Environmental Emergencies Paramedic
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Transcript of Environmental Emergencies Paramedic
ObjectivesObjectives
Define “environmental emergency” and list the major Define “environmental emergency” and list the major types.types.
Identify risk factors most predisposing to environmental Identify risk factors most predisposing to environmental emergencies.emergencies.
Identify environmental factors that may cause illness or Identify environmental factors that may cause illness or exacerbate a preexisting illness and those that may exacerbate a preexisting illness and those that may complicate treatment or transport decisions.complicate treatment or transport decisions.
Describe the mechanism of normal body temperature Describe the mechanism of normal body temperature regulation and identify normal, critically high and regulation and identify normal, critically high and critically low body temperatures.critically low body temperatures.
Describe several methods of temperature monitoring.Describe several methods of temperature monitoring. Identify mechanisms by which the body loses and retains Identify mechanisms by which the body loses and retains
heat.heat.
ObjectivesObjectives
Discuss the pathophysiology, high risk groups, signs and Discuss the pathophysiology, high risk groups, signs and symptoms, and field treatment of the following:symptoms, and field treatment of the following:
Heat crampsHeat cramps Heat exhaustionHeat exhaustion Heat stroke (classic and exertional)Heat stroke (classic and exertional)
Define fever and discuss its pathophysiologic mechanism.Define fever and discuss its pathophysiologic mechanism. Identify the fundamental thermoregulatory difference between Identify the fundamental thermoregulatory difference between
fever and heatstroke and discuss how one may differentiate fever and heatstroke and discuss how one may differentiate between the two.between the two.
Discuss the pathophysiology, high risk groups, signs/symptoms, Discuss the pathophysiology, high risk groups, signs/symptoms, field treatment and prevention of the following:field treatment and prevention of the following:
FrostbiteFrostbite HypothermiaHypothermia SuperficialSuperficial MildMild DeepDeep SevereSevere
ObjectivesObjectives
Discuss the importance of attempting resuscitation in Discuss the importance of attempting resuscitation in a pulse less hypothermic patient.a pulse less hypothermic patient.
List factors that contribute to drowning.List factors that contribute to drowning. Differentiate between and describe the Differentiate between and describe the
pathophysiology, signs/symptoms and field treatment pathophysiology, signs/symptoms and field treatment of drowning and near-drowning.of drowning and near-drowning.
Differentiate between the effects of salt vs. fresh Differentiate between the effects of salt vs. fresh water on the lungs and circulatory system in drowning.water on the lungs and circulatory system in drowning.
Discuss the incidence of “wet” vs. “dry” drowning and Discuss the incidence of “wet” vs. “dry” drowning and the differences in their management.the differences in their management.
Describe the effects of cold water on drowning Describe the effects of cold water on drowning patients.patients.
ObjectivesObjectives
Define self-contained underwater breathing Define self-contained underwater breathing apparatus.apparatus.
Describe the pathophysiology, signs/symptoms Describe the pathophysiology, signs/symptoms and field treatment for the following diving and field treatment for the following diving emergencies:emergencies: Decompression illnessDecompression illness b.b. Air embolismAir embolism
Describe the function of the Divers Alert Network Describe the function of the Divers Alert Network (DAN) and how its members may aid in the (DAN) and how its members may aid in the management of diving related illnesses.management of diving related illnesses.
Describe the specific function and benefit of Describe the specific function and benefit of hyperbaric oxygen therapy for the management hyperbaric oxygen therapy for the management of diving accidents.of diving accidents.
ScenarioScenarioYou respond to an athletic field at 3:00 You respond to an athletic field at 3:00 p.m. for a “person down.” It is hot and p.m. for a “person down.” It is hot and humid. You know that the college football humid. You know that the college football team started practice this week. Your team started practice this week. Your patient is an unconscious 21-year-old, 230 patient is an unconscious 21-year-old, 230 pound male. His skin is wet and very hot. pound male. His skin is wet and very hot. Vital sign assessment reveals: BP 82/64 Vital sign assessment reveals: BP 82/64 mm Hg; HR 136/min; R 28/min. As you mm Hg; HR 136/min; R 28/min. As you administer oxygen, he has a grand mal administer oxygen, he has a grand mal seizure. seizure.
