Cold Weather Emergencies

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Cold Weather Emergencies
Presented by Wade Scoles RRT, NREMT Staff
Education Coordinator, NW MedStar
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Emergency Vehicle Safety

• Most serious injuries in ambulance crashes are
  unrestrained medical attendants in the rear
  compartment.
• You are 2.6 times more likely to be injured while
  running code.

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Cold Weather Assessment Mngt

• Exposing your patient
• Bring them inside the ambulance
• Keep them warm
• Remove wet clothing
• Cutting Coats Snowsuits

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Cold Weather Assessment Mngt

• Assessing skin color, temperature and perfusion

• Normal cap refill of 2-3 seconds will be longer
  in cold weather due to vasoconstriction
• Will not necessarily reflect hemodynamic status

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Patient 1

• Typical winter conditions (more than an inch of
  snowfall and temperatures that dip below 20
  degrees) cause death rates from heart attacks to
  triple among men 35 to 49 years old.

Video
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Patient 1

• 55 year old having chest pain while shoveling
  snow
• Initial assessment
• Pale, diaphoretic, no resp. distress
• Vital signs
• Pulse 110, RR 16, BP 158/90, SpO2 96

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Patient 1

• Management
• Rapid transport, call for ALS if available
• Monitor with AED, Oximetry
• Oxygen
• Nitroglycerin
• Contraindicated if BP lt 100 systolic
• Aspirin

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Patient 1

• Why is shoveling a potentially dangerous
  activity?
• Strenuous activity in cold weather
• HR BP increase
• Body constricts vessels when exposed to the cold

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Patient 2

• Approximately 1,000 Americans fall through ice
  each year

Video
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Patient 2

• 11 year old, cold water submersion
• Pale, cold, unresponsive, not breathing
• To resuscitate or not?
• In the water 40-45 minutes
• Water temp 33 degrees

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Patient 2

• Assessing hypothermic patients
• Take extra time to assess pulse RR in
  hypothermic patients
• Allow for slow heart respiratory rates
• Dont start chest compressions if severe
  hypothermic patient shows any signs of life

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Patient 2

• Management
• Rapid transport, call for ALS if available
• High quality BLS
• Remove wet clothing
• Begin active re-warming of truncal area while
  administering BLS
• May attempt defibrillation once if AED says
  Shock indicated

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Patient 2

• Management
• Withhold further defib or meds until body temp
  reaches gt30C (86F)
• Will need transport to facility capable of active
  internal rewarming for severe hypothermia

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Patient 2

• Sudden submersion into cold water triggers the
  Mammalian Dive Reflex
• HR RR slows and blood flow diverts from the
  extremities to the core
• This slowing of metabolism and diversion of blood
  allows longer survival times.
• How cold must the water be, to be protective?
• lt20 C (68 F)

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Hypothermia Severity
Severity Symptoms Treatment
Mild gt34C or 93.2F Shivering, Tachycardia External rewarming all areas
Moderate 30-34C or 86-93.2F Confusion, disorientation, apathy, bradycardia or AFib External rewarming, truncal areas only
Severe lt30C or lt86F Unconsciousness, More cardiac dysrhythmias like V-Fib Truncal external rewarming plus active internal rewarming
Profound lt20C PEA or asystole, EEG flat line at 63F Same as Severe category
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Patient 3
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Patient 3

• Nearby fishermen call 911 to report drunk,
  confused man wandering around the ice
• Upon your arrival
• Pt is confused, dizzy, vomiting and C/O headache
• Vitals
• Pulse 118, RR 24, BP 132/80, SpO2 97 BS clear.
• Differential diagnoses?

