Transcript Slide 1
Cold Weather Emergencies
Presented by: Wade Scoles RRT, NREMT
Staff Education Coordinator, NW MedStar
Emergency Vehicle Safety
• Most serious injuries in
ambulance crashes are
unrestrained medical
attendants in the rear
compartment.
• You are 2.6 times more
likely to be injured while
running “code”.
Cold Weather Assessment & Mngt
• Exposing your patient
– Bring them inside the ambulance
– Keep them warm
– Remove wet clothing
– Cutting Coats & Snowsuits…
Cold Weather Assessment & Mngt
• Assessing skin color,
temperature and
perfusion
•Normal cap refill of 2-3 seconds will be
longer in cold weather due to
vasoconstriction
•Will not necessarily reflect hemodynamic
status
Patient #1
• Typical winter conditions (more than an
inch of snowfall and temperatures that dip
below 20 degrees) cause death rates from
heart attacks to triple among men 35 to 49
years old.
Video
Patient #1
• 55 year old having chest pain while
shoveling snow
• Initial assessment:
– Pale, diaphoretic, no resp. distress
– Vital signs:
• Pulse 110, RR 16, BP 158/90, SpO2 96%
Patient #1
• Management:
– Rapid transport, call for ALS if available
– Monitor with AED, Oximetry
– Oxygen
– Nitroglycerin
• Contraindicated if BP < 100 systolic
– Aspirin
Patient #1
• Why is shoveling a
potentially dangerous
activity?
– Strenuous activity in cold
weather
– HR & BP increase
– Body constricts vessels
when exposed to the cold
Patient #2
• Approximately 1,000 Americans fall
through ice each year
Video
Patient #2
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11 year old, cold water submersion
Pale, cold, unresponsive, not breathing
To resuscitate or not?
In the water 40-45 minutes
Water temp 33 degrees
Patient #2
• Assessing hypothermic patients
– Take extra time to assess pulse & RR in
hypothermic patients
– Allow for slow heart & respiratory rates
– Don’t start chest compressions if severe
hypothermic patient shows any signs of life
Patient #2
• Management
– Rapid transport, call for ALS if available
– High quality BLS
– Remove wet clothing
– Begin active re-warming of truncal area while
administering BLS
– May attempt defibrillation once if AED says
“Shock indicated”
Patient #2
• Management
– Withhold further defib or meds until body temp
reaches >30°C (86°F)
– Will need transport to facility capable of active
internal rewarming for severe hypothermia
Patient #2
• Sudden submersion into cold water
triggers the Mammalian Dive Reflex
• HR & RR slows and blood flow diverts
from the extremities to the core
• This slowing of metabolism and diversion
of blood allows longer survival times.
• How cold must the water be, to be
“protective”?
– <20° C (68 °F)
Hypothermia Severity
Severity
Symptoms
Treatment
Mild:
>34°C or 93.2°F
Shivering,
Tachycardia
External rewarming
all areas
Moderate: 30-34°C or
86-93.2°F
Confusion,
disorientation,
apathy, bradycardia
or AFib
External rewarming,
truncal areas only
Severe: <30°C or
<86°F
Unconsciousness,
More cardiac
dysrhythmias like VFib
Truncal external
rewarming plus
active internal
rewarming
Profound <20°C
PEA or asystole,
EEG flat line at 63°F
Same as “Severe”
category
Patient #3
Patient #3
• Nearby fishermen call 911 to report drunk,
confused man wandering around the ice
• Upon your arrival
– Pt is confused, dizzy, vomiting and C/O headache
– Vitals
• Pulse 118, RR 24, BP 132/80, SpO2 97% BS clear.
• Differential diagnoses?
Patient #3
• What questions are you going to ask to
determine the problem?
– Drunk?
– Hypoglycemia?
– Stroke?
– Head injury?
– Carbon Monoxide Poisoning?
