1. Environmental Emergencies
Andrew Scordato

2. Objectives Pathophysiology, Assessment and management of:
Submersion incidents
Temperature-related illness
Bites and envenomation
Spiders
Marine Animals
Scorpions
High altitude
Diving injuries
Lighting injury

3. Intro Medical emergencies can result from exposure to heat or cold.
Certain populations are at higher risk for heat and cold emergencies.
Children
Older people
People with chronic illnesses
Young adults who overexert themselves

4. Intro Water recreation can also create medical emergencies.
Localized injuries
Systemic injuries
Environmental emergencies require prompt treatment in the hospital.

5. Factors Physical condition Age
Patients who are ill or in poor physical condition will not tolerate extreme temperatures wells.
Age
Infants have poor thermoregulation and are unable to shiver.
Children may not think to put on layers.
Older adults lose subcutaneous tissues and have poor circulation.

6. Factors Environmental conditions
Conditions that can complicate or improve environmental situations:
Air temperature
Humidity level
Wind
Extremes in temperature and humidity are not needed to produce injuries.

7. Factors Environmental conditions (cont’d)
Most hypothermia occurs at temperatures between 30°F and 50°F.
Most heatstroke occurs when the temperature is 80°F and the humidity is 80%.
Examine the environmental temperature of your patient.

8. Cold exposure The five ways the body loses heat
Cold exposure may cause injury to:
Feet
Hands
Ears
Nose
Whole body (hypothermia)
The five ways the body loses heat
Conduction
Radiation
Respiration
Convection
Evaporation

9. Hypothermia Lowering of the core temperature below 95°F (35°C)
Body loses the ability to regulate its temperature and generate body heat
Vital organs such as the heart slow down.
Can lead to death
Air temperature does not have to be below freezing for it to occur.
People at risk:
Those with out heat
Homeless
Lower income/ fixed income
Outdoor enthusiast
Geriatric/ill
infants and children

10. Factors Factors in determining the severity of a local cold injury:
Temperature and Duration of the exposure
Wind velocity during exposure
Exposure to wet conditions
Inadequate insulation from cold or wind
Restricted circulation from tight clothing or shoes, or circulatory disease
Fatigue/Poor nutrition
Alcohol or drug abuse
Hypothermia
Age and medical Hx i.e. Cardiovascular disease/Diabetes

11. Hypo assessment
Mild
Occurs when the core temperature is between 90°F and 95°F (32°C and 35°C)
Patient is usually alert and shivering
Increased HR/RR.
Skin may appear red, pale, or cyanotic.

12. Hypothermia
Severe
Occurs when the core temperature is less than 90 F or 32C
Patient is usually alert but confused
Initially Pulse rate and respirations are rapid
Bradycardia develops
V-Fib as the body falls below 86
Assess for Pulse and respiration Longer than normal
Skin may appear red, pale, or cyanotic
No shivering
Loss of voluntary muscle control
Ekg shows J-wave (osborn)
Mild to sever hypothermia is more of a continum

13. J-wave
Associated with temp below 90 commonly seen in leads two and v6

14. Hypothermia Tx Note the weather conditions (for You and for Pt.) ABC
CPR, Resp./Pulse ?
Perfusion will be compromised.
Skin not a good indicator to determine shock.
Bleeding may be difficult to find.
Cardiac arrhythmias
Rewarming
V/S
May be altered by the effects of hypothermia, an indicator of its severity
Pulse OX ?

15. Hypothermia Tx
If the patient is AOX3 shivering, and the core body temperature is between 90°F to 95°F, then the hypothermia is mild.
Apply heat packs to the groin, axillary, and neck
Increase ambient temperature
Rewarm slowly.
Warm IV fluids
Warm humidified O2

16. Hypothermia
When the Pt.has moderate or severe hypothermia, never try to actively rewarm
Active rewarming should be reserved for an appropriate facility.
Rewarming shock-reflex peripheral vasodilation
Cold diuresis-Volume depletion/kidneys remove excess fluid from core
The goal prevent further heat loss.
Remove wet clothing, cover with a blanket, and transport

17. Hypothermia (arrest) BLS ALS Start CPR immediately
Longer pulse/respiration check
One shock with AED until temp >86
ALS
Limit one defibrillation until temp is above 86
Limit one round of ACLS Rx until temp is above 86

18. Remember they are not Dead until they are Warm and Dead
Warning
Remember they are not Dead until they are Warm and Dead

