Environmental Emergencies

1
Chapter 15

• Environmental Emergencies

2
Objectives (1 of 4)

• List the signs and symptoms of exposure to cold.
• Explain the steps in providing emergency medical
  care to a patient exposed to cold.
• List the signs and symptoms of high altitude
  illnesses.
• Explain the steps in providing emergency care to
  a patient with high altitude illness.

3
Objectives (2 of 4)

• Explain the steps in providing emergency care for
  an avalanche victim.
• List the signs and symptoms of exposure to heat.
• Explain the steps in providing emergency care to
  a patient exposed to heat.

4
Objectives (3 of 4)

• Explain the steps in providing emergency care for
  a patient who has been struck by lightning or
  received an electrical injury.
• Recognize the signs and symptoms of water-related
  emergencies.
• Demonstrate the assessment and emergency care of
  a patient with exposure to cold.
• Demonstrate the assessment and emergency care of
  a patient with high altitude illnesses.

5
Objectives (4 of 4)

• Demonstrate the assessment and emergency care of
  an avalanche victim.
• Demonstrate the assessment and emergency care of
  a patient with exposure to heat.
• Demonstrate the assessment and emergency care of
  a patient affected by lightning or electrical
  exposure.

6
Cold Exposure

• Normal body temperature exists within a narrow
  range
• Cold may cause injury to parts of the body
• Cold may cause injury to the body as a whole

7
Loss of Body Heat (1 of 2)

• Conduction
• Transfer of heat from body to colder object
• Convection
• Transfer of heat through circulating air
• Evaporation
• Cooling of body through sweating

• Radiation
• Loss of body heat directly into a colder
  environment
• Respirations
• Loss of body heat during breathing

8
Loss of Body Heat (2 of 2)

• Rate and amount of heat loss can be modified in
  three ways
• Increase heat production (shivering).
• Move to sheltered area where heat loss is
  decreased.
• Wear insulated clothing.

9
Hypothermia

• Lowering of the body temperature below 95F
  (35ºC)
• Weather does not have to be below freezing for
  hypothermia to occur.
• As the body cools, functions slow.
• A cooler body loses the ability to regulate
  temperature and to generate heat.
• The patient is unaware of the change and the
  condition is insidious.

10
Hypothermia Risks

• Elderly persons and infants are at higher risk.
• People with other illnesses and injuries are
  susceptible to hypothermia.
• High altitude can increase the risk.

11
Hypothermia and Death

• 50 of severe cases are lethal.
• Patients may appear dead, but
• No one is dead until warm and dead!
• Death is usually the result of ventricular
  fibrillation (V-fib).

12
Hypothermia Categories

• Grouped into three categories
• Acute (less than an hour)
• Subacute (1 to 24 hours)
• Chronic (a day or more)

13
Mild Hypothermia

• Rectal temperature above 90F (32C)
• Shivering can provide needed heat.
• Treat dehydration with warm, sweetened liquids.
• Avoid alcohol and caffeine.

14
Severe Hypothermia

• Rectal temperature below 90F (32C)
• Out-of-hospital mortality is high due to V-fib,
  metabolic, or electrolyte complication.
• Best results occur with detection, stabilization
  of core temperature, gentle handling, and
  transport.

15
Severe Hypothermia Treatment (1 of 2)

• Spend several minutes evaluating vital signs.
• Avoid aggressive rewarming.
• CPR can precipitate V-fib.
• If CPR is started, it must continue until
  hospitalization.

16
Severe Hypothermia Treatment (2 of 2)

• Carefully evaluate the method of evacuation.
  Avoid rough handling.
• In a wilderness setting, use a slow rewarming
  method, usually body-to-body contact.

17
Hypothermia Settings

• Immersioncontact with cold water
• Fieldcontact with cold weather
• Urbanindividuals predisposed to poor or
  inadequate thermoregulation
• Submersiondrowning and near drowning

18
Assessment of Hypothermic Patients (1 of 2)

• It is always preferable to anticipate and
  prevent.
• Mental status and physical actions can help
  estimate core temperature.
• Shivering and appropriate actions,
• temperature gt 90F (32C)
• Uncoordinated actions and no shivering,
  temperature lt 90F (32C)

19
Assessment of Hypothermic Patients (2 of 2)

• Scene size-up
• Include consideration of setting and
  predisposing conditions.
• Initial assessment
• Prevent further heat loss.
• Take your time assessing vital signs.

