam War, Falkland’s War 1982
Has even occurred at winter festivals 1998, 2007, 2009, 2012
Can lead to gangrene and amputation
32
Trench Foot Feet are cold and wet while wearing
constrictive footwear Temperatures do not need to be freezing
Has occurred in 600F temperature with 13 hour exposure
Keeping feet cold and wet for extended periods is the key causative factor
Excessive sweating is a contributory factor Prevention – keep feet warm and dry!!!
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Trench Foot Exposure followed by blistering
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Frostbite Freezing of tissue,
usually skin, when blood vessels contract
Blood flow and oxygen is reduced to affected body tissues
35
Frostbite There are three degrees of cold injury Classified by depth of injury and clinical presentation
Frostnip Superficial frostbite Deep frostbite
Ice crystals form; expand and damage surrounding tissue
Damage dependent on length of exposure and depth of damage If frozen tissue dies, would lead to amputations
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Frostbite Normal sensation is lost; area becomes numb Color change noted in tissues Most affected are body parts farthest from the
core Nose, ears, fingers, hands, feet, and toes
Highest risk population Children, elderly, those with circulation problems
Majority of cases in adults 30-49 year-old
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Frostbite Don’t break blisters
Serve as protective bandaging
Treat as a burn Can’t tell if wounds
are from cold or heat exposure without knowing the history
Frostbite on a climber -parts of digits eventually needed amputation
Is this a problem???
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Preparing Site for Treatment Any constrictive jewelry or other pieces
MUST be removed As extremities/digits swell, any circumferential
articles will further constrict blood flow Any article removed from patient MUST be
documented that they were removed Document what you did with the articles
Given to patient/significant other? Turned over to ED staff?
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Pain Management Rewarming is a VERY PAINFUL!!! process
Once started, rewarming must continue regardless of the pain the patient is experiencing
Superficial frostbite is rewarmed over approximately 20- 40 minutes
Deep frostbite may take an hour to rewarm Constantly reassess pain levels and document
40
Dressing Application Use fluffy, loosely wrapped dressings Separate digits with gauze
Do not want skin on skin – may become stuck together and separating will cause more tissue damage
41
Adult Hypothermia/Cold Emergencies Adult Routine Medical Care (Region X SOP) Frostbite
Move patient to a warm environment Rapidly rewarm frozen areas (of frostbite) with warm
water if available (1000 – 1080F) OR Hot packs wrapped in a towel (not with direct contact to
fragile tissue) Handle skin like a burn
Light, dry sterile dressing; skin surfaces not to rub together
Elevate and immobilize Manage pain appropriately
42
Rewarming Shock Hazard of rewarming extremities
Drop in core temperature if extremities rewarmed pushing colder blood into core
Recommended to rewarm thorax only and not hands or feet with hot packs
Occurs due to peripheral reflex vasodilation Cooled blood returns to core and metabolic acid
(wastes) from extremities May have paradoxical drop in core temperature
further worsening hypothermia
43
Pain Management Region X SOP Fentanyl 0.5 mcg/kg IVP/IN/IO
May repeat in 5 minutes Same dose as initial dose Max total dosing of 200 mcg
FYI - A 450 pound patient would get 200 mcg by 2 doses Synthetic narcotic Less cardiovascular side effects than experienced with
Morphine Availability of IN route is advantage
44
Basic Principles to Interventions Move the patient to a warmer environment
Get out of the elements of wind, wetness, and cold – prevent further heat loss
Remove any wet clothing Do not allow any body part to refreeze after
warming A freeze, thaw, refreeze cycle is more damaging to tissue
than prolonged freezing alone Do not massage tissues Do not allow patient to walk
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Systemic Hypothermia SOP Avoid rough handling and excess activity Apply heat packs to axilla, groin, neck, thorax Assess for presence of pulse
If present, continue assessment If absent, cannot withdraw resuscitative efforts
until warmed
46
EKG Changes in Hypothermia Prolongation of the PR interval; then QRS;
then QT interval J waves (Osborn waves) can occur at any
temperature less than 900F (32.30C) Most frequently seen in Lead II and V6 As temperature drops, J wave increases
Can be confused with ST elevation indicating acute MI
47
J wave (Osborne waves) – Development in Hypothermia
48
Severe Hypothermia Signs and symptoms
Absence of shivering Dysrhythmia Loss of voluntary muscle control Decrease blood pressure Undetected pulse and respirations Cardiac arrest
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Systemic Hypothermia SOP cont’d No pulse
Begin CPR Evaluate extremities – can they be flexed? If no,
Follow appropriate cardiac protocol based on rhythm noted If defibrillation required, limit to one shock Do not administer medications – they will
not circulate effectively
50
Systemic Hypothermia SOP cont’d No pulse
Begin CPR Evaluate extremities – can they be flexed? If yes,
Follow appropriate cardiac protocol based on rhythm noted If defibrillation required, repeat as core temp rises To administer medications – extend time between
medications Distribution slowed in the cold state
51
Active vs Passive Rewarming Passive
Using person’s own heat generating abilities Moving to warm environment Blankets Dry clothing
Active Applying warming devices externally
Hot packs or heating pads placed in areas with superficial blood flow Neck, arm pits, groin
52
Question Which of the following is NOT an example of
passive rewarming? A. Removing cold, wet clothing B. Administration of fluids by mouth C. Turning up heat in ambulance D. Covering patient with a blanket
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Answer: B – Fluid by mouth Passive rewarming involves allowing a
patient's body temperature to rise gradually and naturally.
