1. BLS 2014: Environmental Emergencies

2.  This course addresses:  Cold and heat related emergencies  Water emergencies  Stings & bites  Anaphylaxis and use of the epi-pen  Toxic gases  Electric shock and lightning strike Introduction

3. Objectives  Identify the ways the body produces and loses heat.  Identify signs, symptoms, and emergency care of heat-related emergencies.  Identify signs, symptoms, and emergency care of cold-related emergencies.  Identify signs, symptoms, and emergency care of water-related emergencies  Identify signs, symptoms, and emergency care of bites and stings  Identify signs, symptoms, and emergency care of anaphylaxis and severe allergic reaction  Identify signs, symptoms, and emergency care of bites and stings  Identify signs, symptoms, and emergency care of toxic gas exposure  Identify signs, symptoms, and emergency care of electric shock and lightning strike

4. Heat Production and Loss

5. Heat Production  Three ways body can produce heat:  Metabolism  Shivering  Exercise

6. Metabolism  Metabolism  Conversion of food to energy  Activity of bodily functions (such as circulation, respiration and muscle tone)  Some substances broken down to create energy while other substances are synthesized into tissue building material

7. Shivering  Rapid contraction & expansion of muscle tissues  Shivering can produce 40 times more heat than baseline metabolism

8. Exercise  Produce heat through exercise  Happens as long as there is activity, fuel (for instance, glucose or fat), oxygen and water

9. Factors That Affect Heat Production  Many factors affect how well body can produce heat:  Core temperature  Medical conditions  Body fluid status (dehydration)  Drugs and chemicals

10. Factors That Affect Heat Production Core Temperature  Colder body – less able it to produce adequate heat through metabolism  Hypothermia greatly reduces body’s ability to produce heat  Cooling slows chemistry of body Medical Conditions  Cardiac disease decreases ability to compensate for heat stress  Endocrine diseases such as thyroid, adrenal & insulin deficiencies may contribute to hypothermia  Strokes can cause immobility with reduced muscular activity Temperature control centers of brain may be damaged

11. Factors That Affect Heat Production Body Fluid Status  Metabolism is not as efficient when the body is dehydrated  Dehydration is a common problem in hot environments. Drugs and Chemicals  Beta-blockers decrease cardiac output & peripheral vascular control mechanisms  Effect works to lower body temperature  Drugs such as cocaine and amphetamines may contribute to hyperthermia (heatstroke)  Mimic stimulation of sympathetic nervous system

12. Heat Loss  Four heat loss mechanisms are:  Conduction  Convection  Radiation  Evaporation Under normal conditions, heat loss mechanisms are balanced with heat production mechanisms

13. Conduction  Transfer process – heat moves between two touching objects (F rom warmer object to colder object)  Motion of molecules bumping into one another spreads heat  Molecules bump around like billiard balls on a billiards table  Major source of heat loss in case of cold-water immersion  Water conducts heat 25 times more quickly than air

14. Convection  As air warms, rises & cooler air replaces it  Cool air then is warmed  Example – blow on your food to cool it  Transfer of heat between body & air or water that surrounds it  Occurs when a gas or liquid carries heat away  Body’s heat energy is lost more rapidly in moving air or water  Example – rising warm air from earth’s surface

15. Radiation  Warm body releases energy without direct contact  Heat energy travels by bumping molecules (as in conduction)  Also travel through electromagnetic waves  Sun is best known example of heat transfer through radiation

16. Evaporation  Conversion of a liquid to a gas  Heat pan of water, energy applied to water will cause to evaporate  Requires a lot of heat  Takes a lot of energy to break water molecules apart & convert liquid to gas  Human body takes advantage of evaporation’s heat loss powers by sweating

17. Heat Illness

18. Heat Cramps  Heat cramps or muscle cramps result from uneven distribution of body fluids & salts  Muscle cramps from this condition can be mild to severe, involving the extremities or the abdomen  Cramps can be accompanied by:  Dizziness  Weakness  Nausea

19. Heat Exhaustion  Named for feeling of exhaustion people experience  Result of excessive heat & dehydration  Reduce circulating blood volume & increase peripheral pooling due to vasodilation  Cooling mechanisms of radiation & evaporation become inefficient due to loss of fluids :  Clinical findings associated with heat exhaustion include:  Dizziness, weakness and nausea  Rapid, weak pulse  Cool, clammy skin  Profuse sweating  Altered LOC

