Chapter 18

18: Environmental Emergencies

Cognitive Objectives

(1 of 2)

4-7.1 Describe the various ways that the body loses heat. 4-7.2 List the signs and symptoms of exposure to cold. 4-7.3 Explain the steps in providing emergency medical care to a patient exposed to cold. 4-7.4 List the signs and symptoms of exposure to heat. 4-7.5 Explain the steps in providing emergency care to a patient exposed to heat.

Cognitive Objectives (2 of 2) 4-7.6 Recognize the signs and symptoms of waterrelated emergencies. 4-7.7 Describe the complications of near drowning. 4-7.8 Discuss the emergency medical care of bites and stings. • There are no affective objectives for this chapter.

Psychomotor Objectives 4-7.9

Demonstrate the assessment and emergency medical care of a patient with exposure to cold. 4-7.10 Demonstrate the assessment and emergency medical care of a patient with exposure to heat. 4-7.11 Demonstrate the assessment and emergency medical care of a neardrowning patient. 4-7.12 Demonstrate completing a prehospital care report for patients with environmental emergencies.

Factors Affecting Exposure • • • •

Physical condition Age Nutrition and hydration Environmental conditions

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

Loss of Body Heat (2 of 2) • Rate and amount of heat gain or loss can be modified in three ways: – Increase or decrease heat production. – Move to sheltered area where heat loss is increased or decreased. – Wear insulated clothing.

Hypothermia • Lowering of the body temperature below 95°F (35°C) • Weather does not have to be below freezing for hypothermia to occur. • Older persons and infants are at higher risk. • People with other illnesses and injuries are susceptible to hypothermia.

Signs and Symptoms of Mild Hypothermia • Shivering • Rapid pulse and respirations • Red, pale, cyanotic skin

Signs and Symptoms of More Severe Hypothermia • Shivering stops. • Muscular activity decreases. • Fine muscle activity ceases. • Eventually, all muscle activity stops.

Core Temperature Less Than 80°F • Patient may appear dead (or in a coma). • Never assume that a cold, pulseless patient is dead.

Scene Size-up

• Note weather conditions. • Identify safety hazards such as icy roads, mud, or wet grass.

Initial Assessment

• Check temperature on patient’s abdomen. • Mental status can be affected. • Ensure adequate airway. • Warmed, humidified oxygen helps warm from inside out. • Palpate for carotid pulse; wait 30–45 seconds. • Transport immediately or move to warmer location.

Focused History and Physical Exam

• If unconscious, do a rapid physical exam. • If conscious, attempt to obtain SAMPLE history. – Determine how long the patient was exposed to the cold. – Medications can affect the patient’s metabolism. • Focused physical exam – Concentrate on areas of body directly affected by exposure.

Baseline Vital Signs • Can be altered by hypothermia • Monitor for changes in mental status. • Check for core body temperature.

Interventions • Move from cold environment. • Do not allow patient to walk, eat, use any stimulants, or smoke or chew tobacco. • Remove wet clothing. • Place dry blankets under and over patient. • Handle gently. • Do not massage extremities. • Give warm, humidified oxygen.

Detailed Physical Exam

• Aimed at determining degree and extent of cold injury • Evaluate skin temperature, texture, and turgor.

Ongoing Assessment

• Rewarming can be harmful; monitor carefully. • Communicate conditions at scene, clothing, changes in mental status.

Local Cold Injuries • Frostnip – Freezing of the skin but not the deeper surface • Immersion (trench) foot – Prolonged exposure to cold water • Frostbite – Freezing of a body part, usually an extremity

Emergency Care for Local Cold Injury • Remove the patient from further exposure to the cold. • Handle the injured part gently. • Administer oxygen. • Remove any wet or restrictive clothing. • Never rub the area. • Do not break blisters. • Transport.

Warm-Water Bath • Water temperature should be between 100-112oF. • Recheck water temperature and stir to circulate. • Keep body part in water until warm and sensation returns. • Dress with dry, sterile dressings.