DiscussionDiscussion What factors point to a heat-What factors point to a heat-
related emergency on this call?related emergency on this call? What other emergencies should What other emergencies should
you rule out?you rule out? Describe additional assessments Describe additional assessments
that should be donethat should be done Outline your priorities of care Outline your priorities of care
based on your current informationbased on your current information
Environmental emergencyEnvironmental emergency
Medical condition caused or Medical condition caused or exacerbated by weather, terrain, exacerbated by weather, terrain, atmospheric pressure, or other local atmospheric pressure, or other local factors factors
A medical emergency resulting from A medical emergency resulting from physical exposure to the environmental physical exposure to the environmental elements – water, heat, humidity, cold, elements – water, heat, humidity, cold, altitude, windaltitude, wind
ThermoregulationThermoregulation
Regulatory center - Hypothalamus Regulatory center - Hypothalamus
Peripheral thermoreceptorsPeripheral thermoreceptors
Central thermoreceptorsCentral thermoreceptors
ThermoregulationThermoregulation
Body temperature increased or Body temperature increased or decreased by:decreased by: Regulation of heat productionRegulation of heat production
ThermogenesisThermogenesis Regulation of heat loss Regulation of heat loss
ThermolysisThermolysis
Normal body temperature is 37 degrees Centigrade Normal body temperature is 37 degrees Centigrade or or 98.698.6 F, though it may range from F, though it may range from 96.5-99.96.5-99.5o 5o
(Recent studies show that (Recent studies show that 98.2o98.2o is more average) is more average)
Your body temp fluctuates daily – sleep vs exercise, Your body temp fluctuates daily – sleep vs exercise, etc.etc.
Extremely elevated body temperatures can cause Extremely elevated body temperatures can cause multisystem damage and physiological collapse: multisystem damage and physiological collapse:
(>105.8oF or 41oC(>105.8oF or 41oC))
Body temperatures below 90oF (32C) cause Body temperatures below 90oF (32C) cause decreased LOC, poor judgment, the cessation of decreased LOC, poor judgment, the cessation of
shivering, and uncoordination.shivering, and uncoordination.
Body temperatures below 82.4oF (28C) usually Body temperatures below 82.4oF (28C) usually result in unconsciousness and possible vfib.result in unconsciousness and possible vfib.
Regulating Heat ProductionRegulating Heat Production MuscularMuscular
Baseline muscular activityBaseline muscular activity ExertionExertion ShiveringShivering
MetabolicMetabolic Processing of food and nutrientsProcessing of food and nutrients
Carbohydrates (sugars and starches)Carbohydrates (sugars and starches) FatsFats ProteinsProteins
GlycogenGlycogen EndocrineEndocrine
Role of hormones in basal metabolic rateRole of hormones in basal metabolic rate
Regulating Heat LossRegulating Heat Loss Radiation Radiation Heat waves rise off of our skin (head) Heat waves rise off of our skin (head)
This starts to be ineffective above 88 degrees. This starts to be ineffective above 88 degrees. Most body heat is lost through the skinMost body heat is lost through the skin
Conduction Conduction Heat loss by direct contact with Heat loss by direct contact with colder object- snow, icecolder object- snow, ice
Convection Convection Heat loss by moving air (wind chill, Heat loss by moving air (wind chill, ceiling fans)ceiling fans)
Evaporation Evaporation Any fluid absorbs heat from Any fluid absorbs heat from surrounding objects and air. We lose heat by surrounding objects and air. We lose heat by sweating, being wet or in wet clothes, and from sweating, being wet or in wet clothes, and from respirations. This is why animals pant! Sweating respirations. This is why animals pant! Sweating is only effective if humidity is low enough for the is only effective if humidity is low enough for the water to evaporate! Evaporative rate decreases water to evaporate! Evaporative rate decreases if humidity is above 75%. At levels approaching if humidity is above 75%. At levels approaching 90%, evaporation essentially ceases.90%, evaporation essentially ceases.