20. Heatstroke  Life-threatening emergency – occurs when body's heat- regulating ability fails  Happens when body is subjected to more heat than it can deal with & four heat loss mechanisms overwhelmed  Clinical findings of heatstroke include:  Altered LOC (confusion, disorientation, or unconsciousness)  Rapid, bounding pulse  Rapid, deep respirations  Hot, dry, flushed skin*  Dilated pupils  Seizures * Can be damp if rapid onset

21. Emergency Care for Heat-Related Emergencies  Reduce core temperature:  Remove or loosen clothing  Provide a cool environment  Apply cool packs  Request paramedics when ALS indicators are present  provide oxygen and/or ventilatory assistance  Position patient appropriately  Monitor vital signs  Patient responsive & not nauseated, consider giving water

22. Cooling Strategies  Provide a Cool Environment  As soon as time allows, move patient to back of air-conditioned aid car with the air conditioner running on maximum  Fan patient aggressively if staffing allows  Keep skin wet by applying cool water with a sponge or wet towel

23. Cooling Strategies  Remove Clothing  Loosen or remove clothing to promote efficient convention  Consider applying water with a sponge or wet towels on patient’s skin  If you apply water to skin to encourage evaporation, use room temperature water  Do not induce shivering

24. Cooling Strategies  Apply Cold Packs  Neck, groin & armpits  Hospitals generally have tools necessary to properly lower core temperature  Do not delay transport  Notify hospital early to allow ED staff time to prepare

25. Cold Exposure

26. Hypothermia  Cooling of core temperature below 98.6°F  Caused by loss of body heat or decreased heat production  Exposure to a cool environment  Immobile elderly person lying on a floor  Drowning victim & who has been submerged Hypothermia can occur rapidly in wet environments

27. Hypothermia Early recognition increases chances of survival Hypothermia StageSigns & Symptoms Mild Hypothermia 90-95°F  Alert, signs of fatigue & weakness  Poor circulation  Muscle stiffness Moderate Hypothermia 80-90°F  Confusion, lethargy  Weak pulse, dysrhythmias  Slow respirations Severe Hypothermia less than 80°F  Coma  Fixed and dilated pupils  Cardiac arrest

28. Frostbite Superficial Injury - Clinical Findings  Blanching of skin  Loss of feeling & sensation in injured area  Tingling sensation if re- warmed Deep Injury - Clinical Findings  White, waxy skin  Swelling and/or blisters  Skin can appear flushed with areas of purple & blanching or mottled & cyanotic

29. Emergency Care for Cold-Related Emergencies  Pre-hospital emergency care for a hypothermic patient is as follows:  Remove patient from cold environment  Protect from heat loss  Provide high-flow oxygen

30. Emergency Care for Hypothermia  Remove from Cold/Protect from Heat Loss  Move patient to aid car warmed to 80°F  Keep patient flat  Remove wet clothing  May need to protect from heat loss by insulating patient with blankets  Provide High Flow Oxygen  Provide high flow oxygen via BVM for a non- breathing patient

31. Hypothermic Cardiac Arrest  Hypothermic patient in cardiac arrest or with profound bradycardia, following guidelines apply:  If no pulse detected after 1 minute, begin CPR & apply AED  If breathing, assume there is cerebral perfusion, therefore NO CPR  If AED analysis yields a “shock indicated” follow cardiac arrest protocol  If pulse is present withhold CPR regardless of rate or BP

32. Emergency Care for Frostbite  Protect affected area from further injury  Remove constricting or wet clothing & jewelry  Cover with dry bulky dressing  Splint affected extremity, prevent use of extremity

33. Transport Times Over Two Hours  Do not re-warm frozen tissue unless transport time will exceed 2 hours & you are certain the thawed tissue will not refreeze  Obtain medical direction prior to initiating re- warming  Re-warming should be done with 100 – 105°F water  Do not use dry heat—it heats unevenly and can burn frozen tissue  Stop re-warming when tissue turns red-purple & becomes pliable

34. Water Related

35. Drowning and Near Drowning  Several things you should determine:  Length of submersion  Temperature of water  Depth of water  Drowning – death caused by hypoxia following submersion in water  Near drowning – submersion in water that does not result in death  Without oxygen, hypotension, bradycardia & cardiac arrest ensue

36. Length of Submersion  Include length of submersion in report to hospital staff May have to estimate based on bystander testimony & other indicators  Submersion is short duration (2 minutes or less), a short period of CPR likely will result in successful resuscitation  Significant number of near-drowning patients who look fine initially develop pulmonary edema several hours later  Non-cardiac related condition is called acute respiratory distress syndrome (ARDS).