19. Local Cold Injuries Frost bite Frost nip Immersion Foot
Serious local cold injury tissues are actually frozen
Gangrene requires surgical removal
Frost nip
Prolonged exposure to the cold, skin is freezing but deeper tissues are okay.
Ear, nose, and fingers
Usually not painful, Pt. often is unaware that a cold injury has occurred
Immersion Foot
Prolonged exposure to cold water
Hikers and Hunters

20. Cold injuries

21. Frost Bite

22. Local Assessment
Assess the areas of the body affected by cold exposure.
degree and extent of damage.
attention to skin temperatures, textures, and turgor.
Frost Nip and Immersion foot
Skin= pale/cold to the touch
Normal color does not return after palpation of the skin.
The skin of the foot, wrinkled but remains soft.
The Pt. reports loss of feeling/sensation
Frost Bite
Hard and waxy with blisters and swelling
Feels firm to frozen as you gently touch it.
In light-skinned individuals with a deep injury, the skin may appear red with purple and white, or mottled and cyanotic.
Depth of Injury (unknown)
Superficial
Deep

23. Local Cold Injuries Treatment
Note the weather conditions (for you and for Pt.)
ABC
With frostnip, contact with a warm object may be all that is needed.
With immersion foot, remove wet shoes, boots, and socks, and rewarm the foot gradually.
With a late or deep cold injury, do not apply heat or rewarm the part.

24. Local Tx Move the patient from the cold environment.
Do not allow the patient to walk.
Remove any wet clothing.
Place dry blankets over and under the patient.
If available, give the patient warm, humidified oxygen.
Handle the patient gently.
Do not massage the extremities.

25. Heat Exposure Normal body temperature is 98.6°F.
The body tries to rid itself of excess heat.
Sweating
Dilation of skin blood vessels
Removal of clothing and relocation to a cooler environment
Hyperthermia is a core temperature of 101°F (38.3°C) or higher.
Risk factors of heat illness include:
High air temperature/Humidity (reduces radiation/evaporation)
Lack of acclimation to the heat
Exercise (loss of fluid and electrolytes)

26. Heat Persons at risk for heat illnesses are:
Children (especially newborns and infants)
Geriatric patients
Patients with heart disease, COPD, diabetes, dehydration, and obesity
Patients with limited mobility

27. Heat Assess for: Three types of Heat Emergencies High temperature
Red, dry skin
Tachycardia
Poor perfusion
Absence of perspiration
Confusion/Decreased level of consciousness
Muscle cramping
Nausea/Vomiting
Three types of Heat Emergencies
Heat Cramps
Heat Exhaustion
Heat Stroke

28. Heat Cramps/Exhaustion I
Painful muscle spasms that occur after exercise , usually in the leg or abdominal muscles
Do not occur only when it is hot outdoors
Exhaustion
Common illness
Causes include:
Heat exposure
Stress/Fatigue
Fluid replenishment

29. Heat Cramps/Exhaustion
Signs and symptoms
Cold, Pale, Diaphoretic
Dry tongue and thirst
Normal vital signs/or slightly elevated body temperature
Dizziness, weakness, Syncopal episode
Change in LOC
Muscle cramping, nausea, vomiting, or headache
Onset =working hard or exercising in a hot, humid, or poorly ventilated area, sweating heavily

30. Heatstroke Least common but most serious
The body is subjected to more heat than it can handle and normal mechanisms are overwhelmed
Typical situations
Physical activity
Outdoors or in a closed, poorly ventilated, humid space
During heat waves
Elderly/Homeless/Fixed income
Child left unattended in a car on a hot day
Untreated heatstroke always results in death.

31. Heatstroke S/Sx Signs and symptoms
Hot, dry, flushed skin/Early on, skin may be moist or wet.
Rising body temperature
Changes in LOC/behavior
Unresponsiveness
Seizures
Strong, rapid pulse at first, becoming weaker with falling blood pressure (signs of Shock)
Increasing respiratory rate
Note:
Inadequate oral intake
Diuretics
Certain psychiatric medications

32. Heat Treatment Cramps/Exhaustion Stroke
Remove the patient from the hot environment.
O2,IV fluids (cool), EKG
Rest cramping muscles.
Cool the patient (remove clothing, turn on air conditioning)
Stroke
All the above plus apply cold packs to neck, groin and axillary
Avoid Vasopressors and Anticholinergic RXs
Rapid transport
Vasopressors and anit-thes agents may potentiate stroke and inhibit sweating they acan also produce a hypermetabolic state in the presence of high tempatures.