Hyperthermia CompensationHyperthermia Compensation
Hyperthermia compensationHyperthermia compensation Increased heat lossIncreased heat loss
Vasodilation of skin vesselsVasodilation of skin vessels SweatingSweating
Decreased heat productionDecreased heat production Decreased muscle tone and voluntary Decreased muscle tone and voluntary
activityactivity Decreased hormone secretionDecreased hormone secretion Decreased appetiteDecreased appetite
Hypothermic CompensationHypothermic Compensation
Decreased heat lossDecreased heat loss Peripheral vasoconstrictionPeripheral vasoconstriction Reduction of surface area by body position Reduction of surface area by body position
(or clothing)(or clothing) Piloerection (not effective in humans)Piloerection (not effective in humans)
Hypothermic CompensationHypothermic Compensation
Increased heat productionIncreased heat production ShiveringShivering Increased voluntary activityIncreased voluntary activity Increased hormone secretionIncreased hormone secretion Increased appetiteIncreased appetite
External Environmental FactorsExternal Environmental Factors
May contribute to a medical May contribute to a medical emergencyemergency
ClimateClimate SeasonSeason WeatherWeather Atmospheric pressureAtmospheric pressure TerrainTerrain
Predisposing FactorsPredisposing Factors History of exposureHistory of exposure Poor planning, preparation, educationPoor planning, preparation, education Conditioning, health, nutritional status, Conditioning, health, nutritional status,
other illnesses or associated traumaother illnesses or associated trauma AgeAge Use of alcohol, drugs, and prescription Use of alcohol, drugs, and prescription
medicationsmedications PovertyPoverty
Environmental FactorsEnvironmental Factors Heat HumidityHeat Humidity
Cold WaterCold WaterWind AltitudeWind Altitude
Possible remote location and delay in identifying Possible remote location and delay in identifying problemproblem
(lost person) and accessing EMS(lost person) and accessing EMS
Difficulty in accessing or extricating patientDifficulty in accessing or extricating patient(identifying lack of contact with elderly who lives (identifying lack of contact with elderly who lives
alone in aalone in a common urban scenario)common urban scenario)
HyperthermiaHyperthermia Thermoregulatory mechanisms Thermoregulatory mechanisms
overwhelmed by:overwhelmed by: Environmental conditionsEnvironmental conditions
Heat stressHeat stress Excessive exercise in moderate to Excessive exercise in moderate to
extreme environmental conditionsextreme environmental conditions Failure of thermoregulatory Failure of thermoregulatory
mechanismsmechanisms Older adults or ill or debilitated patientsOlder adults or ill or debilitated patients
Either may result in heat illnessEither may result in heat illness
Heat CrampsHeat Cramps Brief, intermittent, often severe Brief, intermittent, often severe
muscular cramps occuring in muscular cramps occuring in muscles fatigued by heavy work or muscles fatigued by heavy work or exercise. Caused primarily by a exercise. Caused primarily by a rapid change in extracellular fluid rapid change in extracellular fluid osmolarity resulting from sodium osmolarity resulting from sodium and water loss.and water loss.
Heat CrampsHeat Cramps
1-3 L of water per hour may be lost through1-3 L of water per hour may be lost through
Sweating.Sweating.
Each liter contains between 30 and 50 mEq Each liter contains between 30 and 50 mEq
of sodium chloride. of sodium chloride.
Muscle cramping is caused by the water andMuscle cramping is caused by the water and
sodium loss.sodium loss.
Signs & SymptomsSigns & Symptoms
Alert, hot, sweaty skin, localized Alert, hot, sweaty skin, localized muscle cramps in extremities, muscle cramps in extremities, occasionally in abdomen. occasionally in abdomen.
Vital signs normal with tachycardia, Vital signs normal with tachycardia, BODY TEMP NORMAL; skin cool or BODY TEMP NORMAL; skin cool or slightly warmslightly warm
Field treatment:Field treatment: remove from hot remove from hot environment, replace the sodium and environment, replace the sodium and water (sodium especially), IV NaClwater (sodium especially), IV NaCl
HEAT EXHAUSTIONHEAT EXHAUSTION
Usually caused by exercising or Usually caused by exercising or exertion in hot ambient temperature, exertion in hot ambient temperature,
more severe water and salt more severe water and salt deficiency occurs. This electrolyte deficiency occurs. This electrolyte
imbalances causes vasomotor imbalances causes vasomotor regulatory disturbances and regulatory disturbances and
inadequate cerebral and peripheral inadequate cerebral and peripheral perfusion.perfusion.
Heat ExhaustionHeat Exhaustion More severe form of heat illnessMore severe form of heat illness
Temperature elevation (<103Temperature elevation (<103°° F [39 F [39°° C]) C])
Mental status changesMental status changes Nausea, headacheNausea, headache SweatingSweating ManagementManagement
Remove from heatRemove from heat Oral or IV fluidsOral or IV fluids
Signs & SymptomsSigns & Symptoms Minor aberrations in mental status, such Minor aberrations in mental status, such
as irritability, confusion, poor judgment, as irritability, confusion, poor judgment, headache, or light-headedness. Skin headache, or light-headedness. Skin pale with excessive sweating, slight or pale with excessive sweating, slight or no temperature increase no temperature increase (<103 (<103 degrees)degrees) Tachycardia, BP normal or Tachycardia, BP normal or slightly decreased, increased respiratory slightly decreased, increased respiratory raterate
Field treatmentField treatment includes removing the includes removing the patient from the hot environment, patient from the hot environment, oxygen, IV oxygen, IV
HEAT STROKEHEAT STROKE
Syndrome occurring when the Syndrome occurring when the thermoregulatory mechanisms that thermoregulatory mechanisms that normally cool the body fail normally cool the body fail completely. completely.
This results in a body temperature of This results in a body temperature of usually usually > 105.8o> 105.8o. Damage occurs . Damage occurs to the hypothalamus itself as a result to the hypothalamus itself as a result of prolonged exposure to heat.of prolonged exposure to heat.