37. Water Temperature  Submersion times greater than 10 minutes make successful resuscitation unlikely  High survival rates for cold water drowning's are a myth – there are rare cases of successful resuscitations after long submersions, but most long submersions do not survive, or survive with devastating neurologic outcomes.  Contrary to popular belief, children do not have better neurologic outcomes than adults

38. Depth of Water  Spinal injuries seen in many water-related accidents  Diving into shallow water common mechanism for head & spinal injury & subsequent drowning  Potential for a spinal injury, stabilize cervical spine while in the water, if possible  Other conditions associated with drowning:  Skeletal & soft tissue injuries  Drug or alcohol intoxication  Underlying medical conditions

39. Emergency Care for Drowning/Near Drowning  Management requires prompt basic life support & following measures:  Safely remove victim from the water  Stabilize c-spine and place patient on a backboard*  Follow resuscitation protocols for cardiac or pulmonary arrest  Administer oxygen and/or ventilatory assistance  Place in a supine position to avoid cerebral edema  Prepare suction and expect vomiting  Warm up the aid unit  Monitor vital signs *If spine injury is suspected or patient is unresponsive. If possible, initiate stabilization during removal from water.

40. Diving Emergencies  Use of compressed air in an underwater environment can be hazardous  In addition to drowning, common diving- related hazards include air embolism and decompression illness

41. Air Embolism  Air embolism – presence of gas bubbles in bloodstream that obstruct circulation  Occurs during ascent when pressure in lungs forces air

42. Air Embolism Signs:  Apnea (no breathing)  Frothy fluid from nose or mouth  Loss of consciousness  Partial weakness or paralysis  Seizures  Irregular pulse  Death Symptoms:  Dizziness  Confusion  Chest pain  Diminished sensation in parts of the body  Visual blurring

43. Decompression Sickness  Nitrogen in blood forms bubbles due to rapid ascent  Bubbles collect in tissues & interfere with blood flow  Significant history for all diving emergencies includes:  Number of dives in past 24 hours  Depth of dive  Length of time underwater  Problems encountered while diving  Significant medical history (including meds)

44. Decompression Sickness  Dive usually at depth of at least 33 feet  Less likely at depths <33 feet  Still can happen  Longer & deeper the dive, more nitrogen dissolves in blood  Dehydration, exertion & air travel within 12 hours after diving all increase the probability of DCI  Symptoms of DCI vary widely depending on where bubbles collect  Joint pain, abdominal pain, neurological symptoms & difficulty urinating are common  Diver who complains of feeling ill after diving should be evaluated for DCI  Symptoms can appear within a few minutes of surfacing or it may take hours

45. Treatment for Diving Injuries Definitive treatment for any significant diving emergency is recompression in a hyperbaric facility!  Emergency care  ABCs  High flow 100% oxygen  Place the patient in a position of comfort (“head down, feet up” is no longer recommended)  Request ALS intervention as needed  Gather information on:  Maximum depth dived  Time on the bottom  Time since reaching surface  Whether the dive was single or multiple dives were done.  If the patient is to be flown by helicopter then advise the crew that this is a decompression accident. This prepares the crew for low fly or cabin pressure alterations during flight.

46. Bites and Stings

47. Bites and stings  Animals of all types from dogs to bees may bite or sting to defend themselves or their young. Bites and stings can cause problems ranging from local tissue damage to systemic symptoms.

48. Mammal Bites and Scratches  Local tissue damage  Bleeding (can be significant depending on the size of the animal and patient, and location of the wound)  Puncture wounds increase the risk of infection  Remote risk of rabies (viral disease transmitted by saliva of infected mammals)  Emergency care  ABCs  Control bleeding, sterile dressing  Identify the animal (contain if possible)  Evaluation at ER or clinic for possible antibiotics

49. Snake Bites  Snakes bite if threatened or to obtain food (typically small mammals)  Only a small percentage of snakes in the US are poisonous  Even poisonous snakes often bite without envenomation  Sometimes people keep poisonous snakes as pets  Alcohol use is a significant factor in many snakebites  Signs and symptoms range from local tissue damage to systemic effects, and vary depending on the type of snake  Zoos are excellent sources of information about snakebites and often stock antivenom