20
Emergency Medical Care

• Stabilize body temperature and prevent further
  heat loss.
• Rewarm the patient appropriately.
• Rewarm the core first if possible.
• Treat gently.
• If conscious, give warm sweet fluids to treat
  dehydration.

21
Rewarming Methods Fast

• Usually water based
• Baths
• Heated blankets
• Peritoneal dialysis
• Heart-lung machine

22
Rewarming Methods Slow

• Shivering
• Body-to-body contact
• Hot water bottles or warm rocks
• Chemical heating pads
• O2 heater
• Stoves or fires

23
Local Cold Injuries (1 of 3)
24
Local Cold Injuries (2 of 3)

• Frostnip
• Cold-induced superficial blood vessel
  constriction
• Immersion (trench) foot
• Prolonged exposure to cold water
• Frost bite
• Freezing of a body part, usually an extremity

25
Local Cold Injuries (3 of 3)

• Investigate any predisposing factors.
• The development of frostbite is progressive.
• It is difficult to predict the severity of injury
  and the patients outcome.

26
Frostbite

• The actual freezing of a body part
• The amount of damage depends on the extent and
  duration of freezing.
• The part will have a wooden or waxy appearance.
• Blisters often form with thawing.
• Gangrene is a complication in severe cases.

27
Assessment and Emergency Care of Frostbite

• Based on direct inspection and palpation
• For frostnip, provide direct body heat and seek
  shelter.
• Consider the possibility of hypothermia.
• Rewarm the part rapidly in a water bath.

28
Water Bath

• Water temperature should be between 102oF to
  108oF.
• Recheck water temperature and stir to circulate.
• Remove constricting bands rings, watches, etc.
• Keep body part in water for 20 to 30 minutes.
• Watch for tissue color change.
• Give warm drinks and advise of impending pain.

29
Wilderness and Frostbite

• Refreezing will lead to gangrene.
• Wrap in bulky dressings and leave blisters intact
  if possible.
• Patients can be evacuated after thawing, but
  guard against refreezing.
• Prevention is the best treatment!

30
Cold Exposure and You

• Rescuers are at risk for hypothermia when working
  in a cold environment.
• Stay aware of local weather conditions.
• Dress appropriately and be prepared.
• Never allow yourself to become a casualty!

31
High Altitude Illness (1 of 5)

• With ascent, the following changes occur
• Solar radiation increases.
• Temperature and humidity fall.
• PO2 and atmospheric pressure decrease.

32
High Altitude Illness (2 of 5)

• For every 1000 (309 m) of altitude gain
• Dry temperatures drop 3.5F (1.6C).
• The barometer drops 20 mm Hg.
• Ultraviolet radiation increases 5.
• Oxygen concentration remains constant at 21, but
  the PO2 drops.

33
High Altitude Illness (3 of 5)

• Rapid ascent produces acute and chronic effects.
• Acute effects are due to hypoxia.
• Chronic effects lead to circulatory, respiratory,
  and nervous system changes.

34
High Altitude Illness (4 of 5)

• Factors that influence the effects of altitude
  include
• Speed of ascent
• Final altitude attained
• Duration of exposure
• Exertion
• Type of travel foot, car, airplane
• The altitude at which one sleeps

35
High Altitude Illness (5 of 5)

• Types of illnesses
• Acute mountain sickness (AMS)
• High altitude cerebral edema (HACE)
• High altitude pulmonary edema (HAPE)

36
Acute Mountain Sickness (1 of 3)

• The most common high-altitude illness
• Reported in 20 of all snowsports guests at Rocky
  Mountain resorts
• Documented in Yellowstone National Park
• Caused by
• Failure to increase respirations
• Fluid retention
• Increased cerebral blood flow and inflammation

37
Acute Mountain Sickness (2 of 3)

• Signs and symptoms include
• Headache, worse at night or when bending over
• Apathy
• Insomnia
• Lightheadedness
• Loss of appetite, nausea, and vomiting
• Other generalized symptoms of malaise

38
Acute Mountain Sickness (3 of 3)

• Predisposing factors include
• Speed of ascent
• Overexertion
• Cold weather
• Youthfulness in adults
• Fitness does not seem to promote immunity.
• A brisk respiratory response seems to lessen
  susceptibility.

