1. CHAPTER 22 Environmental Emergencies

2. Temperature Regulation

3. The body tries to balance heat loss and heat gain to maintain normal temperature.

4. Exposure to Cold

5. If heat loss exceeds heat gain, hypothermia (low body temperature) occurs.

6. The body loses heat in 5 ways: Conduction Convection Radiation Evaporation Respiration Heat Loss

7. Heat Loss from Conduction

8. Heat Loss from Convection

9. Heat Loss from Radiation

10. Heat Loss from Evaporation

11. Heat Loss from Respiration

12. Generalized Hypothermia Predisposing Factors Cold Environment Cold water immersion Cold air exposure

13. Age – Very Old Failing body systems Chronic illness Lack of exercise Certain medications Generalized Hypothermia Predisposing Factors

14. Age – Very Young Large skin surface area/less fat Little or no shivering Inability to put on or take off clothing Generalized Hypothermia Predisposing Factors

15. Generalized Hypothermia Medical Conditions Shock (hypoperfusion) Head/spinal cord injury Burns Generalized infection Diabetes and hypoglycemia Drugs and poisons Predisposing Factors

16. Signs & Symptoms of Hypothermia Shivering in mild cases (lack of, in more severe cases) Numbness Stiff or rigid posture Drowsiness/mental status changes Continued…

17. Breathing changes Rapid (early) Shallow, slow, absent (late) Blood pressure (low to absent) Poor motor function Signs & Symptoms of Hypothermia Continued…

18. Pulse changes Rapid (early) Slow, weak, irregular, absent (late) Muscle and joint stiffness Signs & Symptoms of Hypothermia Continued…

19. Skin Red (early) Pale Cyanotic Stiff/hard (late) Signs & Symptoms of Hypothermia

20. Stages of Hypothermia Core Body TemperatureSymptoms 99°F-96°F37.0°C-35.5°C Shivering. 95°F-91°F35.5°C-32.7°C Intense shivering, difficulty speaking. 90°F-86°F32.0°C-30.0°C Shivering decreases and is replaced by strong muscular rigidity. Muscle coordination is affected and erratic or jerky movements are produced. Thinking is less clear, general comprehension is dulled, possible total amnesia. Patient generally is able to maintain the appearance of psychological contact with surroundings. 85°F-81°F29.4°C-27.2°C Patient becomes irrational, loses contact with environment, and drifts into stuporous state. Muscular rigidity continues. Pulse and respirations are slow and cardiac. 80°F-87°F26.6°C-20.5°C Patient loses consciousness and does not respond to spoken words. Most reflexes cease to function. Heartbeat slows further before cardiac arrest occurs.

21. Passive vs. Active Rewarming Passive Allows body to rewarm itself. Remove wet clothing. Cover with blanket(s). Active Application of external heat sources to patient.

22. Emergency Care of Hypothermia Remove patient from environment and prevent further heat loss. Remove wet clothing and cover with blanket. Handle patient gently. Continued…

23. Emergency Care of Hypothermia Do not allow patient to walk or exert self. Give high-concentration oxygen (warmed and humidified). If apneic, check pulse 30-45 seconds before starting CPR. Continued…

24. Emergency Care of Hypothermia Do not allow patient to eat or drink stimulants. Do not massage extremities. Transport patient. Continued…

25. Emergency Care of Hypothermia If patient is responding appropriately, rewarm actively: Apply heat to groin, armpits, neck. Warm trunk first. Do not warm too quickly. Increase heat in ambulance. Warm bath if delayed transport. Continued…

26. Emergency Care of Hypothermia If patient unresponsive or responding inappropriately, rewarm passively: Open airway; provide high-concentration oxygen. Apply blankets. Increase heat in ambulance. Transport.

27. Predisposing Factors Usually occurs in extremities and exposed ears, nose, face Localized Cold Injuries

28. Clear boundary separates injured/ uninjured areas

29. Signs & Symptoms of Superficial (Early) Local Cold Injury Blanching of skin Loss of feeling in affected area Skin remains soft When rewarmed, area tingles

30. Emergency Care of Superficial (Early) Local Cold Injury Remove patient from environment. Protect area from further injury. Splint and cover extremity. Do not rub or massage. Do not re-expose to cold.

31. Signs & Symptoms of Deep (Late) Local Cold Injury Also known as frostbite White, waxy skin Firm or frozen on surface Swelling and blisters may occur Skin blotchy, mottled, or grayish yellow or blue

32. Local Cold Injury Local Cold Injury

33. Remove patient from environment. Protect area from further injury. Administer high-concentration oxygen. Transport. Emergency Care of Deep (Late) Local Cold Injury

34. Do not: Break blisters Rub or massage area Allow patient to walk on affected extremity Emergency Care of Deep (Late) Local Cold Injury

35. Active Rewarming of Frozen Parts Seldom recommended Perform only if: Transport extremely delayed AND Medical control orders it OR Protocols allow it Large potential to permanently injure frozen tissue

36. Fill container with 100-105°F water. Remove jewelry, bands, clothing. Completely immerse the frozen part. Maintain warm temperature until completely thawed. Active Rewarming of Frozen Parts

37. Immerse affected part in warm- water bath.

38. Remove when part no longer feels frozen and begins to turn red or blue. Dress area with dry, sterile dressings. Active Rewarming of Frozen Parts Continued…

39. Protect against refreezing. Expect complaint of severe pain. Reassess and transport. Active Rewarming of Frozen Parts

40. Frostbite A case study from “Facebbok”

41. This is 2 days post-injury, after the blisters were debrided (cut off). Foot is very swollen and mildly infected. I REALLY wish I would have taken a picture of the blisters, they were about an inch thick and covered the entire bottom of the foot, plus the toes.