Remove wet clothing Turn up heat in ambulance Cover with a blanket Drinking warm fluid is active rewarming
54
Induced Hypothermia in ROSC Research indicates controlled induction of
hypothermia could be protective to the brain and other organs
General consensus is to cool patient to 32 – 34 0C for 12-24 hours (89.6 – 93.20F)
Patient can be placed on ventilator while being cooled and taken to the cath lab Cooling does not interfere with these interventions
55
SOP- ROSC Hypothermia Induction Indications
Any patient after out of hospital cardiac arrest Remains unconscious and unresponsive ROSC greater than 5 minutes Able to maintain systolic B/P>90 with or without
vasopressors Airway secured Presumed cardiac etiology
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SOP- ROSC Hypothermia Induction Relative Exclusions
Major head trauma or traumatic cardiac arrest Recent major surgery within 14 days Systemic infection Coma from other causes such as drug induced or overdose Active bleeding Hypothermia is not recommended for isolated respiratory
arrest Suspected hypothermia already present 340C/93.20F
57
SOP- ROSC Hypothermia Induction
If patient meets inclusion criteria with no relative contraindications, induce pre-hospital therapeutic hypothermia
Place ice packs in axilla and around neck and groin
Place an ice pack over the IV/IO site If shivering, contact Medical Control for
possible medication order
58
Cooling after ROSC Ice paks place under neck, in armpits, in groin
59
Marine Corps “COLD” Protection Principle & Preventive Measures C – clothing free of dirt & oil
Insulation capability declines O – avoid overheating that causes you to
sweat wetting clothing L – layer correctly to trap air between layers
Avoid constrictive clothing D – keep clothing dry
Wet clothing means wet skin
60
Review of Initiating IV Access Under Routine Medical Care, IV access is
established based on patient's condition If stable, may establish saline lock
Develop habit of always adding the saline lock/extension tubing to the IV catheter Exact saline lock device may be different
depending on where you replace your supplies They all work on the same principle
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Establishing Saline Lock Equipment
IV start pack IV catheter Saline lock Saline flush IV bag if
indicated
62
IV Site Prep Skin prep applicator contains antiseptics
chlorhexidine and isopropyl alcohol Cleanse site for 30 seconds Allow to air dry for 30 seconds
Do not blot or wipe away antiseptic FYI – some hospitals have a policy to
automatically change in-field IV sites Consider IV’s started in less than the best,
cleanest conditions
63
Benefit Saline Locks/Extension Tubing Gain IV access in case of patient deterioration If IV tubing connected, easier on the patient for staff
to change the IV tubing avoiding manipulation of the IV catheter at the site of insertion Reduces the incidence of irritation that could lead to
phlebitis at the site IV can be started with or without use of the saline
lock – some ED staff prefer the additional length of tubing the saline lock provides
64
Mechanical Skills Using Equipment Personnel preference starting IV with saline lock Place IV catheter
Then add individual pieces to the line Saline lock, flush, remove syringe, attach IV tubing
OR Attach saline lock to IV tubing; prime the whole line; then
attach to IV catheter
Neither way is more right/wrong than other Just another way to get to the same end result
65
Adding IV Bag of Fluid – 1 Method Pre-connect saline lock to IV tubing Spike IV bag Run through IV tubing AND saline lock as one unit Keep cap on distal end of tubing to keep tip sterile Initiate IV Connect primed IV tubing, with saline lock attached,
to IV catheter Check for patency and adjust IV flow rate Secure tubing
66
IV Start with Saline Lock – Alternate Method Spike IV bag and run out IV tubing, set aside
Keep cap on distal end of tubing to keep tip sterile Flush saline lock; can leave flush syringe attached Initiate IV Connect saline lock to IV tubing Flush the line and check for infiltration, remove
syringe Swab port and connect primed IV tubing to saline
lock; confirm IV flow rate Secure tubing
67
IV Don’ts Don’t add gauze under the tape - increases the
risk of infection Don’t leave site wet with blood if possible Do not leave large loops of tubing that could
be inadvertently pulled
68
IV Tips Cover insertion site with op-site type product
Site can be observed for changes Entire catheter tip should be inserted up to hub
69
Infection Control The main risk factor for infections is the
presence of a medical device in a patient Field environments usually less than optimal
compared with healthcare facilities related to sterility of equipment
Hand hygiene is the first step in infection control Handwashing before and after every patient Clean gloves used for invasive skills
70
Routes of Infection with Catheter Use Migration of organisms on patient’s skin from
site of insertion, along catheter, to catheter tip Contamination of equipment via direct contact
Improperly cleaned hands/glove use Improper handling of equipment Contaminated injection ports not cleaned prior to
use for injection Contamination of IV solution – rare occurrence
71
Infection Prevention Have you contaminated the IV catheter? Have you kept the distal tip of the IV tubing
covered? If you rip your tape early, where did you put
it? Are you sure the side of the cot is clean??? Are you sure the side rails of the cot are clean all
the way around???
