1. CHAPTER 30: ENVIRONMENTAL EMERGENCIES
PATIENT ASSESSMENT & CARE II
EMS 246
Dr.Bushra Bilal

2. ENVIRONMENTAL EMERGENCIES
Environmental emergencies are defined as “sudden-onset disasters or accidents resulting from natural, technological or human-induced factors, or a combination of these, that causes or threatens to cause severe environmental damage as well as loss of human lives and property.

3. Factors Affecting Exposure
Physical condition.
Age (infants and older adults affected more)
Nutrition and hydration
Alcohol will change the body’s ability to regulate temperature.
Environmental condition:
Air temperature
Humidity level
Wind

4. Cold Exposure (1 of 3) Cold exposure may cause injury to: Feet Hands
Ears
Nose
Whole body (hypothermia)
There are five ways the body can lose heat.

5. Cold Exposure (2 of 3) Conduction
Direct transfer of heat from a part of the body to a colder object by direct contact e.g. When a warm hand touches cold metal or ice
Convection
is the circular motion that happens when warmer air or liquid — which has faster moving molecules, making it less dense — rises, while the cooler air or liquid drops down (weather).
Evaporation
is the process of a substance in a liquid state changing to a gaseous state due to an increase in temperature and/or pressure.

6. Cold Exposure (3 of 3) Radiation
Transfer of heat by radiant energy( a type of invisible light that transfers heat (microwave oven ).)
Respiration
Loss of body heat during normal breathing

7. Hypothermia (1 of 4)
Lowering of the core temperature below 95°F (35°C).
Can lead to death
People at risk:
Homeless people
Swimmers
Geriatric, young infants and children

8. Hypothermia (2 of 4)
Progresses through four general stages

9. Hypothermia (3 of 4) Assess general temperature.
Pull back your gloves and place the back of your hand on the patient’s abdomen.
Use a hypothermia thermometer.

10. Hypothermia (4 of 4)
More severe hypothermia
Occurs when the core temperature is less than 90°F (32°C)
Shivering stops.
Muscular activity decreases.
Mild hypothermia
Occurs when the core temperature is between 90°F and 95°F (32°C and 35°C)
Patient is usually alert and shivering
Pulse rate and respirations are rapid.

11. Local Cold Injuries (1 of 2)
Most injuries from cold are confined to exposed parts of the body.
Extremities (especially the feet)
Ears
Nose
Face

12. Local Cold Injuries (2 of 2)
Underlying factors:
Exposure to wet conditions
Restricted circulation from tight clothing or shoes, or circulatory disease
Poor nutrition, Alcohol or drug abuse
Hypothermia
Diabetes
Cardiovascular disease
Older age/Fatigue

13. Frostnip and Immersion Foot (1 of 2)
After prolonged exposure to the cold, skin is freezing but deeper tissues are unaffected. is a superficial cooling of tissues without cellular destruction.
Usually affects the ear, nose, and fingers
Immersion foot
Also called trench foot
Occurs after prolonged exposure to cold water
Common in hikers and hunters

14. Frostnip and Immersion Foot (2 of 2)
Signs and symptoms of both
Skin is pale and cold to the touch.
Normal color does not return after palpation of the skin.
The skin of the foot may be wrinkled but can also remain soft.
The patient reports loss of feeling and sensation in the injured area.

15. Frostbite Signs and symptoms Most frostbitten parts are hard and waxy.
The injured part feels firm to frozen.
Blisters and swelling may be present.
the skin may appear red with purple and white, or mottled and cyanotic.
Most serious local cold injury because the tissues are actually frozen

16. Assessment of Cold Injuries
Patient assessment steps
Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment

17. Scene Size-up Scene safety Mechanism of injury/nature of illness
Note the weather conditions.
Identify safety hazards such as icy roads, mud, or wet grass.
Use appropriate standard precautions.
Mechanism of injury/nature of illness
Look for indicators of the MOI.

18. Primary Assessment Form a general impression. Perform a rapid scan.
Evaluate mental status using the AVPU scale.
Airway and breathing
Ensure that the patient has an adequate airway
Circulation
Palpate for a carotid pulse and wait 30 to 45 seconds to decide if the patient is pulseless
Transport decision
All patients with hypothermia require immediate transport

19. History Taking Investigate the chief complaint.
Obtain a medical history..
SAMPLE history
Find out how long your patient has been exposed to the cold environment.