• Pt. states he was just fishing with his buddy,
had a couple of beers and doesn’t
remember anything else
Patient #3
• With bystanders help, you figure out where
he was fishing and find his friend in the hut
• His friend is passed out inside
• Pulse 120, RR 12, BP 116/70, SpO2 92%
• What are your priorities?
– Additional resources needed?
– Secure airway
– Oxygen
Carbon Monoxide
• Carbon Monoxide is colorless, odorless,
tasteless gas
• CO exposure accounts for an estimated
15,000 emergency department visits and
500 unintentional deaths in the United
States each year
Carbon Monoxide
Carbon Monoxide
• CO has a half-life of 4-5 hours
– Oxygen can reduce that
– Hyperbaric Oxygen can reduce it even more
• Hyperbaric chambers in the Northwest
– WA: Spokane (Deac), Seattle (Virginia Mason),
Clarkston (Tri-State), Richland (Kadlec)
– Alaska: Anchorage, Juneau, Wasilla
– Montana: Billings Clinic
– Idaho: Boise, Idaho Falls, Pocatello
– Oregon: Portland, Hillsboro, Eugene, McMinnville
Carbon Monoxide
• Detecting CO in blood
– Standard oximetry not helpful
– Co-oximetry
Carbon Monoxide
% COHb
Symptoms
≤10
No symptoms
≤15
25
Mild headache
Nausea & serious headache
30
45
Nausea & vomiting intensify,
confusion, lethargy
Unconsciousness
60
Death
Patient #4
Patient #4
• 65 year old woman rescued from house
fire
• Scene safety concerns
• Patient condition
– Unresponsive
– No evidence of trauma or burns
– HR 140, RR 12, BP 130/78,
– SpO2 on Oxygen is 98%
Patient #4
• Differential diagnoses?
– Head trauma, CO poisoning, Medical Event
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CO level is 12%
Patient still unresponsive
Consider Cyanide Poisoning
Management
– Secure Airway
– O2
– Assist respirations
– Cyanokit
Cyanide Poisoning
• Cyanide may be a factor in ~4,000 firerelated deaths in the U.S. each year
• Study of smoke inhalation deaths
– 87% of the fatalities had toxic levels of
cyanide
• Cyanide is commonly found in the smoke
of closed-space fires
– Synthetic construction materials, furniture
– Natural materials like wool and cotton
produce cyanide when burned
Cyanide Poisoning
• Treatment
– Hydroxocobalamin (Cyanokit)
– 5 grams (diluted in 200ml) over 15 minutes
– Can safely be used for suspected cyanide
poisoning as it bonds with cyanide in the body
to form Vitamin B-12
Patient #5
You are called to the home of a 28
year old pregnant woman with
respiratory distress
Patient #5
• 34 weeks pregnant
• 2 day history of cough, muscle
aches
• Now with fever and increasing
respiratory distress
• VS: HR 120, RR 24, SpO2 82%
Protect yourself
N-95 mask, gloves
Patient #5
• After Oxygen:
– SpO2 87%
– Still in respiratory distress
• Breath sounds:
– Insp. Crackles & exp. wheezes
• Impression?
– Influenza, Respiratory distress
Novel H1N1 in the US, By Age Group
Novel H1N1 U.S. Deaths, By Age Group
Flu Hospitalizations, Spokane Area
Patient #6
• 24 year-old male crashes on snowmobile
http://www.youtube.com/watch?v=UoA7jK26SOE
Patient #6
• Scene safety concerns
• Transport decision
• Helicopter safety concerns
– Skids sinking into snow
– White-out conditions upon landing
Patient #6
• Upon your arrival:
– Pt is conscious, sitting on tailgate of truck
– c/o back and neck pain
– HR 80, RR20, BP hard to hear through
clothes, SpO2 97%
– Skin feels cool
• Your assessment
– Are you going to cut off his snowsuit?
Patient #6
• Management:
– C-spine immobilization
– ABCs
• How are you going to place him in C-spine
precautions?
http://www.emsonline.net/head2009/skills.asp
Contact: Renee Anderson
509-232-8155
1-866-630-4033
[email protected]
Fax: 509-232-8168