Cold Exposure and You • EMT-Bs are at risk for hypothermia when working in a cold environment. • Stay aware of local weather conditions. • Dress appropriately and be prepared. • Vehicle must be properly equipped and maintained. • Never allow yourself to become a casualty!

Heat Exposure • Normal body temperature is 98.6°F. • 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.

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

Signs and Symptoms of Heat Exhaustion (1 of 2) • Dizziness, weakness, or fainting • Onset while working hard or exercising in hot environment • In older people and young, onset may occur while at rest in hot, humid, and poorly ventilated areas. • Cold, clammy skin

Signs and Symptoms of Heat Exhaustion (2 of 2) • Dry tongue and thirst • Patients usually have normal vital signs, but pulse can increase and blood pressure can decrease. • Normal or slightly elevated body temperature

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

Signs and Symptoms of Heatstroke • 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.

Care for Heat Stroke (1 of 2) • Move patient out of the hot environment. • Provide air conditioning at a high setting. • Remove the patient’s clothing. • Give the patient oxygen. • Apply cold packs to the patient’s neck, armpits, and groin.

Care for Heat Stroke (2 of 2) • Cover the patient with wet towels or sheets. • Aggressively fan the patient. • Immediately transport patient. • Notify the hospital of patient’s condition.

• You are dispatched to the Green Valley Mobile Home Park for a sick person. • An older woman found her husband on the couch not responding. • You note that it is very hot with no source of ventilation. You are the Provider

• The man is on the couch and conscious but disoriented. • Patent airway, breathing shallow at 22 breaths/min • Skin is red, hot, and dry. • What medical emergency could the patient be experiencing? You are the Provider (continued)

Scene Size-up

• Do environmental assessment. • Protect yourself from heat and biological hazards. • ALS may need to give IV fluids.

• Your partner applies high-flow oxygen via nonrebreathing mask; you call for ALS backup. • Rapid, thready pulse; low BP; sluggish pupils; temp 104°F • No signs of traumatic injury • You remove constricting clothing, jewelry. • You move patient into ambulance. • Is this patient a priority? You are the Provider (continued)

Initial Assessment

• The more altered the mental status, the more severe the exposure. • Keep airway patent. • Oxygen may decrease nausea. • Hot, dry, or moist skin may indicate elevated core temperature. • Treat for shock aggressively. • If any signs of heatstroke, transport immediately.

• You set A/C on high, remove patient’s clothing, apply cool packs. • Patient’s wife states that husband came in after working outside 2 hours. Complained he was hot and dizzy. • She made him a sandwich and went to the neighbor’s for a few minutes. You are the Provider (continued) (1 of 2)

• He has an allergy to milk and cats. • Takes Lasix twice a day and a medication for high BP. • Do you expect this patient’s blood pressure to be high? You are the Provider (continued) (2 of 2)

Focused History and Physical Exam

• Note activities/medications that may make patient susceptible to heat-related problems. • Determine exposure and activities prior to symptoms. • Assess for muscle cramps, confusion. • Examine for mental status, skin temperature, wetness.

Baseline Vital Signs • May be tachycardic or tachypneic • In heat exhaustion, patient may have normal skin temp; may also be cool and clammy. • In heat stroke, patient will have hot skin.

Interventions • • • • • •

Remove from hot environment. Give cool fluids by mouth. Cover with sheet and soak with cool water. Set A/C on high. Place ice packs on groin and axillae. Fan aggressively.

Detailed Physical Exam

• Pay attention to skin temperature, turgor, wetness. • Turgor = skin’s ability to resist deformity • In dehydration, skin will tent when pinched on back of hand. • Perform careful neurologic exam.

• ALS is 25 minutes away. • You choose to rendezvous. • En route, you: – Elevate the patient’s legs. – Cover patient with wet sheet. – Fan him. – Reassess. • What actions should you take during transport to the hospital?