Heat StrokeHeat Stroke Thermoregulatory mechanisms failThermoregulatory mechanisms fail
Body temperature >105.8Body temperature >105.8°° F [41 F [41° ° C])C]) Multisystem tissue damageMultisystem tissue damage Physiological collapsePhysiological collapse
Medical emergencyMedical emergency Two typesTwo types
Classic heat strokeClassic heat stroke Exertional heat strokeExertional heat stroke
Classic Heat StrokeClassic Heat Stroke
High temperatures and humidityHigh temperatures and humidity Risk factorsRisk factors
AgeAge Infants, elderlyInfants, elderly
Chronic illnessChronic illness Diabetes, heart disease, alcoholismDiabetes, heart disease, alcoholism
Medications Medications Psychotropics, diuretics, antihypertensivesPsychotropics, diuretics, antihypertensives
Exertional Heat StrokeExertional Heat Stroke Young, healthy patientsYoung, healthy patients
Athletes, military recruitsAthletes, military recruits
Vigorous exercise in high heatVigorous exercise in high heat
Inadequate hydrationInadequate hydration
No acclimationNo acclimation
Signs & SymptomsSigns & Symptoms
Dizzyness, headache, bizarre or Dizzyness, headache, bizarre or unusual behavior, seizures, coma. unusual behavior, seizures, coma.
Vital signs include a normal or Vital signs include a normal or decreased BP, tachycardia with a decreased BP, tachycardia with a bounding pulse, tachypnea. bounding pulse, tachypnea.
Skin is usually hot, red, and dry, but Skin is usually hot, red, and dry, but may be wet or have wet clothing if may be wet or have wet clothing if exertional heatstroke. Temp is exertional heatstroke. Temp is highly elevated!highly elevated!
Heat StrokeHeat Stroke——AssessmentAssessment Confusion, coma, seizuresConfusion, coma, seizures Skin flushingSkin flushing Dry skin (25% sweat)Dry skin (25% sweat) Tachycardia, hypotensionTachycardia, hypotension Pulmonary edemaPulmonary edema Other systems affectedOther systems affected
Heat StrokeHeat Stroke——ManagementManagement Move to cool locationMove to cool location
Maintain airway, oxygen, ventilationMaintain airway, oxygen, ventilation Active coolingActive cooling
Fan wet skin Fan wet skin Ice PaksIce Paks
IV fluid: 500 mL over 15 minIV fluid: 500 mL over 15 min For hypotensionFor hypotension
Medications as prescribedMedications as prescribed Sedation, seizure controlSedation, seizure control ECG - ECG -
FEVERFEVER
Increased body temperature kills many Increased body temperature kills many microorganisms and has adverse effects of microorganisms and has adverse effects of the growth and replication of othersthe growth and replication of others
Body temperature decreases serum levels Body temperature decreases serum levels of iron, zinc, and copper, all of which are of iron, zinc, and copper, all of which are needed for bacterial replicationneeded for bacterial replication
Body temperature causes lysosomal Body temperature causes lysosomal breakdown and autodestruction of cells, breakdown and autodestruction of cells, thus preventing viral replication in infected thus preventing viral replication in infected cellscells
FEVERFEVER body temperature (heat) increases body temperature (heat) increases
lymphocytic transformation and lymphocytic transformation and motility of polymorphonuclear motility of polymorphonuclear neutrophils, thus facilitating the neutrophils, thus facilitating the immune responseimmune response
body temperature enhances body temperature enhances phagocytosisphagocytosis
body temperature may augment body temperature may augment the production of antiviral interferonthe production of antiviral interferon
HypothermiaHypothermia
Hypothermia Hypothermia
Marked decrease in the body’s core Marked decrease in the body’s core temperature. (or systemic cooling)temperature. (or systemic cooling)
FrostbiteFrostbite
Localized hypothermia (or freezing) of Localized hypothermia (or freezing) of the body’s tissues; more common in lower the body’s tissues; more common in lower extremities than upper, also seen in nose, extremities than upper, also seen in nose, ears, cheeks CBT less than ears, cheeks CBT less than 93.293.2°° F [34 F [34°° C]C]
HypothermiaHypothermia——PathophysiologyPathophysiology
VasoconstrictionVasoconstriction Sympathetic dischargeSympathetic discharge Shivering, tachycardiaShivering, tachycardia Shivering stops: Rapid coolingShivering stops: Rapid cooling Respiration, pulse, BP decreaseRespiration, pulse, BP decrease ECG changesECG changes Respiratory and cardiac arrestRespiratory and cardiac arrest
HypothermiaHypothermia
Progression of signs and symptoms Progression of signs and symptoms MildMild
Core temperature 93.2Core temperature 93.2°°-96.8-96.8°° F (34 F (34°°-36-36° ° C)C) ModerateModerate
Core temperature 86Core temperature 86°°-93-93°° F (30 F (30°°-34-34°° C) C) SevereSevere