72
Scenario Discussions Participate in discussions of the following
cases Determine your general impression Decide on treatment/interventions you would
initiate Review outcomes
73
Scenario #1 24 year old male found unresponsive outdoors Ambient temperature late afternoon – 450F
Cloudy 71% humidity Winds calm
Background information: Unknown length of time down O-O-O Monitor showed ventricular fibrillation Patient worked as a full arrest
74
Scenario #1 – Time of year - January Found by passer-by unresponsive laying face
down in mud 200´ off road Rolled over prior to EMS arrival Found cold, pale, apneic, pulseless, pupils
fixed and non-reactive O-O-O
What would you do if this were your call?
75
Scenario #1 - Narrative “Moved to ambulance; c-collar and back board
applied; clothes removed; CPR started with active warming process”
“Rapid trauma assessment no trauma found”
What else do you need/want to know for assessment information that would help guide decision making for care of this patient? Do extremities flex or not?
76
Scenario #1 Skills as listed in Image Trend
BVM Airway clearing Spinal immobilization Warming with hot packs Defibrillation x5 King airway IO access lower left extremity Medications: Epinephrine, Amiodarone, Narcan
77
Scenario #1 – Questions Hypothermic patient – Could extremities be flexed? BVM – What rate??? Airway cleared – Why? What method? Spinal immobilization – What method/equipment? Hot packs – Where were they placed? Defib- When was each individual one delivered? King airway – What size? Placement confirmed? IO access – What length and size needle? Was
patient banded?
78
Scenario #1 - Medications VF per monitor
Epinephrine 1;10,000 – 1 mg IO Epinephrine 1;10,000 – 1 mg IO Amiodarone 300 mg IO Epinephrine 1;10,000 – 1 mg IO Epinephrine 1;10,000 – 1 mg IO Narcan 2 mg IO
What do you think of the medication order for VF?
79
Scenario #1 Follow-up Patient was resuscitated, admitted to ICCU Patient regained consciousness
Protected by hypothermia and sedation of self-administered drugs
Patient survived to discharge Awake, oriented, able to care for self (eat, dress, walk)
Unbelievable but true!!!
And a VERY lucky gentleman
80
Scenario #2 43 year old female developed chest pain 7/10
while at work History hypertension VS: B/P 153/100; P – 86; R-16; SpO2 99% RA Unable to establish IV Given 4 baby ASA to chew Administered 1 NTG sl due to the pain Then obtained 12 lead EKG
81
Scenario #2 – Any ST elevation?
II, III, aVF
82
Scenario #2 Were the interventions appropriate? How would you have handled the call?
If unable to obtain IV access, need to contact Medical Control prior to administration of NTG
Need to obtain a 12 lead EKG prior to NTG Need to review for ST elevation
If ST elevation in II, III, aVF (inferior leads), need to contact Medical Control prior to administration of NTG
83
Scenario #2 In the field, no negative effects from NTG
dose In the ED, 12 lead EKG was normal Taken to cath lab based on EMS 12 lead During procedure, might have seen distal
blockage that resolved Catheter maneuvers may have dislodged a clot
and reopened a vessel Patient to undergo further testing
84
Scenario #3 A 19 year-old female had walked several
miles in a frozen field Feet are white, hard, and cold to touch You determine that she has frostbite in both
feet
What would you do if this were your call?