50. Snake Bites Emergency care  Non-poisonous snake: wound care  Poisonous snake:  ABCs  Request ALS if indicated  Constricting bands, suction of bite are no longer recommended  Remove jewelry from affected limb before swelling begins, if possible  Bandage and immobilize site of injury

51. Invertebrate Stings and Bites  Include bees and wasp stings, spider bites, and stings of marine animals such as urchins  Reactions can include tissue irritation, local allergic reaction, anaphylaxis, or systemic symptoms  If possible, identify the type of animal responsible for the bite/sting

52. Stings and Bites  Insects & spiders inject a poison when they bite or sting  Two types of spiders deliver life- threatening bites: brown recluse & female black widow Brown recluseBlack widow

53. Stings and Bites  Many marine animals, such as sharks or urchins, have spines that contain proteins that can cause a local reaction and, occasionally, an anaphylactic reaction  Some tropical species (e.g., the Lionfish) found in aquariums can cause envenomation.

54. Emergency Care for Invertebrate Bites and Stings  Request ALS if indicated  Scrape the sting site to remove the stinger  Wash the area  Remove jewelry from affected limb before swelling begins, if possible  Bandage and immobilize site of injury  If there are signs and symptoms of anaphylaxis or severe allergic reaction, administer epinephrine via EpiPen if indicated

55. Anaphylaxis/Severe Allergic Reaction  Exaggerated response of the body to a foreign protein (for example, the venom in a bee sting or peanuts)  Caused by an overproduction of histamine  Too much histamine causes:  Vasodilitation, resulting in hypotension  Bronchoconstriction, resulting in dyspnea  GI distress, including diarrhea and abdominal pain  There may also be local or generalized swelling and widespread urticaria (hives)

56. Emergency Care for Anaphylaxis  ABCs  Request ALS  Oxygen  Trendelenberg if patient is hypotensive  Administer epinephrine via EpiPen

57. Epi-pen Administration Injection Procedure for the Epi-Pen or epi-pen jr: 1.Check medication date and that the EpiPen dose matches with the patient’s size. 2.Remove the patient’s clothing and prep the thigh with an alcohol pad. 3.Remove safety cap and locate injection site on lateral thigh. 4.Place the black tip of the injector against the patient’s thigh and push hard until it activates. 5.Hold it in place for 10 seconds, and document the time of injection. 6.Remove the injector and place it in a sharps container. Massage the injection site for 10 seconds. 7.Reassure the patient and monitor for response and side effects to the injection. 8.Continue to provide oxygen. Ventilate the patient if necessary. 9.Monitor and document patient vitals every 5 minutes. 10.Update incoming medics on patient status and response to the injection.

58. Toxic Gases

59. Toxic Gas Poisoning  Scene safety is of paramount importance  Determine type of exposure and length of time exposed  Consider toxic gas if multiple people are affected  Carbon monoxide is the most common toxic gas  unvented burning of fuel in the winter (particularly during power outages as people try to stay warm)  smoke inhalation from house fires  suicide  Be aware of possible toxic gas in tunnels, silos, and other unvented locations  If large numbers of people are affected and circumstances are suspicious, be alert to the possibility of terrorism

60. Toxic Gases Carbon monoxide (CO)  Odorless, colorless gas  Found in products of combustion, such as those produced by cars and trucks, small engines, stoves, burning charcoal, wood, gas ranges and heating systems.  Can build up in enclosed spaces  Can also occur in structure fires  Binds to the hemoglobin of red blood cells, impairing oxygen carrying capacity  Half-life of CO in the blood:  Room air: 240-360 minutes  O2 (100%): 80 minutes  Hyperbaric (high pressure) O2: 22 minutes

61. Toxic Gases Cyanide (CN)  Toxic compound often in the form of a gas (hydrogen cyanide)  Can be formed in the burning of plastics and other materials (for example in house fires)  Rare cases of industrial exposure, suicide, or poisoning  Cellular poison

62. Nerve Agents Nerve agents (organophosphates)  Used in agriculture as insecticides (examples include parathion, diazinon)  Can be absorbed through skin or lungs, or ingested  Since WWII, have been used for chemical warfare  More recently have been used by terrorists (sarin release in Tokyo subway)  Occasional cases of suicide by ingesting organophosphate pesticides  Alters the transmission of nerve impulses by affecting neurotransmitters throughout the body