Core temperature below 86Core temperature below 86°° F (30 F (30°° C) C)
HypothermiaHypothermia——Risk Risk FactorsFactors Outdoor enthusiastsOutdoor enthusiasts
Older adults, young childrenOlder adults, young children Medical/psychiatric illnessMedical/psychiatric illness TraumaTrauma MedicationsMedications
Alcohol, antidepressantsAlcohol, antidepressants Antipyretics, phenothiazinesAntipyretics, phenothiazines
HypothermiaHypothermia——ManagementManagement
High index of suspicionHigh index of suspicion Evacuate to warmthEvacuate to warmth Remove cold, wet clothesRemove cold, wet clothes Cover with warm blanketsCover with warm blankets Rapid transportRapid transport
HypothermiaHypothermia——ManagementManagement
Passive rewarmingPassive rewarming Move to warm environment and remove wet Move to warm environment and remove wet
clothesclothes Active external rewarmingActive external rewarming
Radiant heatRadiant heat Forced hot airForced hot air Warm IVFWarm IVF
Active internal rewarmingActive internal rewarming Warmed oxygenWarmed oxygen LavageLavage Cardiopulmonary bypassCardiopulmonary bypass
Mild HypothermiaMild Hypothermia——TreatmentTreatment
Passive rewarmingPassive rewarming Warm drinksWarm drinks
With sugarWith sugar External hot packsExternal hot packs No alcoholic beveragesNo alcoholic beverages Warm, heated oxygenWarm, heated oxygen
Moderate HypothermiaModerate Hypothermia——TreatmentTreatment
Can’t shiver or perform tasksCan’t shiver or perform tasks Passive rewarming firstPassive rewarming first
Keep patient at restKeep patient at rest External rewarmingExternal rewarming
Cover warm packs to prevent burnsCover warm packs to prevent burns Transport for evaluationTransport for evaluation
Severe HypothermiaSevere Hypothermia Support airway, ventilation and Support airway, ventilation and
circulationcirculation
Passive and external rewarmingPassive and external rewarming
OxygenOxygen
If ventricular fibrillation - start CPR and If ventricular fibrillation - start CPR and shock onceshock once
Rapid transportRapid transport
Considerations in Considerations in HypothermiaHypothermia
Assess for vital signs for 30-45 secAssess for vital signs for 30-45 sec If presence of pulse questionable - start If presence of pulse questionable - start
CPRCPR IntubateIntubate Sinus bradycardia may be protectiveSinus bradycardia may be protective
Pacing usually not indicatedPacing usually not indicated Withhold IV drugs until T>30CWithhold IV drugs until T>30C
If T>30C increase time between dosesIf T>30C increase time between doses
FrostbiteFrostbite
Localized injuryLocalized injury Freezing of body tissuesFreezing of body tissues PathophysiologyPathophysiology Predisposing factorsPredisposing factors
FrostbiteFrostbite——Classification/Classification/SymptomsSymptoms
Superficial frostbite (frostnip)Superficial frostbite (frostnip) Minimal tissue lossMinimal tissue loss
Deep frostbiteDeep frostbite Significant tissue loss even with Significant tissue loss even with
appropriate therapyappropriate therapy
Superficial FrostbiteSuperficial Frostbite
Some freezing of epidermal tissueSome freezing of epidermal tissue
Initial redness followed by blanchingInitial redness followed by blanching
Diminished sensationDiminished sensation
Deep FrostbiteDeep Frostbite Freezing of epidermal and Freezing of epidermal and
subcutaneous layerssubcutaneous layers White appearanceWhite appearance Hard (frozen) to palpationHard (frozen) to palpation Loss of sensationLoss of sensation pale, cold, yellow, bluepale, cold, yellow, blue
numb numb decreased movement decreased movement
Field ManagementField Management Remove patient from cold environmentRemove patient from cold environment Support the patient’s vital functions (be wary Support the patient’s vital functions (be wary
about systemic hypothermia)about systemic hypothermia) Rewarm in tepid (105o) H2O; no contact with Rewarm in tepid (105o) H2O; no contact with
containercontainer No rewarming if a possibility of refreezingNo rewarming if a possibility of refreezing No walking on frozen extremitiesNo walking on frozen extremities No coffee, alcohol, nicotineNo coffee, alcohol, nicotine No rubbingNo rubbing Remove wet and/or tight clothingRemove wet and/or tight clothing Wrap affected extremities in dry, sterile Wrap affected extremities in dry, sterile
dressings; then immobilizedressings; then immobilize
FrostbiteFrostbite
Edema and blister formation 24 hrs afterEdema and blister formation 24 hrs afterfrostbite injury in area covered by tightly fitted boot frostbite injury in area covered by tightly fitted boot
FrostbiteFrostbite
Gangrenous necrosis 6 wks after frostbite injury Gangrenous necrosis 6 wks after frostbite injury
Pulseless Hypothermic Pulseless Hypothermic Patient.Patient.