20. Secondary Assessment Physical examinations
Assess the areas of the body directly affected by cold exposure and extent of damage
Vital signs
Respirations may be slow and shallow.
Low blood pressure and a slow pulse indicate moderate to severe hypothermia.
Evaluate for changes in mental status.
Monitoring devices
Determine a core body temperature using a thermometer.

21. Reassessment . Repeat the primary assessment
Monitor the patient’s vital signs.
Interventions
Review all treatments that have been performed.
Communication and documentation
Communicate all of the information you have gathered to the receiving facility .

22. General Management of Cold Emergencies (1 of 2)
Move the patient from the cold environment..
Remove any wet clothing.
Place dry blankets over and under the patient.
When the patient has moderate or severe hypothermia, never try to actively rewarm the patient.

23. General Management of Cold Emergencies (2 of 2)
Give the patient warm, humidified oxygen.
Do not allow the patient to eat, smoke or chew tobacco.
In case of mild hypothermia:
Apply heat packs or hot water bottles to the groin, axillary, and cervical regions.
Rewarm the patient slowly.
Give warm fluids by mouth

24. Emergency Care of Local Cold Injuries
Remove the patient from further exposure to the cold.
Administer oxygen.
Remove any wet or restricting clothing over the injured part.
Consider active rewarming.

25. Heat Exposure Normal body temperature is 98.6°F
Hyperthermia is a core temperature of 101°F (38.3°C) or higher.
Risk factors :
High air temperature,High humidity,Vigorous exercise
Persons at greatest risk:
Children, Geriatric patients
Patients with heart disease, COPD, diabetes, dehydration, and obesity

26. 1.Heat Cramps Painful muscle spasms that occur after vigorous exercise
Usually occur in the leg or abdominal muscles

27. 2.Heat Exhaustion Causes : Heat exposure, stress, Hypovolemia etc.
Signs and symptoms
Dizziness, weakness, or faintness
Change in LOC with accompanying nausea, vomiting, or headache
Muscle cramping
Cold, clammy skin with ashen pallor
Dry tongue and thirst

28. 3.Heatstroke (1 of 2) Typical onset situations
During vigorous physical activity
Outdoors
During heat waves without sufficient air conditioning or poor ventilation
Child left unattended in a locked car on a hot day

29. Heatstroke (2 of 2) Signs and symptoms Hot, dry, flushed skin
Early on, skin may be moist or wet.
Quickly rising body temperature
Falling LOC (leading to unconsciousness)
Change in behavior , Unresponsiveness
Seizures
Strong, rapid pulse at first, becoming weaker with falling blood pressure
Increasing respiratory rate, Lack of perspiration

30. Assessment of Heat Injuries
Patient assessment steps
Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment

31. Scene Size-up Scene safety
Protect yourself from heat and biologic hazards.
Mechanism of injury/nature of illness
Look for indicators of the MOI.
Form a general impression.
Perform a rapid scan and avoid tunnel vision.
Assess mental status

32. Primary Assessment Airway and breathing Transport decision
Provide oxygen.
If unresponsive, insert an airway and provide bag-mask device ventilations.
Circulation
Palpate a pulse..
Assess the patient’s skin condition.
Treat for shock
Transport decision
If your patient has any of the following signs of heatstroke, transport immediately.
High temperature
Red, dry skin
Altered mental status
Tachycardia
Poor perfusion

33. History Taking Investigate the chief complaint.
Be alert for injury-specific signs and symptoms.
Absence of perspiration
Decreased level of consciousness
Confusion
Muscle cramping
Nausea and vomiting
SAMPLE History
Note any activities, conditions, medications. exposure to heat and activities prior to onset.