39
High Altitude Cerebral Edema

• Signs and symptoms include
• Similar to AMS, but more intense
• Ataxia, the inability to balance or walk
• Altered mental status progressing to
  unresponsiveness

40
High AltitudePulmonary Edema (1 of 3)

• 10X more frequent than HACE
• Researched extensively in the Himalayas, Canada,
  and Alaska
• Hypoxia-induced changes lead to
• Increased pulmonary arterial pressure
• Capillary wall damage
• Opening of high pressure shunts
• Increased fluid in alveoli

41
High Altitude Pulmonary Edema (2 of 3)

• Early signs and symptoms include
• Dry, nighttime cough
• Increasing dyspnea
• Mild chest pain
• A decrease in the ability to exercise

42
High Altitude Pulmonary Edema (3 of 3)

• Late signs and symptoms include
• Cyanosis
• Cough that produces pink frothy sputum
• Tachycardia and tachypnea at rest
• Loud, wet rales
• Severe dyspnea

43
Assessment of High Altitude Illness

• Scene size-up, consider setting
• Initial assessment, especially respiratory rate
  and rhythm
• Complete SAMPLE history
• Assess lung sounds, the ability to walk, and
  balance.

44
Emergency Care of High Altitude Illness (1 of 2)

• Skiing, trekking, and climbing parties
• Rapid descent for HACE and HAPE patients
• Preferably 2,000 (610 m)
• O2 (1 to 2 L/min), if available
• Rest, without further ascent, may resolve mild
  AMS.
• Aspirin or ibuprofen for headache (HA)
• Gamow bag

45
Emergency Care of High Altitude Illness (2 of 2)

• High altitude resorts
• Rapid access to medical treatment
• High-flow oxygen
• May require immediate descent
• Rest, mild diet, and abstinence may resolve mild
  AMS.
• Prescriptions can help acutely and
  prophylactically

46
Sunburn, Windburn, and Snowblindness

• Altitude, snow, and bodies of water increase
  risk.
• Clouds do not offer protection.
• Sunburn is a 1 or 2 burn cause by ultraviolet
  light
• UVA at 290 320 nanometers
• UVB at 320 400 nanometers

47
Sunburn

• Repeated exposures can lead to
• Wrinkling, darkening, and thickening of skin
• Benign and malignant cancers
• Actinic keratoses, basal and squamous cell
  carcinomas
• Malignant melanoma

48
Types of Sunscreen

• Physical
• Blocks the sunlight mechanically
• Zinc oxide, titanium dioxide, red petrolatum
• Chemical
• Chemicals filter rays
• UVA- Parsol, anthranilates, oxybensone
• UVB- salicylates, cinnamates, PABA, Padimate

49
Sunscreen

• Sun protection factor (SPF), 2 to 50
• Number refers to how much longer a person can be
  safely exposed.
• SPF 15 is the practical minimum SPF 30 is the
  practical maximum.
• Apply early and often. Thicker preparations can
  prevent windburn as well.
• Treat burn patients with cool compresses and
  later with lotion and aloe.
• Extensive/blistered burns need physician care.

50
Snowblindness

• A burn of the conjunctiva caused by UV radiation
• Can be prevented by wearing sunglasses or goggles
  
• Symptoms develop 6 to 12 hours after exposure.

51
Snowblindness Signs and Symptoms

• Sand in the eye irritation
• Pain with eye motion
• Tearing
• Light sensitivity
• Swelling around the eye

52
Snowblindness Treatment

• Remove to darker surroundings
• Cover both eyes
• Apply cool compresses.
• Nonprescription pain relievers
• Prescription medications in severe cases

53
Body Temperature

• Normal body temperature is 98.6ºF.
• Body attempts to maintain normal temperature
  despite ambient temperature.
• Body cools itself by sweating (evaporation) and
  dilation of blood vessels.
• High temperature and humidity decrease
  effectiveness of cooling mechanisms.

