Environmental Emergencies

1
Environmental Emergencies
Condell Medical Center EMS System CE August
2009 Site Code 107200E-1209

• Prepared by Captain Tony Carraro
• Greater Round Lake F.P.D.
• Reviewed/revised by Sharon Hopkins, RN, BSN,
  EMT-P

2
Objectives

• Upon 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.

3
Objectives contd

• 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.

4
Objectives contd

• 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 11000 IM and SQ.
• Describe when to use CPAP and how to monitor
  effectiveness.

5
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.

6
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

7
Water Chill

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

8
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.

9
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

10
Conversion Formula For Temperature

• 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

• 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

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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.

12
Predisposing Factors

• Age Very Young
• Larger skin surface area/less fat compared to
  adults
• Little or no shivering
• Shivering mechanism immature so cant generate
  heat via shivering
• Too immature in skills to independently put on or
  take off clothing

13
Predisposing Factors

• Age Very Old
• Failing body systems
• Chronic illness
• Lack of exercise
• Certain medications

14
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

15
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

16
Severe Frostbite
17
Partial Thickness (2nd Degree) Burn

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

18
Localized Cold Injury

• Clear boundaryseparates injured/ uninjured
  areas

19
Emergency Care ofSuperficial (Early) LocalCold
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

20
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

21
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

22
Core Body Temperature Core Body Temperature Symptoms
99F-96F 37C-35.5C Shivering.
95F-91F 35.5C-32.7C Intense shivering, difficulty speaking.
90F-86F 32C-30C 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.
85F-81F 29.4C-27.2C 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
80F-78F 26.6C-20.5C 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

• Severe Hypothermia

• Lethargy
• Shivering
• Lack of coordination
• Pale, cold, dry skin
• Early rise in blood pressure, heart and
  respiratory rate

• 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

• Frostbite
• Routine 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 used
• HANDLE SKIN LIKE A BURN
• Protect with light, dry, sterile dressing
• Do not let affected skin surfaces rub together

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Hypothermia SOP contd

• SYSTEMIC HYPOTHERMIA
• Routine Medical Care
• Avoid rough handling and excess activity
• Apply heat packs to axilla, groin, neck and
  thorax
• Assess pulse
• Pulse present Pulse Absent
• Transport (see next page)

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Hypothermia SOP contd

• Pulse absent
• Can extremities be flexed?

• No
• Follow appropriate cardiac
• protocol, but limit shocks to 1 and withhold IV
  medications
• Transport

• Yes
• Follow appropriate
• cardiac protocol but
• extend times between
• meds repeat defib
• as core temp rises
• Transport

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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 persons 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
  bodys 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 Factors

• Young age Newborns/Infants
• Poor thermoregulation system (under developed)
• Cant remove own clothing (skills immature)
• Older age Elderly
• Poor thermoregulation system
• Dont sense the heat level
• Interference with prescribed medication
• Limited ability to escape heat
• Often wear multiple layers of clothing
• Lack 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

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Signs and Symptoms Heat Cramps

• Alert
• Normal body temperature
• Normal vital signs
• Sweating, pale
• Skeletal muscle cramps
• c/o weakness, dizziness, faintness

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Signs Symptoms Heat Exhaustion

• Anxiety to possible loss of consciousness
• Body temperature slightly elevated (gt1000F)
• Normal B/P
• Pulse weak
• Respirations rapid, shallow
• Skin normal to cool clammy heavy sweating
• Occasional muscle cramps
• CNS symptoms Headache, paresthesia, diarrhea

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Signs Symptoms of Heat Stroke

• Confusion, 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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Its 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.