You are the Provider (continued)

Ongoing Assessment

• • • •

Watch for deterioration. Reassess vital signs every 5 minutes. Do not cause shivering. Document weather conditions and activities prior to emergency.

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

Drowning Process

Spinal Injuries in Submersion Incidents • Suspect spinal injury if: – Submersion has resulted from a diving mishap or long fall. – Patient is unconscious. – Patient complains of weakness, paralysis, or numbness.

Spinal Stabilization in Water • Turn the patient supine. • Restore the airway and begin ventilation. • Secure a backboard under the patient. • Remove the patient from the water. • Cover the patient with a blanket.

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.

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

Signs and Symptoms of Air Embolism (1 of 2) • Blotching • Froth at the mouth and nose • Severe pain in muscle, joints, or abdomen • Dyspnea and/or chest pain

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

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 hours. • Treatment is BLS and hyperbaric chamber.

Scene Size-up

• Never drive through moving water; be cautious driving through still water. • Never attempt water rescue without proper training and equipment. • Consider trauma and spinal stabilization. • Check for additional patients.

Initial Assessment

• Pay attention to chest pain, dyspnea, complaints of sensory changes. • Be suspicious of alcohol use. • Maintain airway; suction. • If pulse cannot be obtained, begin CPR per guidelines. • Evaluate for shock and adequate perfusion. • Treat trauma.

Transport Decision • Always transport near-drowning patients to hospital. • Decompression sickness and air embolism must be treated in recompression chamber. • Perform interventions en route.

Focused History and Physical Exam

• If responsive, perform exam on lungs and breath sounds. • If unresponsive: – Look for signs of trauma or complications. – Check divers for indications of air embolism or bends. – Focus on pain in joints and abdomen. – Check for signs of hypothermia; complete Glasgow Coma Scale score.

Baseline Vital Signs/ SAMPLE History • • • •

Check pulse rate, quality, rhythm. Check peripheral, central pulses. Check for pupil size, reactivity. Determine length of time patient was underwater or time of onset of symptoms. • Note physical activity, alcohol/drug use, other medical conditions. • Determine dive parameters in history depth, time, previous dive activity.

Drowning Interventions • Begin artificial ventilations as soon as possible. • Stabilize and protect spine. • Maintain patent airway. If there is no spinal injury, turn patient on side to allow draining from upper airway. • Make sure patient is warm, especially after coldwater immersion.

Diving Interventions • Remove patient from water. • Begin BLS; administer oxygen. • Place patient in left lateral recumbent position with head down. • Provide prompt transport to nearest recompression facility. • Administer oxygen and provide rapid transport.

Detailed Physical Exam

• Examine respiratory, circulatory, neurologic systems. • Distal circulatory, sensory, and motor function tests determine extent of injury. • Examine for peripheral pulses, skin color, and discoloration, itching, pain, numbness/tingling.

Ongoing Assessment

• May deteriorate rapidly • Assess mental status frequently. • Document: – Circumstances of drowning and extrication – Time submerged – Temperature of water – Clarity of water – Possible spinal injury • Bring dive log, dive computer, and dive equipment to hospital.

Other Water Hazards • Hypothermia from water immersion • Breath-holding syncope • Injuries from recreational equipment or marine animals

Prevention • Pools should be surrounded with appropriate enclosures. • Alcohol involved in adult and teenage drownings.

Lightning • • •

Strikes boaters, swimmers, golfers, anyone in large, open area Cardiac arrest and tissue damage are common. Three categories of lightning injuries 1. Mild: Loss of consciousness, amnesia, tingling, superficial burns 2. Moderate: Seizures, respiratory arrest, asystole (spontaneously resolves), superficial burns 3. Severe: Cardiopulmonary arrest

Emergency Medical Care • Protect yourself. • Move patient to sheltered area or stay close to ground. • Use reverse triage. • Treat as for other electrical injuries. • Transport to nearest facility.

Spider Bites • Spiders are numerous and widespread in the US. • Many species of spiders bite. • Only the female black widow spider and the brown recluse spider deliver serious, even life-threatening bites. • Your safety is of paramount importance.