42. This is 9 days. Note black tissue forming at edges of wound, and white areas near heel which are the 3rd degree burns. Also note the blisters on the toes which are more visible now. I think this is when it looked the worst.

43. Had to add this for the fun factor. Dog bite and frostbite together! This is also 9 days into healing. Eric is doing hyperbaric oxygen therapy 5 days/week at this point to keep infection away, reduce swelling, and speed healing.

44. 16 days post-injury. The rest of the toes have been debrided and the big toe is well on its way to healing. The more severely burned areas have turned black. The black area does not feel like a normal scab- it's sort of leathery. Done with hyperbarics.

45. 1 month post-inury. Medial areas have new pink skin and black areas are slowly receding. Lateral edge (near the outside edge of black tissue) is irritated and red, might be mildly infected since he d/c antibiotics last week. Note my little Shizzy dog in the background!

46. 5 weeks. You can see the black areas sloooooowly receding and being replaced first by the red granulation tissue, which is the immature skin cells, then eventually layers of pink normal skin build on top of that. The black area is starting to look drier and crispier (for lack of a better term). Hopefully that means that it's thinning out because viable skin underneath is pushing it out.

47. Close-up shot taken by Jacob at 5 wks.. It really does look like something that got left on the barbecue a bit too long.

48. 6 weeks and 2 days. Note the upper black section has been removed by Dr.... good granulation tissue underneath, hooray! Bottom black part is not doing much and Dr. said this week to re-think skin graft.

49. 7 weeks. Note how the black area at the bottom is starting to narrow and turn yellow at the sides, good! Since this was the most severe area, it's really encouraging to see it making progress on its own.

50. 7 weeks again, you can really see how much tissue has completely healed in this one. The whole pink area was burn.

51. 8 weeks. Wound care Dr. removed a lot of the black scabby stuff today- that is the yellow sloughy areas you see.

52. 8 weeks. Believe it or not, this is progress.

53. 8 wks. Yes, this is what you think it is. Eric got so attached to his scabs that he brought them home in a specimen cup. (the knife is for size comparison- we didn't do a home job)

54. 10 wks. Foot is inflamed and red because Eric decided he should walk on it for a day since he's going to have surgery anyway, right ? Wrong.... Yellow areas are fat, red is granulation tissue.

55. 10 wks- at this angle you can really see how much tissue has completely healed. The remaining tissue is progressing very slowly compared to the rest of the foot and the toes, since deeper layers of tissue were damaged.

56. This is the donor site on Eric's Thigh, it is 7 inches long. It looks shiny cause it's covered in a plastic bandage

57. wide shot of thigh

58. Foot is splinted for 1 week- surgeon will take it off next Monday and see if the graft is taking.

59. 6 days post-graft. Gauze pads were stapled TO the foot- how rude!! This is the gauze/staple-removing process.

60. Now removing about half of the staples that attach the graft to the foot. Other half will come out next week.

61. And here's the glorious graft, looking like a good graft should. Big fat sigh of relief.

62. Eric's very sexy leg. His skin started reacting to the adhesive and is all welted up around the donor site.

63. Extreme close-up of the extreme foot makeover. (for those of you who desire more detail) The criss-cross pattern is the skin- it gets run through a press-type machine that stamps it into the mesh pattern. This gives the skin the ability to drain out blood from underneath, increasin the chances of adhesion

64. 19 days post op- WE HAVE SKIN !! Note the area to the right (top of the wound) where it appears white. This is a thin layer of skin, hooray yippee!

65. 19 days post op again, heel area. The little islands of white puffy tissue are more skin!! The little red buds are granulation tissue which are the buds which skin cells will proliferate from. Black around the edges is normal- just dead skin where the surgery was cauterized.

66. 21 days. Started using an herbal wound salve and a wheatgrass juice spray extract directly on the wound the day before. The difference in the amount of pink skin is pretty amazing when you compare this to the previous picture 2 days ago.

67. 25 days. continue to use herbals and Eric has done 2 hyperbaric dives. There is now more mature pink epithelium than there is immature red granulation tissue, and the black dead skin around the edges of the wound is falling off.

68. 25 days. Look how much the really deep indented area has healed here compared to 4 days ago, and when you compare it to the photo at 19 days it's freakin amazing!

69. 31 days. Love that pretty pink skin.

70. 31 days. That deep area mid-foot is going to be the last to heal, it still has a bit of tissue to fill in.

71. 7 wks post-op. So close! The remaining areas are pretty shallow. Have follow up appt with the surgeon in 2 days to see if Eric can start bearing full weight on it again.

72. Eric's favorite hyperbaric chamber.

73. Fasten your seat belt...sorta looks like the beginning of Space Mountain