Cold Emergencies Patients with Renal Disease

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Cold EmergenciesPatients with Renal Disease
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Objectives

• Describe the mechanisms of heat gain and heat
  loss
  
• Review general patient assessment related to cold
  emergencies
  
• Describe the pathophysiology, predisposing
  factors, signs and symptoms and management of
  mild and severe hypothermia and superficial and
  deep frostbite

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• Review protocol regarding care of a patient with
  a renal graft or fistula
  
• Understand the Mark I protocol
• Participate in case review
• Participate in system guideline review
• Successfully complete the quiz with a score of
  80 or greater

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Cold Emergencies

• Physical exposure to environmental conditions
• Can occur at any time of the year
• To effectively manage these types of emergencies
  it is essential that you understand their causes
  and underlying pathophysiology

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Who is at risk?

• Infants and children
• Elderly
• Those who cannot regulate their temperatures due
  to trauma, brain damage, hemorrhage, hypoxia
  
• Drug overdoses or intoxicated patients, due to
  central nervous system depression
  
• Outdoorsman

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Thermoregulation

• The human body functions within a very narrow
  temperature range
  
• Normal core temperature is 98.60F(37oC)
• The body must maintain a balance between
  internally generated heat and the external
  environment
  

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Hypothalamus

• Temperature regulating center of the body
• Located at the base of the skull
• Acts like a thermostat
• Skin has temperature receptors, deep tissue as
  well as mucous membranes
  
• Together they all act to prevent hypothermia

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Heat Generation

• Thermogenesis is the production of heat
• Heat production can be increased from
• routine cellular metabolism. The endocrine
  glands regulate heat production through
  sympathetic nerve stimulation and release
  norepinephrine and epinephrine from the adrenal
  glands

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• Skeletal muscles produce the largest amount of
  heat through shivering
  
• Shivering is regarded as the bodys best defense
  against cold
  
• Heat production can be increased by as much as
  400

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Heat Loss

• Heat is a by-product of metabolism and is always
  being lost in the environment
  
• Heat is lost by the body through skin, excretions
  and lungs
  
• Heat loss occurs because the body is warmer than
  the environment
  
• The body can lose heat by radiation, conduction,
  convection and evaporation

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• Radiation- Standing outside in the middle of a
  deep freeze
  
• Conduction- Sitting in a snow bank
• Convection- Standing outside during a very cold
  wind storm
  
• Evaporation- Sweating while shoveling snow

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Hypothermia

• Hypothermia results from prolonged exposure to
  temperatures and environmental conditions that
  cause an overall drop in body temperature
  
• Hypothermia can occur at temperatures well above
  freezing
  
• Cold exposure produces a downward progression of
  clinical signs and symptoms as the body attempts
  to preserve core heat

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• If improperly identified or treated
• hypothermia can be fatal

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Mild to Moderate Hypothermia

• Core temperature of approximately 96.80F
• Initially the patient will have an increase in
  blood pressure, heart rate, respiratory rate
  
• Continued cold exposure leads to shivering
• Shivering usually stops at about 860F
• The patient might appear lethargic, muscles may
  be stiff, gait may be unsteady

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Severe Hypothermia

• Core temperature of less than 860F
• Judgment may be impaired, slurred speech, loss of
  deep tendon reflexes, pupils may be fixed and
  dilated
  
• Blood pressure and pulse rate decline with
  continued cooling
  
• Respiratory depression, myocardial irritability

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• As the body continues to cool bradycardia and
  atrial fibrillation are often seen
  
• Muscles may be stiff or rigid
• Continued respiratory depression
• Absence of shivering
• Prolonged PR, QRS, and QT intervals appear on the
  EKG
  
• Cardiac and respiratory arrest are imminent

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Management of Mild Hypothermia

• Always maintain a high index of suspicion
• Ensure adequate airway, breathing and
  circulation
  
• Provide routine supportive medical care
• Prevent continued exposure
• Remove wet clothing
• Wrap the patient in a dry blanket

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• Apply heat packs to the axilla, groin, neck and
  thorax
  
• Horizontal position-to avoid aggravating
  hypotension
  
• IV, Oxygen, Monitor
• Avoid rough handling or excessive movement, which
  can potentiate dysrhythmia-Transport to the
  closest facility
  

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Moderate to Severe Hypothermia

• Remove patient from the environment
• Airway, Breathing and Circulation
• The patient will present altered level of
  consciousness, confusion and lethargy
  
• They will have lost the ability to shiver
• At temperatures below 82.40F they will be
  unconscious, without vital signs or respiratory
  effort
  

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• Pupils may be fixed and dilated
• Muscles rigid or stiff
• Provide routine care remove them from the
  environment, remove wet clothing, apply heat
  packs
  
• Begin with basic ventilatory assistance the use
  of airway adjuncts, including intubation, can
  cause ventricular dysrhythmias

