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 • • • • • 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 • • • • 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