Black Widow Spider • Found in all states except Alaska • Black with bright red-orange marking in hourglass shape on abdomen • Venom poisonous to nerve tissue • Requires patient transport as soon as possible

Brown Recluse Spider • Mostly in southern and central US • Short-haired body has violin-shaped mark, brown to yellow in color, on its back. • Venom causes local tissue damage. • Area becomes swollen and tender, with pale, mottled, cyanotic center. • Requires patient transport as soon as possible.

Snake Bites • 40,000 to 50,000 reported snake bites in the US annually. • 7,000 bites in the US come from poisonous snakes. – Death from snake bites is rare. – About 15 deaths occur each year in the US.

Four Types of Poisonous Snakes in the US

Rattlesnake

Copperhead

Cottonmouth

Coral snake

Pit Vipers • Rattlesnakes, copperheads, and cotton mouths • Store poison in pits behind nostrils • Inject poison to victim through fangs

Signs and Symptoms of a Pit Viper Bite • • • •

Severe burning at the bite site Swelling and bluish discoloration Bleeding at various distant sites Other signs may or may not include: – Weakness – Fainting – Sweating – Shock

Care for Pit Viper Bites (1 of 2) • • • • • •

Calm the patient. Locate bite and cleanse the area. Do not apply ice. Splint area to minimize movement. Watch out for vomiting caused by anxiety. Do not give anything by mouth.

Care for Pit Viper Bites (2 of 2) • If the patient is bitten on the trunk, lay the patient supine and transport quickly. • Monitor patient’s vital signs. • Mark the swollen area with a pen. • Care for shock if signs and symptoms develop. • Bring the snake to hospital if it has been killed.

Coral Snakes • Small snake with red, yellow, and black bands • “Red on yellow will kill a fellow, red on black, venom will lack.” • Injects venom with teeth, using a chewing motion that leaves puncture wounds • Causes paralysis of the nervous system

Care for Coral Snake Bites (1 of 2) • Quiet and reassure the patient. • Flush the area with 1 to 2 quarts of warm, soapy water. • Do not apply ice. • Splint the extremity. • Check and monitor baseline vital signs.

Care for Coral Snake Bites (2 of 2) • Keep the patient warm and elevate the lower extremities to help prevent shock. • Give supplemental oxygen if needed. • Transport promptly. Give advance notice to hospital of coral snake bite. • Give the patient nothing by mouth.

Scorpion Stings • Venom gland and stinger found in the tail end. • Mostly found in southwestern US • With one exception, the Centruroides sculpturatus, most stings are only painful. • Provide BLS care and transport.

Tick Bites (1 of 3) • Ticks attach themselves to the skin. • Bite is not painful, but potential exposure to infecting organisms is dangerous. • Ticks commonly carry Rocky Mountain spotted fever or Lyme disease.

Tick Bites (2 of 3) • Rocky Mountain spotted fever develops 7 to 10 days after bite. • Symptoms include: – Nausea, vomiting – Headache – Weakness – Paralysis – Possible cardiorespiratory collapse

Tick Bites (3 of 3) • Lyme disease has now been reported in over 35 states. • Lyme disease symptoms may begin 3 days after the bite. • Symptoms include: – Target bull’s-eye pattern – Rash – Painful swelling of the joints

Caring for a Tick Bite • Do not attempt to suffocate or burn tick. • Use fine tweezers to grasp tick by the body and pull it straight out. • Cover the area with disinfectant and save the tick for identification. • Provide any necessary supportive emergency care and transport.

Injuries from Marine Animals • Coelenterates are responsible for more envenomations than any other marine life animal • Have stinging cells called nematocysts • Results in very painful, reddish lesions • Symptoms include headache, dizziness, muscle cramps, and fainting.

Care for Marine Stings • Limit further discharge by minimizing patient movement. • Inactivate nematocysts by applying alcohol. • Remove the remaining tentacles by scraping them off. • Provide transport to hospital.