41
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

43
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 environment
• Remove as much clothing as possible to facilitate
  cooling
• Place in supine position with feet elevated

44
Region X SOP- Heat Emergencies, Adult

• Heat Stroke
• IV fluid challenge in 200 ml increments
• Rapid cooling procedure
• Follow gradual procedure along with
• Douse towels or sheets with cool water, place on
  patient, and fan body
• Cold packs to lateral chest wall, groin, axilla,
  carotid arteries, temples, and behind knees
• If actively seizing, follow seizure protocol
• Transport

45
Region X SOP- Heat Emergencies, Pediatrics

• Heat Stroke Peds
• IV fluid challenge 20 ml/kg may repeat to max 60
  ml/kg
• Rapid 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 begins
• Consider 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

46
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

48
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.

49
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

50
Pathophysiology of Drowningcontd

• 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

51
Pathophysiology of Drowningcontd

• 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

52
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.

53
Predisposing Factors Drowning

• Use of alcohol
• Lack of ability to swim
• Swimming in unprotected,
  non-monitored areas
• Not following posted
  warnings

54
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

55
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

56
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

57
Treatment

• Primary concerns
• Everyones 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.

58
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

59
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 Care
• C-spine precautions
• Oxygen 100
• Consider CPAP if patient condition indicates
• Stable Unstable
• Awake, alert, normal
• respirations
• Transport

61
SOP Near Drowning contd

• Unstable
• Abnormal respirations altered mental status
• Evaluate for gag reflex
• Negative Positive
• Intubate assist Assist
  ventilations via
• ventilations via BVM
  BVM
• Asses for hypothermia
• Normothermic
  Hypothermic
• Treat dysrhythmias per Refer to
  hypothermia
• protocol
  protocol

62
Region X SOP Near Drowning

• Pediatric Consideration
• Aggressive airway management
• Be aware of potential for C-spine injury and
  hypothermia
• Studies indicate potential for survival after
  prolonged submersion especially in cooler water

63
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

64
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

65
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

66
Ascent Injuries contd

• 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

67
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

68
Treatment

• ABCs
• CPR (if required) and high flow O2
• Secure airway (if required)
• Keep patient supine
• Protect from excessive heat or cold
• Evaluate and transport

69
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

70
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!!!

71
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)

72
Pathophysiology of Anaphylaxis

• Antigen exposure
• Release of chemicals including histamine

Constriction of extravascular smooth muscle

• Capillary
• permeability

Peripheral vasodilation
Abdominal cramps, diarrhea, vomiting bronchoconstr
iction, laryngeal edema
3rd spacing intravascular fluid

• Peripheral
• vascular
• resistance

73
Pathophysiology contd
3rd spacing (fluid leaking from intravascular
space
Relative hypovolemia
Edema
Decreased cardiac output
Decreased tissue perfusion
Impaired cellular function
Cellular death
74
Systemic Reactions
HIVES
3RD SPACING
Laryngeal edema
HIVES
75
Body Systems Affected

• Immune system
• Principle system affected
• Cardiovascular system
• Respiratory system
• Nervous system
• Gastrointestinal system
• (Note this list is not all inclusive)

76
Effects on Body Systems

• Skin
• Flushing
• Itching
• Hives
• Swelling
• Cyanosis
• Cardiovascular system
• Vasodilation
• Increased heart rate
• Decreased blood pressure

77
Effects contd

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

78
Effects contd

• Gastrointestinal system
• Nausea and vomiting
• Abdominal cramping
• Diarrhea
• Nervous system
• Dizziness
• Headache
• Convulsions
• Tearing

79
Allergic Response Helpful or Killer?

• Cascade of events after exposure to an antigen
• To remove antigen from the body prevent further
  ones from entering
• Bronchospasm prevents entrance into the
  respiratory system
• Coughing removes antigen from the respiratory
  system
• 3rd spacing (leaky capillaries) shifts antigen
  from vascular space into interstitial space for
  removal via the lymph system
• Vomiting diarrhea removes antigen from GI
  system

80
Severe Allergic Response

• Bronchospasm
• Respiratory compromise
• 3rd spacing
• Cardiovascular collapse
• Decreased cardiac output from vasodilation
• Fluid shift
• Relative hypovolemia