54
Hyperthermia (1 of 2)

• Core temperature gt 101F (38F)
• Cooling mechanisms become overwhelmed and the
  body is unable to cope.
• Illnesses can develop when
• Air temp is high
• Humidity is high
• Dehydration curtails the ability to sweat

55
Hyperthermia (2 of 2)

• Predisposing risk factors include
• Extremes of age
• Poor thermoregulation
• Heart disease, COPD, diabetes, and obesity
• Limited mobility
• Drug and alcohol abuse

56
Heat Cramps

• Painful muscle spasms
• Remove the patient from hot environment.
• Rest the cramping muscle.
• Replace fluids by mouth.
• If cramps persist, arrange for transport to
  hospital.

57
Heat Exhaustion

• Onset while working hard or exercising in hot
  environment
• In elderly and young, onset may occur while at
  rest in hot, humid, and poorly ventilated areas.
• Signs and symptoms
• Cold, clammy skin
• Dry tongue and thirst

58
Heat Exhaustion Signs and Symptoms

• Normal vital signs, but pulse can increase and
  blood pressure can decrease.
• Dizziness, weakness, or fainting
• Normal or slightly elevated body temperature

59
Emergency Care for Heat Exhaustion

• Remove extra clothing, remove patient from hot
  environment.
• Give patient oxygen.
• Have patient lie down and elevate legs.
• If patient is alert, give water or diluted
  electrolyte solution slowly.
• Be prepared to transport.

60
Heatstroke

• Signs and symptoms
• Hot, dry, flushed skin
• Change in behavior leading to unresponsiveness
• Pulse rate is rapid, then slows.
• Blood pressure drops.
• Death can occur if the patient is not treated.

61
Emergency Care for Heatstroke (1 of 2)

• Move patient out of the hot environment.
• Remove the patients clothing.
• Administer oxygen.
• Apply cold packs to the patients neck, armpits,
  and groin.

62
Emergency Care for Heatstroke (2 of 2)

• Cover the patient with wet towels or sheets.
• Aggressively fan the patient.
• Immediately transport patient.
• Notify hospital of patients condition.

63
Lightning and Electrical Injury

• Significant hazard
• 1,000 deaths annually
• 100 to 200 due to lightning
• Power transmission lines are widespread.
• Outdoor activities in the spring and summer
  increase the risk of lightning strike.

64
Electrical Injury (1 of 2)

• Insult to respiratory centers that lead to
  respiratory arrest
• Cardiac arrest
• AC current V-fib
• DC current asystole
• Severe burns to skin, muscle, bone, and organs
• Can produce large and devastating burns

65
Electrical Injury (2 of 2)

• Direct injury to nerves that lead to pain,
  paralysis, blindness, deafness, and loss of
  speech
• Kidney overload and injury due to toxic
  concentrations of waste
• Falls due to loss of balance or muscle
  contractions

66
Lightning Injury

• Lightning is usually associated with cumulonimbus
  clouds (thunderheads).
• Can occur during snowstorm
• 30 fatality rate with strikes
• Victims may display a characteristic burn pattern
  that is fern shaped.
• Can be direct strike or by conducted current

67
Emergency Care for Electrical Injury (1 of 3)

• Rescue may require special training and
  equipment protect yourself.
• Remove the victim from the electrical source.
• Those trapped in vehicles will need to jump clear
  to avoid being grounded.

68
Emergency Care for Electrical Injury (2 of 3)

• Dont touch victims until live wires are clear.
• Start CPR immediately in the case of cardiac
  arrest.
• During triage, these patient (electrical injury)
  should be cared for first.

69
Emergency Care for Electrical Injury (3 of 3)

• Be prepared for burns, fractures, multiple
  trauma, neck, and spinal injuries.
• Provide high-flow oxygen.
• Pulses may return, but patients may require
  lengthy respiratory support.
• Provide assessment, stabilization, and evacuation
  consistent with trauma care.

70
Prevention of Electrical Injury(1 of 2)

• Conductors transmit electricity and insulators
  resist electrical flow.
• Electricity follows the path of least resistance.
  
• Urban injuries usually involve appliances or
  accidental contact with power lines.