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• THE PATIENT IS NOT DEAD UNTIL THEY
• ARE WARM AND DEAD

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REMEMBER

• WITHDRAWAL OF RESUSCITATIVE EFFORT
• DOES NOT APPLY TO THESE PATIENTS

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Frostbite

• Defined as a localized injury that results from
  environmentally induced freezing of body tissues
  
• Ice crystals form in the tissue, which then cause
  vascular and cellular injury
  
• Cold injuries are divided into superficial and
  deep frostbite

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Superficial Frostbite

• Present with signs and symptom of coldness and
  numbness to the affected area, followed by
  tingling and throbbing during rewarming
  
• Very painful during rewarming
• After rewarming edema presents, usually 3 hours
  post injury, followed by the appearance of
  vesicles, after 3-24 hours
  
• If you palpate a superficial injury the
  underlying tissue springs back
  

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Deep Frostbite

• Deep frostbite injury occurs when the capillary
  flow is not restored
  
• Tissue presents cold, mottled, and blue or grey
• The affected area will remain this way, even
  after rewarming
  
• If you palpate a deep frostbite injury the
  underlying tissue is hard

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• Edema is slow to develop
• Deep purple colored blood containing blister may
  form 1-3 weeks after injury
  
• Due to ischemia, the affected area often produces
  sloughing of nonviable skin and structures

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Management

• Prehospital care is often supportive in nature
• Move the patient to a warm environment as quickly
  as possible
  
• Provide routine medical care
• Handle the affected extremity like a burn
• DO NOT massage the affected area, as this will
  cause more damage

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• You may re-warm affected areas with tepid water,
  or hot packs wrapped in a towel
  
• Protect the affected area with light, dry sterile
  dressings
  
• Do not let affected skin surfaces rub together
• Remember to remove all wet or restrictive
  clothing
  
• Transport

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Renal Disease

• The kidney acts as a filter to remove waste and
  fluid
  
• Several disease conditions can lead to kidney
  failure hypertension, glomerulonephritis,
  polycystic kidneys, renal cancer, kidney stones
  and certain medications

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Signs and Symptoms of Approaching Kidney Failure

• Hypertension
• Blood found in the urine
• Pain in the lower back at the waistline
• Swelling to the arms, legs and face
• Frequent urination at night
• Nausea and vomiting

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Signs and Symptoms of Chronic or Long Term Kidney
Failure

• Loss of appetite, due to build up of waste
  products
  
• Swelling of extremities, face and eyes, due to
  fluid retention
  
• Pale and tired, due to decreased red blood cell
  production
  
• Shortness of breath, due to fluid retention
• Decreased urine output because less blood and
  products are being filtered by the kidney
  
• Itching from increased phosphorus, and urea
• crystals

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Treatment

• Three options to sustain life
• hemodialysis
• peritoneal dialysis
• kidney transplant

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Hemodialysis

• Process where the patients blood is passed
  through a semi-permeable filter called a dialyzer
  to remove waste products
  
• Access is made to the circulatory system enabling
  blood to flow out through a machine and return to
  the patient
  
• Access types Arteriovenous fistula and
  Arteriovenous graft

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Grafts and Fistulas

• ARTERIOVENOUS FISTULA
• Surgically created vascular access placed in the
  patients arm to allow for high speed and large
  volumes of blood and waste products to be
  exchanged during dialysis
• An artery and vein are surgically connected

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AV Fistula

• Blood from the artery flows into the vein
• Over time vein becomes stronger and bigger
• Once surgically connected the fistula will take
  approximately 6-8 weeks to develop

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ARTERIOVENOUS GRAFT

• Surgically created vascular access
• Synthetic tube is placed between the artery and
  vein
  
• Once the graft is created, it can be used in
  approximately 2-3 weeks

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Caring for the Patient with a Graft or Fistula

• Do not take blood pressures or start an IV
• where an active graft is present
• Circulation must not be cut off as it will damage
  access and prevent blood flow
  
• If bleeding is present apply pressure for at
  least 10 minutes

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Identifying location of a graft or fistula

• When you feel a pulsing flow or buzz it is called
  a thrill
  
• You may also check for flow using a stethoscope
• You will hear a swishing sound, called a bruit
  (brew-ee),
  

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• Most fistulas and grafts can last for years
• A common complication is a blood clot which could
  block blood flow
  
• A special procedure is needed to remove the clot
  before the graft or fistula may be used
  
• Infection, which is more common in grafts is
  treated with antibiotics

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• Narrowing or aneurysm of a graft or fistula
  interferes with blood flow
  
• This requires surgical intervention to restore
  blood flow

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• In the event of cardiac arrest a graft or fistula
  may be used
  
• Obtain access using an 18g needle or angiocath,
  venous side
  
• There is no thrill or bruit in the arrested
  patient

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Venous Catheter

• A tube is placed in the internal jugular under
  sterile conditions and tunneled to exit below the
  clavicle
  