34. Secondary Assessment Physical examinations
Assess the patient for muscle cramps or confusion and take the patient’s vital signs
Vital signs
Patients who are hyperthermic will be tachycardic and tachypneic.
In heat exhaustion, the skin temperature may be normal or cool and clammy.
In heatstroke, the skin is hot

35. Reassessment Watch for deterioration
Monitor vital signs at least every 5 minutes.
Interventions
Remove the patient from the hot environment.
Patients with symptoms of heatstroke should be transported immediately.
Communication and documentation
Inform the staff at the receiving facility early on that your patient is experiencing a heatstroke

36. Management of Heat Emergencies
Heatstroke
Move the patient out of the hot environment .
Set air conditioning to maximum cooling.
Remove the patient’s clothing.
Give 100% oxygen.
Cover the patient with wet towels or sheets.
Transport immediately to the hospital
Heat cramps
Remove the patient from the hot environment.
Administer high-flow oxygen.
Rest the cramping muscles.
Replace fluids by mouth.
Cool the patient with water spray or mist.

37. Radiation Exposure Causes of radiation exposure: Cell phones
Microwave ovens
Ultraviolet (UV) light from the sun
Long-term exposure to UV light is one of the main risk factors of skin cancer. .

38. Drowning Risk factors Alcohol consumption
Preexisting seizure disorders
Geriatric patients with cardiovascular disease
Unsupervised access to water

39. Spinal Injuries in Submersion Incidents
Suspect spinal injury if:
Submersion has resulted from a diving mishap or long fall.
The patient is unconscious.
The patient complains of weakness, paralysis, or numbness.
Stabilize the suspected injury while the patient is still in the water.

40. Resuscitation Efforts
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.
Slowing of the heart rate caused by submersion in cold water

41. 1.Descent Emergencies
Caused by the sudden increase in pressure as the person dives deeper into the water
Typical areas affected
Lungs, Sinus cavities, Middle ear, Teeth, Face
Perforated tympanic membrane
Cold water may enter the middle ear through a ruptured eardrum.
The diver may lose his or her balance and orientation

42. 2.Emergencies at the Bottom
Caused by faulty connections in the diving gear
Can cause drowning or rapid ascent

43. 3.Ascent Emergencies Air embolism Most dangerous diving emergencies
Bubbles of air in the blood vessels
. Decompression sickness
Also called “the bends”
Bubbles of gas, especially nitrogen, obstruct the blood vessels.
Causes:
Too rapid an ascent from a dive
Too long of a dive at too deep of a depth

44. Ascent Emergencies Signs and symptoms Severe abdominal or joint pain
Treatment is the same for both.
Basic life support (BLS)
Recompression in a hyperbaric chamber

45. Assessment of Drowning and Diving Emergencies
Patient assessment steps
Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment

46. Scene Size-up Scene safety Gloves and eye protection
Never attempt a water rescue without proper training and equipment.
Consider trauma and spinal stabilization..
Mechanism of injury/nature of illness
Look for indicators of the MOI

47. Primary Assessment Circulation Form a general impression.
If the pulse is unmeasurable, the patient may be in cardiac arrest.
Begin CPR
Evaluate for shock and perfusion.
Transport decision
Always transport near-drowning patients to the hospital.
Form a general impression.
Pay attention to chest pain, dyspnea, and complaints of sensory changes.
Determine the LOC.
Airway and breathing
Open the airway and assess breathing in unresponsive patients.
Consider spinal trauma and continually monitor breath sounds

48. History Taking Investigate the chief complaint.
Obtain a medical history.
Be alert for injury-specific signs.
SAMPLE history
Determine the length of time the patient was underwater or the time of onset of symptoms.
Note any physical activity, alcohol or drug use, or other medical conditions

49. Secondary Assessment Vital signs Physical examinations
Pulse rate, quality, and rhythm
Respiratory rate, quality, and rhythm
Pupil size and reactivity .
Physical examinations
Examine lungs and breath sounds.
Look for trauma, indications of the bends or air embolism, and signs of hypothermia.
Obtain a Glasgow Coma Scale score.
Assess for:
Peripheral pulses, Skin color and discoloration, Itching, Pain, Paresthesia (numbness and tingling).