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Patient 3

• What questions are you going to ask to determine
  the problem?
• Drunk?
• Hypoglycemia?
• Stroke?
• Head injury?
• Carbon Monoxide Poisoning?
• Pt. states he was just fishing with his buddy,
  had a couple of beers and doesnt remember
  anything else

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Patient 3

• With bystanders help, you figure out where he was
  fishing and find his friend in the hut
• His friend is passed out inside
• Pulse 120, RR 12, BP 116/70, SpO2 92
• What are your priorities?
• Additional resources needed?
• Secure airway
• Oxygen

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Carbon Monoxide

• Carbon Monoxide is colorless, odorless, tasteless
  gas
• CO exposure accounts for an estimated 15,000
  emergency department visits and 500 unintentional
  deaths in the United States each year

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Carbon Monoxide
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Carbon Monoxide

• CO has a half-life of 4-5 hours
• Oxygen can reduce that
• Hyperbaric Oxygen can reduce it even more
• Hyperbaric chambers in the Northwest
• WA Spokane (Deac), Seattle (Virginia Mason),
  Clarkston (Tri-State), Richland (Kadlec)
• Alaska Anchorage, Juneau, Wasilla
• Montana Billings Clinic
• Idaho Boise, Idaho Falls, Pocatello
• Oregon Portland, Hillsboro, Eugene, McMinnville

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Carbon Monoxide

• Detecting CO in blood
• Standard oximetry not helpful
• Co-oximetry

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Carbon Monoxide
COHb Symptoms
10 No symptoms
15 Mild headache
25 Nausea serious headache
30 Nausea vomiting intensify, confusion, lethargy
45 Unconsciousness
60 Death
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Patient 4
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Patient 4

• 65 year old woman rescued from house fire
• Scene safety concerns
• Patient condition
• Unresponsive
• No evidence of trauma or burns
• HR 140, RR 12, BP 130/78,
• SpO2 on Oxygen is 98

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Patient 4

• Differential diagnoses?
• Head trauma, CO poisoning, Medical Event
• CO level is 12
• Patient still unresponsive
• Consider Cyanide Poisoning
• Management
• Secure Airway
• O2
• Assist respirations
• Cyanokit

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Cyanide Poisoning

• Cyanide may be a factor in 4,000 fire-related
  deaths in the U.S. each year
• Study of smoke inhalation deaths
• 87 of the fatalities had toxic levels of cyanide
• Cyanide is commonly found in the smoke of
  closed-space fires
• Synthetic construction materials, furniture
• Natural materials like wool and cotton produce
  cyanide when burned

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Cyanide Poisoning

• Treatment
• Hydroxocobalamin (Cyanokit)
• 5 grams (diluted in 200ml) over 15 minutes
• Can safely be used for suspected cyanide
  poisoning as it bonds with cyanide in the body to
  form Vitamin B-12

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Patient 5

• You are called to the home of a 28 year old
  pregnant woman with respiratory distress

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Patient 5

• 34 weeks pregnant
• 2 day history of cough, muscle aches
• Now with fever and increasing respiratory
  distress
• VS HR 120, RR 24, SpO2 82

Protect yourself N-95 mask, gloves
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Patient 5

• After Oxygen
• SpO2 87
• Still in respiratory distress
• Breath sounds
• Insp. Crackles exp. wheezes
• Impression?
• Influenza, Respiratory distress

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Novel H1N1 in the US, By Age Group
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Novel H1N1 U.S. Deaths, By Age Group
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Flu Hospitalizations, Spokane Area

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Patient 6

• 24 year-old male crashes on snowmobile

http//www.youtube.com/watch?vUoA7jK26SOE
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Patient 6

• Scene safety concerns
• Transport decision
• Helicopter safety concerns
• Skids sinking into snow
• White-out conditions upon landing

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Patient 6

• Upon your arrival
• Pt is conscious, sitting on tailgate of truck
• c/o back and neck pain
• HR 80, RR20, BP hard to hear through clothes,
  SpO2 97
• Skin feels cool
• Your assessment
• Are you going to cut off his snowsuit?

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Patient 6

• Management
• C-spine immobilization
• ABCs
• How are you going to place him in C-spine
  precautions?

http//www.emsonline.net/head2009/skills.asp
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• Contact Renee Anderson509-232-81551-866-630-4
  033andersr_at_inhs.org
• Fax [phone]