85
Scenario #3 – Pick the best answer:Treatment at the scene should include:
A. Rubbing feet gently with your warm hands
B. Having her walk around to restore circulation
C. Removing her wet clothing and rubbing her feet briskly with a warm, wet cloth
D. Removing her wet clothes and covering her feet with dry, sterile dressings
86
Scenario #3 – Answer D Rationale #D
To treat frostbite, remove any wet clothing Cover injured area with dry, sterile dressings Do not break any blisters Do not apply heat to rewarm area if there is any
chance of refreezing
87
Scenario #3 – Explanations of wrong answers:#A - Do not rub or massage frostbitten areas
Increases tissue damage
#B – Walking on frostbitten feet increases tissue damage Ice crystals have formed in the tissues and
movement, rubbing, massaging increase damage to surrounding tissue
#C – Never rub cold injured skin; if allowed to freeze, thaw, freeze, increase in damage to tissues occurs
88
Scenario #4 30 year old male who fell through the ice In water 20 minutes; exposed additional 10
minutes while getting to shore VS: 158/84; P – 120; RR – 30; SpO2 99% RA GCS 15 Denies pain IV access; cardiac monitor
89
Scenario #4 Pt wearing snow mobile suit and helmet while in the
water In ambulance, clothing removed
Dried Covered with blankets Hot packs applied
Pt red, shivering Complained of no feeling in right foot; all
extremities move well
90
Scenario #4 What do you think – care and documentation?
What was the ambient temperature? What did the monitor show? Was a hot pack placed over the IV site?
What does it mean when a patient shivers?
91
Scenario #4 Shivering indicates the patient is still capable
of generating heat through the action of shivering Passive rewarming used patient’s own body heat
Removed from cold environment Removed wet clothing Covered with a blanket
Active rewarming Hot packs placed in the neck, armpit, and groin areas
92
Scenario #5 You are called to the scene for a 27 year-old
male who immediately became unconscious after being elbowed in the chest
Upon arrival CPR is being performed; patient confirmed to be 0-0-0
With this initial rhythm, what is your action?
Ventricular fibrillation
93
Scenario #5 When confirming a patient is in VF, provide CPR First action with arrival of equipment is to get
monitor on patient to view rhythm Rhythm viewed with patient presentation drives
decision making As soon as monitor is ready, stop CPR If VF/pulseless VT seen, immediately defibrillate
Immediately resume CPR after defibrillation starting with compressions
94
Scenario #5 – Following Region X SOP’s First shock delivered CPR resumed; attempting to establish IV access After 2 minutes, CPR paused for max of 10
seconds to reevaluate rhythm What is your next action when seeing this on the
monitor?
Check for a pulse!!!
95
Why Limit CPR Pause to <10 sec? When compressions interrupted, blood flow
drops rapidly Decrease in intrathoracic pressures Takes awhile to regenerate adequate perfusion again
Maintain a rate of at least 100 compressions per minute 30:2 in 1 man and 2 man adult CPR Once intubated, compressor stops only after 2
minutes of CPR for rhythm check Ventilations are asynchronous
96
Importance of Adequate Compression Rate During CPR Lengthy pauses in CPR detrimental to blood
flow and ultimately the patient Takes a few compressions to build up enough
pressures to be effective after each pause
97
Negative Effects of Hyperventilation Hyperventilation blows off CO2 Decreased CO2 causes reflexive vasoconstriction
Limits volume of oxygenated blood perfusing to the brain Excessive ventilation can result in gastric inflation
Increases risk of vomiting and aspiration Excessive ventilation rate increases intrathoracic
pressures Can compromise venous return to the heart and diminish
cardiac output Ventilate once every 5-6 seconds with BVM Ventilate once every 6-8 seconds via ETT or King
98
Scenario #5 When viewing a rhythm that should generate
a pulse, including VT, NOW appropriate to check for a pulse
If no pulse, rhythm PEA, resume CPR If pulse, reevaluate patient
Responsiveness Airway/ventilation status Blood pressure 12 lead EKG
99
Scenario #5 – Any ST elevation?
Sinus Tach - NO ST elevation
100
Scenario #5
So why did this patient arrest? Commotio cordis – concussion of the heart
Instant cardiac arrest from a non-penetrating blow to the chest wall
Diagnosis made by exclusion of other etiologies If blow made immediately before peak of T wave, VF
can develop Improved survival rates to immediate CPR and rapid
defibrillation
See October 2012 CE for additional discussion
101
Bibliography American Heart Association. 2010 Guidelines for
CPR and ECC. 2010. Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles & Practices, 4th edition. Brady. 2013. Siegel, M., Kraemer-Cain, J. PICC Line Care at
Home. Advance for Nurses. September 26, 2011. Region X SOP’s; IDPH Approved January 6, 2012. http://www.cdc.gov/niosh/docs/2010-115/pdfs/2010-
115.pdf http://en.wikipedia.org/wiki/Hypothermia