• Placed temporarily for acute dialysis or until a
  permanent access is ready for use
  
• Usually covered with a sterile dressing

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Peritoneal Dialysis (CAPD)

• Peritoneum is used as the filter for waste
• A tube placed in the abdomen is responsible for
  fluid exchanges and waste product removal
  
• Self care treatment
• The patient fills the peritoneum with dialysis
  fluid and allows the fluid to dwell
  

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• The fluid stays in the peritoneum for about 3-6
  hours
  
• During the dwell time the fluid containing waste
  products is drained into a collection bag
  
• This process is usually done four times a day,
  every day

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Kidney Transplant

• Two Types Living and cadaver
• Living- A family member is the donor of the
  kidney
  
• This type of donation works best
• Family members usually have the tissue type most
  closely matching the person receiving the kidney

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• Some transplant centers perform living
  non-related transplants
  
• The donor must have enough tissues to match the
  person receiving the organ

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Cadaver Transplant

• A cadaver transplant is from someone who has died
  and donated their organs
  
• The person who needs the kidney is placed on a
  list.
  
• The person near the top of the list is offered
  the organ if enough tissues match

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Mark I Kits

• Used for exposure to nerve agents
• Used only by Illinois licensed EMS providers
• Only those who are authorized by an EMS medical
  director
  
• Kits are not to be used for prophylaxis

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Contents

• Atropine ( 2 mg in 0.7cc dose per injection)
• 2 PAM (pralidoxime chloride) 600 mg in
• 2 cc total dose per injection

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Indications for Use

• To be used if the patient presents with signs and
  symptoms consistent with exposure to nerve
  agents
  
• The injectors are antidotes not preventative
• SLUDGE BAM-Mnemonic for nerve agent exposure

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SLUDGE BAM

• Salivation-(excessive production of saliva)
  
  
• Lacrimation-(excessive tearing)
• Urination-(uncontrolled urine production)
• Defecation-(Uncontrolled bowel movements)
• Gastrointestinal distress-(cramps)
• Emesis-(excessive vomiting)
• Breathing Difficulty
• Arrhythmias
• Myosis-(pinpoint pupils)

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Treatment for Mild Exposure

• Clinical Presentation
• Shortness of breath, wheezing, runny nose
• Use one Mark I Kit or Atropine 2-4 mg IM/IV and
  2PAM 600 mg IM ( 1 gram IV)
  
• Refer to the table in your handout for pediatric
  and elderly antidote doses

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Moderate Exposure

• Clinical Presentation
• Vomiting, diarrhea, pinpoint pupils,
  drooling
  
• One Two Mark I Kits or Atropine 2-4 mg IM/IV and
  2 PAM 600-1200 mg IM (1 gram IV)

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Severe Exposure

• Clinical presentation
• Unconsciousness, paralysis, seizures
• Three Mark I Kits should be administered in rapid
  succession or Atropine 6 mg IM/IV and 2 PAM 1800
  mg IM or 1 gram 2 PAM IV repeated twice at hourly
  intervals
• Valium or versed per Medical Control may be given
  if convulsions are not controlled

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Nerve Agent Ingestion

• If the nerve agent has been ingested, exposure
  may continue for some time due to longer
  absorption from the lower bowel
  
• Fatal relapses have occurred after initial
  improvement
  
• Continued monitoring and transport is mandatory

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Dermal Exposure

• Decontamination is critical using standard
  decontamination procedures
  
• Monitor for the same signs and symptoms
• SLUDGE BAM

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Injection Sites

• Outer thigh muscle
• If thinly built- upper outer quadrant of the
  buttocks
  
• May be self administered

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Arming the Auto-injector

• Put on your protective mask
• Remove the antidote kit
• With your non-dominant hand, hold the
  auto-injectors by the plastic clip, larger
  auto-injector on top at eye level
  
• With your dominant hand grab the atropine with
  thumb and first two fingers

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• DO NOT HOLD OR COVER THE NEEDLE END WITH YOUR
  HAND
  
• Pull the injector out of the clip with a smooth
  motion
  
• The auto-injector is now armed
• Hold the injector with your thumb and two fingers
  with the green end of the injector against the
  injection site

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• Apply firm even pressure-(triggers the coiled
  spring mechanism)
  
• Do not use a jabbing motion-(may result in
  incomplete injection)
  
• Hold the injector in place for ten seconds
• Remove the injector
• Next pull the 2 PAM auto-injector out of the
  clip, and inject

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• Initiate any decontamination procedures
• Once stabilized with Mark 1 dosages, Atropine
  only may be repeated every 10-15 minutes-(refer
  to handout for repeat dosages)
  
• Mark, label or tag victims who have been given
  Mark 1 antidote kits with medication and doses
  given to the victim

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• ANY
• QUESTIONS