Hypothermic patients who appear dead Hypothermic patients who appear dead may still be successfully resuscitated. may still be successfully resuscitated.
The lowest recorded temperature that The lowest recorded temperature that an adult patient has survived in an adult patient has survived in accidental hypothermia is accidental hypothermia is 61oF.61oF.
Children especially have a better Children especially have a better chance of survival, some believe due to chance of survival, some believe due to the mammalian dive reflex.the mammalian dive reflex.
DrowningDrowning Fifth-leading cause of unintentional Fifth-leading cause of unintentional
deathdeath 85% male, 85% male, ⅔⅔ don’t know how to swim don’t know how to swim DrowningDrowning
Process that results in primary respiratory Process that results in primary respiratory impairmentimpairment
Caused by submersion/immersion in liquidCaused by submersion/immersion in liquid Liquid/air interface at airway prevents Liquid/air interface at airway prevents
breathingbreathing
Factors Contributing To Factors Contributing To DrowningDrowning
ETOH, drugsETOH, drugs TraumaTrauma Inability to swimInability to swim Stupidity, overconfidenceStupidity, overconfidence ExhaustionExhaustion Muscle crampsMuscle cramps Fear, panicFear, panic
Salt vs Fresh waterSalt vs Fresh water
SALTWATERSALTWATER
Hypertonic to body fluids; draws water Hypertonic to body fluids; draws water to it.to it.
Plasma and fluid move into the alveoli, Plasma and fluid move into the alveoli, resulting in pulmonary edema, poor resulting in pulmonary edema, poor ventilations of alveoli, hypoxia.ventilations of alveoli, hypoxia.
Salt vs. Fresh WaterSalt vs. Fresh Water
FRESHWATER FRESHWATER
Hypotonic to body fluids; moves out of Hypotonic to body fluids; moves out of alveoli into circulation. Blood volume alveoli into circulation. Blood volume can increase, causing RBCs to can increase, causing RBCs to rupture (hemolysis), and electrolyte rupture (hemolysis), and electrolyte abnormalities. Surfactant is “washed abnormalities. Surfactant is “washed out” or diluted, causing atelectasis, out” or diluted, causing atelectasis, then hypoxia in the alveoli.then hypoxia in the alveoli.
Submersion Incident - Submersion Incident - PathophysiologyPathophysiology
Wet vs. dry drowningWet vs. dry drowning Fluid in posterior oropharynx stimulates Fluid in posterior oropharynx stimulates
laryngospasmlaryngospasm Aspiration occurs after muscular relaxationAspiration occurs after muscular relaxation Suffocation occurs with or without aspirationSuffocation occurs with or without aspiration Aspiration presents as airway obstructionAspiration presents as airway obstruction
Fresh versus saltwater considerationsFresh versus saltwater considerations No difference in prehospital treatmentNo difference in prehospital treatment
Drowning vs. Near-Drowning vs. Near-drowningdrowning
Drowning Drowning
Asphyxia after submersion (death <24 Asphyxia after submersion (death <24
hours)hours)
Near-drowningNear-drowning
Submersion accident where the patient Submersion accident where the patient
survives for at least 24survives for at least 24
DrowningDrowning
Hypothermic considerationsHypothermic considerations Common concomitant syndromeCommon concomitant syndrome May be organ protective in cold water May be organ protective in cold water
submersionsubmersion Treat hypoxia firstTreat hypoxia first Treat all submersion patients for Treat all submersion patients for
hypothermiahypothermia
Factors that Affect Clinical Factors that Affect Clinical OutcomeOutcome
Water temperature Water temperature
Length of submersionLength of submersion
Cleanliness of waterCleanliness of water
Age of patientAge of patient
Submersion IncidentSubmersion Incident——ManagementManagement ABCsABCs
Trauma considerationsTrauma considerations Spinal precautions if MOI suggests injurySpinal precautions if MOI suggests injury
Post resuscitation complicationsPost resuscitation complications Adult respiratory distress syndrome (ARDS) Adult respiratory distress syndrome (ARDS)
or renal failure often occurs or renal failure often occurs postresuscitationpostresuscitation
Symptoms may not appear for 24 hrsSymptoms may not appear for 24 hrs
Transport all submersion patientsTransport all submersion patients
Diving EmergenciesDiving Emergencies
IncidenceIncidence Medical emergencies caused by:Medical emergencies caused by:
Mechanical effects of pressureMechanical effects of pressure BarotraumaBarotrauma