33. Drowning
Process of experiencing respiratory impairment from submersion/immersion in liquid
Prevention
Drowning VS. Near drowning.
D=Patient dies with in 24 hours after suffocation in water
ND=Refers to a patient who survives at least temporarily (24 hours) after suffocation in water
Drowning's may be complicated by spinal fractures and spinal cord injuries. Suspect Spinal Injury if:
Diving or long fall.
ALOC/Unconscious.
Complaints of weakness, paralysis, or numbness.
Appropriate precautions can prevent most immersion incidents.
All pools should be surrounded by a fence.
The most common problem is lack of adult supervision.
Half of all teenage and adult drowning's are associated with the use of alcohol.

34. Drowning Never give up on resuscitating a cold-water drowning victim.
Hypothermia can protect vital organs from the lack of oxygen.
The diving reflex may cause immediate bradycardia.
Always transport near-drowning patients to the hospital.
Inhalation of any amount of fluid can lead to delayed complications.
Drowning patients may deteriorate rapidly due to:
Pulmonary injury
Fluid shifts in the body
Cerebral hypoxia
Hypothermia

35. Drowning Dry Vs. Wet drowning Salt Vs. Fresh
Dry-Lungs don’t fill with water because of Laryngospasm
Salt Vs. Fresh
Fresh water causes the alveoli to collapse from a lack of surfactant.
Salt water causes pulmonary edema and eventual hypoxemia due to its hypertonic nature.
Factors affecting survival
Cleanliness of Water
Length of Time Submerged
Victim’s Age and Health
Water Temperature
Cold-water drowning.
Mammalian diving reflex.
Dry drowning the patient panics cause alrygopsams and these keeps the water from the lungs but the patient asyphyxiates.

36. Drowning Assessment/Tx
Scene
Never drive through moving water; be cautious driving through still water.
Never attempt a water rescue without proper training and equipment.
Consider trauma (MOI) and spinal stabilization.
Check for additional patients.

37. Drowning Assess and Treat:
Determine the length of time the patient was underwater or the start symptoms
Remove patient from water. If needed start ventilations in the water
Suspect head and neck injuries
Protect the patient form heat loss
ABC/CPR
It may be difficult to find a pulse.
When in doubt start CPR
EKG/Capnography?
Normal temp follow normal ACLS guidelines
Hypothermic treat with one defib and one round of drugs until temp >86 degrees
The cold-water drowning patient is not dead until he is warm and dead.

38. Diving Emergencies
Divided into Injuries on the surface, Descent, injuries at the bottom and Ascent
Injuries at the Surface
Lines or kelp fields
Panic/fatigued
Drown
Boats
Cold water
Shivering and pass-out

39. Diving Descent (barotrauma)
Caused by the increase in pressure
Typical areas affected
Lungs
Sinus cavities
Middle ear
Teeth
The pain forces the diver to return to the surface to equalize the pressures, and the problem clears up by itself.
Perforated tympanic membrane
Cold water may enter the middle ear through a ruptured eardrum.
The diver may lose his or her balance and orientation and run into ascent problems.

40. Diving Emergencies at the Bottom Rare=Commercial divers/Oil Rig
Caused by faulty connections in the diving gear
Inadequate mixing of oxygen and carbon dioxide
Accidental feeding of poisonous carbon monoxide into the breathing apparatus
Can cause drowning or rapid ascent
Nitrogen Narcosis
Occurs During a Dive
Can contribute to accidents during the dive.
Signs and Symptoms
Altered levels of consciousness and impaired judgment.
Diver misjudges amount of air left for dive

41. Diving Ascent Sudden decrease in pressure/Not enough “off Gassing”
Several big Problems
Air Embolism
Dangerous and common
Bubbles of air in the blood vessels
Air pressure in the lungs remains at a high level while pressure on the chest decreases
Signs-Sharp tearing pain, mimics stroke with confusion, vertigo, visual disturbances and LOC
Treatment
Hyperbaric
O2,Iv,EKG
Steriods?

42. Diving Decompression sickness (the bends)
Bubbles of gas, especially nitrogen, obstruct the blood vessels.
Conditions (dive charts)
Rapid ascent
Too long of a dive at too great of a depth
Repeated dives on the same day
Complications
Blockage of tiny blood vessels deprives the body of nutrients
Severe pain in certain tissues or spaces

43. Diving Decompression Occur within 36 hours
Fatigue, paresthesias, and CNS disturbances
Abdominal/joint pain so severe that the patient doubles up
May find it difficult to distinguish between air embolism and decompression sickness.
Air embolism generally occurs immediately on return to the surface.
Symptoms of decompression sickness may not occur for hours.
Tx-Hyperbaric chamber