81
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

82
Generalized Signs Symptoms Bites and Stings

• Dizziness and chills
• Fever
• Nausea and vomiting
• Respiratory distress
• Bite marks or stinger

• Localized pain or itching
• Numbness body part
• Burning sensation followed by pain
• Redness and swelling
• Weakness
• Muscle cramps, chest tightening and joint pain

83
Brown Recluse Spider
84
Early Bite of Brown Recluse
85
(No Transcript)
86
Recluse Bite One Day Old
87
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

88
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

89
Tick (Lyme Disease)

• Tweezers are used to remove the deer tick
• Grasp the tick as close to the skin and pull
  upward

90
Region X SOP Adult Allergic Reaction

• Hives, itching, and rash
• GI distress
• Patient alert
• Skin warm and dry
• Systolic B/P gt 100 mmHg
• Routine medical care
• Benadryl 25 mg IVP slowly over 2 minutes or IM
• Transport

91
Region X SOP Pediatric Allergic Reaction

• Hives, itching, and rash
• GI distress
• Patient alert
• Skin warm and dry
• Apply ice/cold pack to site
• Benadryl 1 mg/kg IVP slowly over 2 minutes or IM
• Maximum 25 mg
• Transport

92
Region X SOP Adult Allergic Reaction with Airway
Involvement

• Patient alert
• Skin warm and dry
• Systolic B/P gt 100 mmHg
• Epinephrine 11000 0.3 mg SQ
• Benadryl 50 mg IVP slowly over 2 minutes or IM
• If wheezing, Albuterol 2.5 mg/3ml may repeat
• Transport

93
Region X SOP Pediatric Allergic Reaction with
Airway Involvement

• Patient alert skin warm dry
• Epinephrine 11000 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

94
Anaphylaxis Life Threatening
95
Region X SOP - Adult Anaphylaxis

• Unstable altered mental status B/P lt100 mmHg
• Maintain and support airway intubate as
  indicated
• IV wide open
• Epinephrine 11000 0.5 mg IM
• Benadryl 50 mg IVP slowly over 2 minutes or IM
• If wheezing, Albuterol 2.5 mg/3ml may repeat
• Transport
• If worsening condition, contact Medical Control

96
Region X SOP - Pediatric Anaphylaxis

• Unstable, altered mental status
• Epinephrine 11000 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 repeat
• If no response and continued deterioration,
  contact Medical Control to consider Epinephrine
  110,000 IV/IO 0.01 mg/kg repeated every 5 min
  as indicated

97
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

98
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

99
EpiPen

• EpiPen
• EpiPen Jr

Firm grip
Jab into outer thigh
100
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

101
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

102
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

103
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 11000

104
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

105
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)

106
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

107
Whisperflow CPAP Device
Mask, head straps, CPAP valve
Generator and 1 way filter
108
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?

109
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 bodys core
  outward

110
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?

111
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

112
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?

113
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

114
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?

115
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

116
Case Scenario 4 Discussion contd

• 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

117
Case Scenario 5

• You are dispatched to a parking lot at 1530 and
  find a 2 y/o male unresponsive in the fathers
  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 gt 2 sec
• VS P - gt 200 R 70 and shallow
• What do you think, what is your action?

118
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 gt200 too fast for an adequate
  cardiac output
• Extreme body temp increases the metabolic demand
  in the body on all organ systems

119
Case Scenario 5 contd

• 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

120
References

• Bledsoe, B. Porter, R., Cherry, R. Paramedic Care
  Principles and Practices. Volume 3
• Dalton, A., Walker, R. Mosbys Paramedic
  Refresher and Review. Elsevier Mosby. 2006.
• Limmer, D., OKeefe, M. Brady Emergency Care 10th
  Edition
• Nagel, K., Coker, N. EMT-Basic Review A Case
  Based Approach. Elsevier Mosby. 2005.
• Region X SOPs. March 2007, Amended January 1,
  2008
• www.epipen.com