Air embolismAir embolism Breathing of compressed airBreathing of compressed air
Decompression sicknessDecompression sickness Nitrogen narcosisNitrogen narcosis
Mechanical Effects of PressureMechanical Effects of Pressure Basic properties of gasesBasic properties of gases
Increased pressure dissolves gases Increased pressure dissolves gases into bloodinto blood
Oxygen metabolizes; nitrogen Oxygen metabolizes; nitrogen dissolvesdissolves
Boyle’s LawBoyle’s Law When pressure is doubled, volume of gas When pressure is doubled, volume of gas
is halvedis halved PV = KPV = K
P = PressureP = Pressure V = VolumeV = Volume K = ConstantK = Constant
Trapped gases expand as pressure Trapped gases expand as pressure decreasesdecreases
Dalton’s LawDalton’s Law Pressure from each gas in a mixture of Pressure from each gas in a mixture of
gases is the same as it would be if gases is the same as it would be if that gas alone occupied the same that gas alone occupied the same volumevolume
Pt Pt -- PO PO22 + PN + PN22 + Px + Px Pt = Total pressurePt = Total pressure POPO22 = Partial pressure of oxygen = Partial pressure of oxygen PNPN22 = Partial pressure of nitrogen = Partial pressure of nitrogen Px = Partial pressure of remaining gasesPx = Partial pressure of remaining gases
Henry’s LawHenry’s Law
At constant pressure, solubility of gas At constant pressure, solubility of gas in liquid is proportionate to partial in liquid is proportionate to partial pressure of gaspressure of gas
%X = Px/Pt x 100%X = Px/Pt x 100 %X = Amount of gas dissolved in liquid%X = Amount of gas dissolved in liquid Px = Partial pressure of gasPx = Partial pressure of gas Pt = Total atmospheric pressurePt = Total atmospheric pressure
Barotrauma of DescentBarotrauma of Descent””Squeeze”Squeeze”
PainPain Sensation of fullnessSensation of fullness HA, disorientationHA, disorientation VertigoVertigo NauseaNausea Bleeding from nose or earsBleeding from nose or ears
Pre-hospital carePre-hospital care SupportiveSupportive
Barotrauma of AscentBarotrauma of Ascent Reverse squeezeReverse squeeze Breath holding during ascentBreath holding during ascent POPSPOPS
Alveolar ruptureAlveolar rupture PneumomediastinumPneumomediastinum Subcutaneous emphysemaSubcutaneous emphysema Air embolismAir embolism
Administer oxygenAdminister oxygen
Transport for possible hyperbaric careTransport for possible hyperbaric care
Air EmbolismAir Embolism
Complication of pulmonary Complication of pulmonary barotraumabarotrauma Expanding air disrupts tissuesExpanding air disrupts tissues Air forced into circulatory systemAir forced into circulatory system Air passes through left side of heartAir passes through left side of heart Lodges in small arteriolesLodges in small arterioles Blocks distal circulationBlocks distal circulation
Air EmbolismAir Embolism Paralysis or sensory changeParalysis or sensory change AphasiaAphasia ConfusionConfusion BlindnessBlindness ConvulsionsConvulsions Loss of consciousnessLoss of consciousness
Signs & SymptomsSigns & Symptoms
History of a recent diveHistory of a recent dive
Change in LOCChange in LOC
CVA-CVA-
ICPICP
MIMI
Air EmbolismAir Embolism——CareCare Maintain ABCsMaintain ABCs Remove wet clothing and keep warmRemove wet clothing and keep warm Oxygen, IV, EKGOxygen, IV, EKG Initially- place on left side trendelenberg Initially- place on left side trendelenberg
positionposition After 30-60 minutes, place supine to After 30-60 minutes, place supine to
prevent the worsening of cerebral prevent the worsening of cerebral edemaedema
Transport to hospital with hyperbaric Transport to hospital with hyperbaric chamberchamber
Decompression SicknessDecompression Sickness
Bends, dysbarism, caisson disease, Bends, dysbarism, caisson disease, and diver's paralysisand diver's paralysis
Multisystem disorderMultisystem disorder Nitrogen in compressed air converts Nitrogen in compressed air converts
from solution to gasfrom solution to gas Forms bubbles in tissues and bloodForms bubbles in tissues and blood
Decompression SicknessDecompression Sickness
DyspneaDyspnea ItchItch RashRash Joint painJoint pain CrepitusCrepitus FatigueFatigue
VertigoVertigo ParesthesiasParesthesias ParalysisParalysis SeizuresSeizures UnconsciousnessUnconsciousness
Decompression SicknessDecompression Sickness
Symptoms 12-36 hrs after diveSymptoms 12-36 hrs after dive Pre-hospital carePre-hospital care
Support vital functionsSupport vital functions High-concentration oxygenHigh-concentration oxygen Fluid resuscitationFluid resuscitation Rapid transport for recompressionRapid transport for recompression