50. Reassessment Repeat the primary assessment. Interventions
Artificial ventilation should begin as soon as possible, even before the victim is removed from the water.
Communication and documentation
Document:
Circumstances of drowning and extrication
Time submerged
Temperature and clarity of the water
Possible spinal injury

51. Emergency Care for Drowning or Diving Emergencies
For air embolism or decompression sickness:
Remove the patient from the water.
Try to keep the patient calm.
Administer oxygen.
Place the patient in a left lateral recumbent position with the head down.
Provide prompt transport.

52. 2.Emergencies at the Bottom
Caused by faulty connections in the diving gear
Can cause drowning or rapid ascent

53. 3.Ascent Emergencies Air embolism Most dangerous diving emergencies
Bubbles of air in the blood vessels
. Decompression sickness
Also called “the bends”
Bubbles of gas, especially nitrogen, obstruct the blood vessels.
Causes:
Too rapid an ascent from a dive
Too long of a dive at too deep of a depth

54. Ascent Emergencies Signs and symptoms Severe abdominal or joint pain
Treatment is the same for both.
Basic life support (BLS)
Recompression in a hyperbaric chamber

55. Assessment of Drowning and Diving Emergencies
Patient assessment steps
Scene size-up
Primary assessment
History taking
Secondary assessment
Reassessment

56. Scene Size-up Scene safety Gloves and eye protection
Never attempt a water rescue without proper training and equipment.
Consider trauma and spinal stabilization..
Mechanism of injury/nature of illness
Look for indicators of the MOI

57. Primary Assessment Form a general impression. Circulation
Pay attention to chest pain, dyspnea, and complaints of sensory changes.
Determine the LOC.
Airway and breathing
Open the airway and assess breathing in unresponsive patients.
Consider spinal trauma and continually monitor breath sounds
Circulation
If the pulse is unmeasurable, the patient may be in cardiac arrest.
Begin CPR
Evaluate for shock and perfusion.
Transport decision
Always transport near-drowning patients to the hospital.

58. History Taking Investigate the chief complaint.
Obtain a medical history.
Be alert for injury-specific signs.
SAMPLE history
Determine the length of time the patient was underwater or the time of onset of symptoms.
Note any physical activity, alcohol or drug use, or other medical conditions

59. Secondary Assessment . Vital signs Pulse rate, quality, and rhythm
Respiratory rate, quality, and rhythm
Pupil size and reactivity .
Physical examinations
Examine lungs and breath sounds.
Look for trauma, indications of the bends or air embolism, and signs of hypothermia.
Obtain a Glasgow Coma Scale score.
Assess for:
Peripheral pulses, Skin color and discoloration, Itching, Pain, Paresthesia (numbness and tingling).

60. Reassessment Repeat the primary assessment. Interventions
Artificial ventilation should begin as soon as possible, even before the victim is removed from the water.
Communication and documentation
Document:
Circumstances of drowning and extrication
Time submerged
Temperature and clarity of the water
Possible spinal injury

61. Emergency Care for Drowning or Diving Emergencies
For air embolism or decompression sickness:
Remove the patient from the water.
Try to keep the patient calm.
Administer oxygen.
Place the patient in a left lateral recumbent position with the head down.
Provide prompt transport.

62. SUMMARY
Local cold injuries include frostbite, frostnip, and immersion foot. Frostbite is the most serious because tissues actually freeze.
Do not consider a patient dead until he or she is “warm and dead.” Local protocol will dictate whether or not such patients receive cardiopulmonary resuscitation or defibrillation in the field.
Heat illness can take three forms: heat cramps, heat exhaustion, and heatstroke.

63. SUMMARY
The first rule in caring for drowning victims is to be sure not to become a victim yourself. Protect the spine when removing patients from the water because spinal cord injuries often occur in drowning. Be aware of the possibility of hypothermia.
Injuries associated with scuba diving may be immediately apparent or may show up hours later. Patients with air embolism or decompression sickness may have pain, paralysis, or altered mental status. Be prepared to transport such patients to a recompression facility with a hyperbaric chamber.
Poisonous spiders include the black widow spider and the brown recluse spider.
Poisonous snakes include pit vipers and coral snakes.

64. UNIT ASSESSMENT How does frostbite differ from frostnip?
What are the two most efficient ways the body can cool itself?
What is the most common and dangerous scuba diving emergency?
What type of spider has venom that is neurotoxic?