63. Other Toxic Gases Other toxic gases  Methane, nitrogen dioxide may be formed in sewers, silos, and other enclosed spaces  Chlorine, phosgene, and others may be released by industrial accidents  Presentation varies depending on type of gas; scene safety and ABCs are always indicated

64. Emergency care  Ensure scene safety, remove the patient from the exposed area  ABCs, vitals  Request ALS if indicated  High flow oxygen  Depending on the scenario, be prepared for multiple patients (notify other responders, hospitals as soon as possible) Possible CN:  ALS may be able to administer a cyanide antidote Possible nerve agent:  Be prepared with suction for massive secretions, vomiting, etc.  ALS may be able to administer a nerve agent antidote Possible CO:  If a CO monitoring is available, obtain a reading from the structure or source, and the patient  Pulse oximeter readings are not reliable in CO poisoning!  Consider transport destination (the patient may benefit from hyperbaric oxygen)

65. Electrical Emergencies

66. Electric Shock  Smaller doses of current (70–700 mA) trigger ventricular fibrillation.  Larger doses of current ( >1amp) cause burns, tissue, cell damage.  Type of current (DC vs. AC), current pathway, and duration of current also influence the severity of injury:  AC current generally causes more damage due to tetanic stimulation and prolonged duration of exposure.  DC current is typically shorter duration, creating a single muscle spasm causing the victim to be thrown from the source.

67. Emergency Care  Scene safety  Do not touch any downed or active power lines, or anything the power lines may be in contact with.  Wear appropriate PPE  Be aware of marked danger zones  Remove the patient to a place of safety, once given the OK by qualified personnel.  ABCs  Provide full spinal stabilization  Look for two burn sites: an entrance and exit site, these may be in unpredictable locations, for example in one hand, out the other; in one hand, out the bottom of the foot, etc.  External wounds do NOT reflect the extent of injury  Electricity can travel through blood vessels, muscle, bone, doing damage as it goes

68. Lightning  Responsible for approximately 50 deaths per year in the US  Estimates of several thousand injuries per year  Lightning safety  Seek shelter indoors or in a car  If trapped outdoors, avoid open fields, water, or metal objects  If indoors, stay off corded phones, don’t touch metal/plumbing  Cardiac arrest may occur; survival rates are high if resuscitation is started promptly  Major burns are uncommon  Patients may suffer long-term neurologic affects

69. Emergency Care  Evacuate to a safe indoor location if lightning is still in the area (30 min since last lightning strike is standard)  If trauma (fall, thrown a distance, etc.), provide spinal immobilization  ABCs and vitals  Request ALS  Defib protocols if patient is in cardiac arrest  Cover burns, if any, with sterile dressing

70. Electrocution Don’t go near downed power line Entrance Wound - Dark spot in center of wound Exit Wound – where body closest to ground

71. Summary: Heat and Cold Exposure  Heat cramps, heat exhaustion, & heatstroke are progressive phases of heat illness managed in the field by addressing dehydration and reducing core temperature  Four mechanisms cause heat loss: conduction, convection, radiation, & evaporation  Steps for prehospital emergency care for a hypothermic patient include: remove patient from cold environment, protect patient from heat loss, and provide oxygen

72. Summary: Water-Related Emergencies  For drowning patients, safely remove from water, stabilize c-spine if indicated, and follow general resuscitation guidelines  Extended submersion time has a poor overall outcome  For diving emergencies, gather significant history including depth of dive and length of time underwater  Treat with high flow oxygen and ALS as indicated  Definitive treatment for any significant diving emergency is recompression in a hyperbaric chamber

73. Summary: Bites and Stings  Control bleeding, identify animal, evaluate at ER of clinic  For bee stings, remove stinger, request ALS if indicated, consider epi-pen  Hypotension, respiratory distress, widespread hives  Epi-pen administration request an ALS eval

74. Summary: Toxic Gases  Scene safety!  Determine type of exposure  Carbon monoxide is the most common (unvented burning of fuel, smoke inhalation from fires, etc.)  Also consider cyanide, organophosphates, others  Treatment: scene safety, high flow oxygen, ALS as indicated

75. Summary: Electrical Injuries  Electric shock can cause burns, tissue damage, and cardiac arrhythmias (particularly VF)  Lightning strike may also cause cardiac arrest  External wounds (burns) do not represent the extent of the internal damage  Treat with normal defib protocols after ensuring that the scene is safe