44. Diving Pulmonary Overpressure Accidents Air becomes trapped on ascent
Trapped by
Mucus
Bronchospasm
Holding breath
Ambient pressure drops, trapped air expands in the lungs
Alveoli Rupture
Hemorrhage
Decreased 02 c02 trans
Air escaping
Treatment-tx for possible pneumothorax

45. Diving Pneumomediastinum Caused by Pulmonary Overpressure
Release of air into the mediastinium and the pericardial sac
Signs
Chest pain
Irregular pulse
Decreased BP
Narrow pulse pressure
Changes in the Voice
Treatment
ABC
O2,IV,EKG
Rapid transport

46. Diving Assessment Determine the dive parameters Assess for:
Depth
Time
Previous dives
Rate of Ascent
Experience of the diver
Equipment
Use of medication or alcohol
Assess for:
Peripheral pulses
Skin color and discoloration
Pain
Paresthesia (numbness and tingling).

47. Diving Tx General Treatment ABC O2 (NRB or BVM prn),IV,EKG
Unconscious should be intubated
Supine or Left lateral recumbent
Pulse OX/Capnnogrpahy
Protect from excessive cold or heat
Monitor for neurological symptoms
Valium
Send patients dive equipment if possible
Assess for Decompression illness

48. High Altitude Reverse of dive injuries/Lack of Pressure
(Dsybarims injuries)
Altitude illness
Caused by diminished oxygen at high altitudes
Effects
CNS
PULMONARY
Three Altitude illness (progressive)
Acute Mountain Sickness
HAPE
HACE

49. Altitude AMS (Acute Mountain Sickness)
diminished oxygen pressure at altitudes above 8,000′
Ascending too high too fast or not being acclimatized to high altitudes
HAPE (High Altitude Pulmonary Edema)
Fluid collects in the lungs, blocks passage of oxygen into the bloodstream.
Altitudes of 10,000
HACE (High Altitude Cerebral Edema)
Occurs above 12,000
Follows HAPE

50. Altitude S/Sx and Management
AMS
Fatigue
Loss of appetite/N&V
Shortness of breath during physical exertion
Swollen face
Headache/Lightheadedness
Tx-
Mild-high flow 02 use of antiemtics
Severe- Dissent, hyperbaric chamber PRN

51. Altitude S/SX cont. HAPE Shortness of breath/Cyanosis
Dry cough with pink sputum
Rapid pulse
Crackles in the lungs Tx
Earlier recognition
High flow 02
Dissent
Hyperbaric Bag (pressure bag simulates a dissent of 5,000 ft)
Meds-Morphine, Procardia, and Lasix

52. Altitude HACE Severe headache Ataxia Fatigue Vomiting
ALOC/Changes in Bx/Unconscious
Tx-
Dissent
High flow 02
steroids
Hyperbaric Bag

53. Lighting Common targets
outdoor activities (boaters, swimmers, golfers)
Anyone in a large, open area
Individuals are indirectly struck when standing near an object that has been struck by lightning.
Cardio and Nervous System injury
Cardiac arrest

54. Lighting Cont. Injuries range from mild to severe S/SX assessment Tx
Move patient quickly
ABC
O2, IV, EKG (monitor for EKG changes)
Reverse triage

55. General Assessment of Insect bites
Signs and Symptoms
Localized pain, redness, swelling, skin wheal.
Idiosyncratic reactions
Observe for signs of an allergic reaction.
Localized pain, redness, swelling, skin wheal
Generalized flushing of the skin or itching
Tachycardia, hypotension, bronchospasm, laryngeal edema, facial edema, uvular swelling

56. General Treatment of Insect bites
Wash the area.
Remove stingers, if present.
Use care not to disturb the venom sac.
Apply cool compresses to the injection site.
Observe for and treat allergic reactions and/or anaphylaxis.

57. Spider bites Numerous spider and spiders species Two to worry about
Black Widow
Brown Recluse
Black with a, bright red-orange marking in the shape of an hourglass on its abdomen
Every state except Alaska
Prefers dry, dark places
Venom is Neurotoxic

58. Spiders
Brown Recluse
Dull brown in color and 1″ long and has a violin-shaped mark on its back
Lives mostly in the southern and central parts of the country but can be found throughout the U. S.
Venom is Cytotoxic
Like dark areas

59. Spiders S/SX Black Widow bite is sometimes overlooked.
Localized pain and symptoms, including muscle spasms
Dizziness
Sweating
Nausea/Vomiting
Rashes
Chest tightness/Difficulty breathing
Symptoms end after 48 hours

60. Spiders S/SX Brown Recluse Local tissue damage
The skin is swollen and tender, with pale, mottled, cyanotic center
The bite is not painful at first
Chills, fever,
nausea, vomiting,
joint pain may also develop.