Nitrogen NarcosisNitrogen Narcosis
““Rapture of the deep”Rapture of the deep”Nitrogen dissolved in bloodNitrogen dissolved in bloodHigh atmospheric pressureHigh atmospheric pressure
Impaired judgmentImpaired judgmentSlowed motor responseSlowed motor response
EuphoriaEuphoriaPotential memory lossPotential memory loss
Nitrogen NarcosisNitrogen Narcosis
Supportive careSupportive care
Assess for injuries Assess for injuries
TransportTransport
High-Altitude IllnessHigh-Altitude Illness
>>8000 ft above sea level8000 ft above sea level Reduced atmospheric pressureReduced atmospheric pressure Hypobaric hypoxiaHypobaric hypoxia Associated with:Associated with:
Mountain climbingMountain climbing Aircraft or glider flightAircraft or glider flight Hot-air balloonsHot-air balloons Low-pressure or vacuum chambersLow-pressure or vacuum chambers
High-Altitude IllnessHigh-Altitude Illness——PreventionPrevention
Gradual ascentGradual ascent Limit exertionLimit exertion Decrease sleeping at altitudeDecrease sleeping at altitude High CHO dietHigh CHO diet MedicationsMedications
ControversialControversial
Acute Mountain Sickness (AMS)Acute Mountain Sickness (AMS)
Rapid ascent of unacclimatized Rapid ascent of unacclimatized person to high altitudesperson to high altitudes 4-6 hrs after reaching high altitude4-6 hrs after reaching high altitude Maximal within 24-48 hrsMaximal within 24-48 hrs Abates on 3Abates on 3rdrd or 4 or 4thth day day Gradual acclimatizationGradual acclimatization
Acute Mountain Sickness (AMS)Acute Mountain Sickness (AMS) HeadacheHeadache Nausea, vomitingNausea, vomiting Dizziness, irritabilityDizziness, irritability Dyspnea on exertionDyspnea on exertion Tachycardia or bradycardiaTachycardia or bradycardia AtaxiaAtaxia AlteredAltered vomitingvomiting postural hypotensionpostural hypotension
Acute Mountain Sickness (AMS)Acute Mountain Sickness (AMS) Pre-hospitalPre-hospital
OxygenOxygen DescentDescent
HospitalHospital DiureticsDiuretics SteroidsSteroids Hyperbaric therapyHyperbaric therapy
High-Altitude Pulmonary Edema High-Altitude Pulmonary Edema (HAPE)(HAPE)
Increased pulmonary artery pressure Increased pulmonary artery pressure develops in response to hypoxiadevelops in response to hypoxia Leukotrienes releasedLeukotrienes released
Increase pulmonary arteriolar permeabilityIncrease pulmonary arteriolar permeability Leakage of fluid into extravascular spacesLeakage of fluid into extravascular spaces 24-72 hrs after reaching high altitudes24-72 hrs after reaching high altitudes Often preceded by exerciseOften preceded by exercise
HAPE Signs & SymptomsHAPE Signs & Symptoms HyperpneaHyperpnea Crackles, rhonchiCrackles, rhonchi TachycardiaTachycardia Hyperpnea (deep, rapid breathing)Hyperpnea (deep, rapid breathing) CyanosisCyanosis Immediate descent to a lower altitudeImmediate descent to a lower altitude Shortness of breath, coughShortness of breath, cough Weakness, lethargyWeakness, lethargy Crackles, rhonchiCrackles, rhonchi Decreased LOC as hypoxia sets inDecreased LOC as hypoxia sets in
High-Altitude Cerebral Edema High-Altitude Cerebral Edema (HACE)(HACE)
Severe acute high-altitude illnessSevere acute high-altitude illness Global cerebral signs with AMSGlobal cerebral signs with AMS Related to increased intracranial pressureRelated to increased intracranial pressure
From cerebral edema and swellingFrom cerebral edema and swelling Distinctions between AMS and HACE are blurredDistinctions between AMS and HACE are blurred
Mild AMS to unconsciousness with HACE Mild AMS to unconsciousness with HACE occurs within 12 hrsoccurs within 12 hrs
1-3 days of exposure to high altitudes1-3 days of exposure to high altitudes Same as AMS, headache to decreased LOCSame as AMS, headache to decreased LOC Hallucinations, stupor, coma, deathHallucinations, stupor, coma, death
HACEHACE Urgent management to preventUrgent management to prevent
ComaComa DeathDeath
Airway, ventilation, circulation Airway, ventilation, circulation supportsupport
Descent to lower altitudeDescent to lower altitude
ConclusionConclusion
Many emergencies result from exposure Many emergencies result from exposure to environmental elements. The to environmental elements. The
paramedic must be able to recognize paramedic must be able to recognize and manage these conditions by and manage these conditions by
understanding their causative factors understanding their causative factors and underlying pathophysiology.and underlying pathophysiology.