1. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DOT National Standard EMT-Intermediate/85 Refresher DOT National Standard EMT-Intermediate/85 Refresher Welcome!

2. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease

3. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES FROSTBITE Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx

4. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective Frostbite: –1st degree –2nd degree –3rd degree –4th degree Frostbite: –1st degree –2nd degree –3rd degree –4th degree

5. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective Groups at high risk for frostbite include military personnel, outdoor workers, the elderly, the homeless, people who abuse drugs including alcohol & those with psychiatric disorders

6. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training perspective The areas most commonly affected by frostbite are –head (31% to 39.1% of cases) –hands (20% to 27.9%) –feet (15% to 24.9%) The areas most commonly affected by frostbite are –head (31% to 39.1% of cases) –hands (20% to 27.9%) –feet (15% to 24.9%)

7. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training epidemiology US –Most cases of frostbite are mild (frostnip) –12% of cases more severe US –Most cases of frostbite are mild (frostnip) –12% of cases more severe

8. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology Several mechanisms have been proposed to explain the pathophysiology of freezing injuries –Freezing alone is usu. not sufficient to cause tissue death –Depth of tissue freezing depends on Temperature, duration of exposure, velocity of freezing Several mechanisms have been proposed to explain the pathophysiology of freezing injuries –Freezing alone is usu. not sufficient to cause tissue death –Depth of tissue freezing depends on Temperature, duration of exposure, velocity of freezing

9. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training pathophysiology Immediately after freezing & thawing, an acid cascade forms & erythrostasis, which results in venule & arterial thrombosis –And subsequent ischemia, necrosis, dry gangrene Immediately after freezing & thawing, an acid cascade forms & erythrostasis, which results in venule & arterial thrombosis –And subsequent ischemia, necrosis, dry gangrene

10. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives First degree (frostnip) –Partial skin freezing –Erythema –Mild edema –Lack of blisters Pt complains of stinging & burning, followed by throbbing

11. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives Second degree injury –Full thickness skin freezing –Formation of substantial edema over 3-4 hours –Erythema –Formation of clear blisters filled with fluid –Pt c/o numbness followed later by aching and throbbing

12. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives Third degree injury –Damage that extends into subdural –Hemorrhage blisters form & are associated with skin necrosis & a gray-blue discoloration of the skin –Pt c/o: it feels like a “block of wood” which is followed later by burning, throbbing, & shooting pains

13. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives Fourth degree injury –Characterized by extension into subcutaneous tissue, muscle, bone, & tendon –Not much edema –Skin is mottled, w/ nonblanching cyanosis, & eventually forms a deep, dry, black, mummified eschar –Pt c/o deep, aching joint pain

14. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Scene Size Up ABCs & spinal immobilization Assessment: VS, trauma, circulation/sensation/function/skin of all extremities, nose, ears, duration, ambient temperature, PMH & meds If appropriate, GO TO PROTOCOL: Altered Mental Status/ALOC or Hypothermia Scene Size Up ABCs & spinal immobilization Assessment: VS, trauma, circulation/sensation/function/skin of all extremities, nose, ears, duration, ambient temperature, PMH & meds If appropriate, GO TO PROTOCOL: Altered Mental Status/ALOC or Hypothermia

15. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Protect: Prevent further heat loss & injury. Remove tight or wet clothing & jewelry Transport: Backup indicated if field re-warming is to be attempted IV: Saline lock if field re-warming to be attempted or analgesia required per PROCEDURE: IV Access & IV Fluid Administration Protect: Prevent further heat loss & injury. Remove tight or wet clothing & jewelry Transport: Backup indicated if field re-warming is to be attempted IV: Saline lock if field re-warming to be attempted or analgesia required per PROCEDURE: IV Access & IV Fluid Administration

16. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment PARKMEDIC BASE HOSPITAL/COMMUNICATION FAILURE ORDERS Rewarm: rarely performed in the field. Consider only if ALL of the following –Evacuation is not possible in <6-12 hours –Pt is not hypothermic –There is sufficient supply of warm water –There is no risk of re-freezing PARKMEDIC BASE HOSPITAL/COMMUNICATION FAILURE ORDERS Rewarm: rarely performed in the field. Consider only if ALL of the following –Evacuation is not possible in <6-12 hours –Pt is not hypothermic –There is sufficient supply of warm water –There is no risk of re-freezing

17. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Use 100.4-107.6 F water only. Use thermometer Provide analgesia is ALS available Immerse until skin is soft, pink, pliable & painful (Do NOT rub) After re-warming place gauze between toes & fingers, and dress Protect from further injury and refreezing if possible Pt should not walk on thawed feet Use 100.4-107.6 F water only. Use thermometer Provide analgesia is ALS available Immerse until skin is soft, pink, pliable & painful (Do NOT rub) After re-warming place gauze between toes & fingers, and dress Protect from further injury and refreezing if possible Pt should not walk on thawed feet

18. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Morphine –Adult: if severe pain, SBP >100, & normal mental status IM: 5mg (0.5ml) q 15 min PRN pain (max 20mg) IV: 4-10mg (0.4-1ml) SIVP q 15 min PRN pain (max 20mg) –Pediatric Base Hospital Order ONLY, NOT in communication failure IM: 0.2mg/kg (0.02ml/kg). Repeat in 15min x1 prn pain IV: 0.1mg/kg (0.01ml/kg). Repeat in 15 min x1 prn pain Morphine –Adult: if severe pain, SBP >100, & normal mental status IM: 5mg (0.5ml) q 15 min PRN pain (max 20mg) IV: 4-10mg (0.4-1ml) SIVP q 15 min PRN pain (max 20mg) –Pediatric Base Hospital Order ONLY, NOT in communication failure IM: 0.2mg/kg (0.02ml/kg). Repeat in 15min x1 prn pain IV: 0.1mg/kg (0.01ml/kg). Repeat in 15 min x1 prn pain

19. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Ondansetron –Adult: IV 4mg SIVP over 2-5 min, repeat in 15 min x 2 prn nausea IM: If no IV, give 8mg IM, repeat in 15min x1 prn nausea –3mos-14yrs: IV/IO: 0.1mg/kg (max 4mg) SIVP over 2-5min, repeat in 15min x 2 IM: If no IV, give 0.2mg/kg (max 8mg) IM, repeat in 15min x 1 prn nausea –0-3mos: IV/IO: Base Hospital Order ONLY. 0.1mg/kg SIVP IM: contraindicated for pts <3 months of age Ondansetron –Adult: IV 4mg SIVP over 2-5 min, repeat in 15 min x 2 prn nausea IM: If no IV, give 8mg IM, repeat in 15min x1 prn nausea –3mos-14yrs: IV/IO: 0.1mg/kg (max 4mg) SIVP over 2-5min, repeat in 15min x 2 IM: If no IV, give 0.2mg/kg (max 8mg) IM, repeat in 15min x 1 prn nausea –0-3mos: IV/IO: Base Hospital Order ONLY. 0.1mg/kg SIVP IM: contraindicated for pts <3 months of age

20. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Treatment Acetaminophen –>10-adult: 1,000mg PO q 4-6 hrs, not to exceed 4,000mg in 24 hr –0-10yrs: 20mg/kg PO q 4-6 hrs, not to exceed 4,000mg in 24 hr Ibuprofen –>10-Adult: 600mg PO q 6 hrs –6mos-10yrs: 5mg/kg PO (liquid or tablet) q 6 hours, max dose 200mg Acetaminophen –>10-adult: 1,000mg PO q 4-6 hrs, not to exceed 4,000mg in 24 hr –0-10yrs: 20mg/kg PO q 4-6 hrs, not to exceed 4,000mg in 24 hr Ibuprofen –>10-Adult: 600mg PO q 6 hrs –6mos-10yrs: 5mg/kg PO (liquid or tablet) q 6 hours, max dose 200mg

21. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Differential diagnosis Peripheral vascular disease Cellulitis Dermatitis Trauma to an extremity Compartment syndrome (mimic or co-exist) Peripheral vascular disease Cellulitis Dermatitis Trauma to an extremity Compartment syndrome (mimic or co-exist)

22. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx

23. ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Questions? References –Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. –Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. –Wolfson, Allan B. ed., Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010. References –Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. –Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. –Wolfson, Allan B. ed., Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.