71
Prevention of Electrical Injury(2 of 2)

• Avoid areas prone to lightning strike
• Bodies of water
• Ridges, high points, and lone trees
• Telephones and appliances
• Small caves or wide open spaces
• Large metal structures
• Count seconds between lightning and thunder and
  divide by 5 the result is distance in miles.

72
Drowning and Near Drowning

• Drowning
• Death as a result of suffocation after submersion
  in water
• Near drowning
• Survival, at least temporarily, after suffocation
  in water

73
Drowning Process (1 of 2)
74
Drowning Process (2 of 2)

• Small amounts of water can cause laryngospasm.
• This may inhibit rescue breathing.
• Hypoxia leads to unresponsiveness.
• 85 to 90 involve significant amount of water in
  the victims lungs.

75
Emergency Medical Care

• Begin rescue breathing as soon as possible.
• Maintain cervical spine stabilization.
• If air does not enter the patients lungs, treat
  for obstructed airway.
• Check pulse and start CPR if needed.
• Keep patient warm and transport.

76
Spinal Injuries in Submersion Incidents

• Suspect spinal injury if
• Submersion has resulted from a diving mishap or
  long fall.
• Patient is unresponsive.
• Patient complains of weakness, paralysis, or
  numbness.

77
Water Rescuer Safety

• Protect yourself!
• Reach, throw, row, and only than go
• Wear a personal flotation device (pfd).
• Guard against hypothermia.
• When working on or near water, develop a
  pre-arranged rescue plan.

78
Spinal Stabilization in Water

• Turn the patient supine.
• Restore the airway and begin ventilations.
• Secure a backboard under the patient.
• Remove the patient from the water.
• Cover the patient with a blanket.

79
Resuscitation Efforts

• Hypothermia can protect vital organs from
  hypoxia.
• Documented case of a survivor of a 66-minute cold
  water submersion
• Diving reflex may cause heart rate to slow.

80
Avalanche Injuries (1 of 2)

• Fatalities
• 80 - asphyxia
• 10 to 15 - trauma
• 5 - hypothermia
• 92 survival rate if uncovered within 15 minutes
• By 35 minutes, only 30 survive.

81
Avalanche Injuries (2 of 2)

• Best chance of survival is by companion rescue.
• Most victims are backcountry skiers,
  snowboarders, climbers, and snowmobile riders.
• Backcountry users should be trained and carry
• Shovel
• Avalanche probe
• Avalanche transceiver

82
Emergency Care for Avalanche Victims

• Uncover head and chest quickly and carefully.
• Treat for hypothermia.
• Provide high-flow oxygen.
• Assess and treat for trauma.

83
Ice Rescue

• Is very hazardous
• Cold water can incapacitate victims quickly.
• Use personal flotation devices (pfd).
• Use ladders or objects to distribute weight.
• Self-rescue with sharp tipped objects or by
  rolling
• Remove skis or snowboard.
• Assess and treat hypothermia.

84
Diving Problems

• Descent problems
• Usually due to the sudden increase in pressure on
  the body as the person dives
• Bottom problems
• Not commonly seen
• Ascent problems
• Air embolism and decompression sickness

85
Signs and Symptoms of Air Embolism (1 of 2)

• Blotchy skin
• Froth at the mouth and nose
• Severe pain in muscle, joints, or abdomen
• Dyspnea and/or chest pain

86
Signs and Symptoms of Air Embolism (2 of 2)

• Dizziness, nausea, and vomiting
• Dysphasia
• Difficulty with vision
• Paralysis and/or coma
• Irregular pulse or cardiac arrest

87
Decompression Sickness (The Bends)

• Occurs when bubbles of gas obstruct blood vessels
• Can result from rapid ascent
• Most common symptom is abdominal and/or joint
  pain.
• Symptoms may develop after several hours.

88
Caring for Air Embolism and Decompression Sickness

• Remove the patient from the water.
• Keep patient calm.
• Begin BLS and administer oxygen.
• Place the patient in the left lateral recumbent
  position with his or her head down.
• Provide prompt transport to hyperbaric chamber.

89
Other Water Hazards

• Hypothermia from water immersion.
• Breath-holding syncope
• Swimmers ear
• Injuries from recreational equipment or marine
  animals