61. Spider Treatment-Supportive
Black Widow
ABC
O2,IV,EKG monitor for dysthymias
Treat signs and symptoms
Consider using muscle relaxants to relieve severe muscle spasms.
Diazepam 2.5–10 mg IV
calcium gluconate solution 0.1–0.2 mg/kg of a 10% IV
Brown Recluse
O2,IV,EKG
Note area and extent of damage

62. Other Insects BEE, ANTS,WASP Scorpions
ABC monitor for Allergic reaction
O2,IV,EKG
EPI PRN
Remove stinger
Scorpions
Eight-legged arachnids/ venom gland/stinger at the end of their tail.
Rare and live southwest
Usually not very dangerous One exception

63. Insects Centruroides sculpturatus Tx Circulatory collapse
Severe muscle contractions
Excessive salivation
Hypertension
Convulsions and cardiac failure
(Sludge mm) Tx
ABC
O2,IV,EKG
Rapid transport
Apply a constricting band?

64. Insects Ticks Burrow under skin Mostly during summer months
Less than an inch long, found in wooded areas/beaches
Saliva carries disease/Transmission 12 hours
Rocky Mountain Spotted Fever
Mechanism
7 to 10 days after the bite
S/Sx
Petechial Rash-Palms to feet
Nausea/Vomiting
Headache
Weakness/Paralysis
Cardiorespiratory collapse
Bacteria Rickettsia RICKETTIS the big sign is this petechial rash which starts on the hands and will travel down to the feet it can be lethal.

65. RMSF

66. Insects Ticks cont. Lyme disease Tx Mechanism
Rash to bull-eyes pattern
Disease of the joints/Pain and Swelling
Ohio reports Tx
Do not attempt to suffocate or burn the tick.
KY Jelly?
Use tweezers, grab the tick by the body and pull it straight out of the skin.
Disinfect the area
Lyme disease mech=spirochete borrelia burgdorferi bacteria. The rash is actually the bodies reaction to the bacteria.
CDC.Ohio reports 36 confirmed cases in 2011

67. Lyme

68. Snakes Cottonmouths Ohio exotic animal problem
Over a hundred different species in US
Most are defensive not aggressive
19 are venomous
Rattlesnakes, copperheads, cottonmouths or water moccasins, and coral snakes
PitVipers
Small pits that contain poison located just behind each nostril and in front of each eye.
Triangular heads
Rattlesnakes
Copperheads
Cottonmouths
Most Common in Ohio?
Rattlesnakes
Most common form of pit viper
Many patterns of color
Can grow to 6′ or longer
Copperheads
Usually 2′ to 3′ long
Reddish coppery color crossed with brown and red bands
Cottonmouths
Olive or brown with black cross-bands and a yellow undersurface
Water snakes with aggressive behavior
Tissue destruction may be severe
Most common in Ohio are the Eastern timber rattlesnake/the northern copperhead/ and the Massasauga rattlesnake

69. PitViper S/SX Burning or pain at the site of injury
Swelling and bluish discoloration
Weakness
Nausea and vomiting
Sweating
Seizures/Fainting
Blurred Vision or changes in vision
Altered level of consciousness

70. PitVipers

71. Coral Snakes “Red on Black venom lack, Red on Yellow kill a fellow”
King Sakes Vs. Coral Snakes
Venom causes paralysis of the nervous system.
Within a few hours of being bitten
Bizarre behavior
Paralysis of eye movements
Paralysis of respiratory system
Other S/SX
Numbness, weakness, drowsiness, ataxia, slurred speech, excessive salivation,
Drooping of the eyelids, double vision, dilated pupils, abdo pain, N&V, LOC, SZR hypotension
Antivenin is available, but most hospitals do not stock it.

72. Snakes
King
Coral

73. Snakes

74. Snake Treatment ABC O2,IV,EKG Note injury area Flush it and Splint it
Keep Pt. Calm and as still as possible
DO NOT apply constricting bands, ice, cold packs, tourniquets
Hospitals with Antivenom?

75. Marine Animals Include: Jelly Fish, Portuguese Man O War, sea Anemones
Nematocysts
Acids (Vinegar, Urine?)
S/Sx
Painful, reddish lesions
Man O War extremely painful
Headache/Dizziness
Muscle cramps
Fainting

76. Marine Animals Tx Establish and maintain the airway.
Apply a constricting band above the site.
Apply heat or hot water.
Inactivate or remove any stingers.
Vinegar

77. PMOW
PMOW
Sting

78. THE END