EMS Module 8 - Ch. 25 Environmental Emergencies

Question 1

Conduction

Answer 1

The transfer of heat from one material to another through direct contact

Question 2

Water chill

Answer 2

Chilling caused by conduction of heat from the body when the body or clothing is wet

Question 3

Convection

Answer 3

Body heat is lost to surrounding air, which becomes warmer, rises, and replaced with cooler air

Question 4

Respiration

Answer 4

Heat is lost through exhalation of warm air and inhalation of cold air

Question 5

Evaporation

Answer 5

Perspiration or wet skin results in body heat loss when the liquid evaporates

Question 6

Wind chill

Answer 6

Chilling caused by convection of heat from the body in the presence of air currents

This is a frequent problem

Question 7

Radiation

Answer 7

Sending out energy, such as heat, in waves into space.

Most radiant heat loss occurs from a person’s head and neck

Question 8

Stages of hypothermia

Answer 8

99°F–96°F - Shivering
95°F–91°F - Intense shivering, difficulty speaking
90°F–86°F - Shivering decreases and is replaced by strong muscular rigidity. Muscle coordination is affected, and erratic or jerky movements are produced. Thinking is less clear, general comprehension is dulled, and possible total amnesia exists. Patient generally is able to main the appearance of psychological contact with surroundings
85°F–81°F - Patient becomes irrational, loses contact with the environment, and drifts into a stuporous state. Muscular rigidity continues. Pulse and respirations are slow, and cardiac dysrhythmias may develop
80°F–78°F - Patient loses consciousness and does not respond to spoken words. Most reflexes cease to function. Heartbeat slows further before cardiac arrest occurs

Question 9

Hypothermia

Answer 9

Also known as “generalized cooling”. Reduces body temperature below normal, which is a life-threatening condition in its extreme

Question 10

Hypothermia is often an especially serious problem for the aged

Answer 10

The effects of cold temperatures on the ederly are more immediate. Failing body systems, chronic illnesses, poor diets, certain medications, and a lack of exercise may combine with the cold environment to bring about hypothermia

Question 11

Infants and children are especially prone to hypothermia

Answer 11

Because they are small with large skin surface areas in relation to heir total body mass and have little body fat.

Because of their small muscle mass, infants and children do not shiver very much or at all - another reason the very young are susceptible to the cold

Question 12

Consider the possibility of hypothermia in the following situations when another condition or injury may be more obvious

Answer 12

• Ethanol (alcohol ingestion)
• Underlying illness
• Overdose or poisoning
• Major trauma
• Outdoor resuscitation
• Decreased ambient temperature (for example, room temperature)

Question 13

Passive rewarming

Answer 13

Allows the body to rewarm itself. It involves simply covering the patient and taking other steps, including removal of wet clothing, to prevent further heat loss.
These actions allow the body to naturally regain its warmth

Question 14

Active rewarming

Answer 14

Includes application of an external heat source to the body

All EMS systems permit passive rewarming. Although some allow the active rewarming of hypothermic patient who is alert and responding appropriately, many do not. Follow your local protocols

Question 15

For the hypothermic patient who is alert and responding appropriately, proceed with active rewarming:

Answer 15

1. Remove all of the patient’s wet clothing. Keep the patient dry, and dress the patient in dry clothing or wrap in dry, warm blankets. Keep the patient still, and handle him very gently. Do not allow the patient to walk or exert himself. Do not massage his extremities
2. During transport, actively rewarm the patient. Gently apply heat to the patient’s body in the form of heat packs, hot water bottles, electric heating pads, warm air, radiated heat, and even your own body heat. Do not warm the patient too quickly. Rapid warming will circulate peripherally stagnated cold blood and rapidly cool the vital central areas of the body, possibly causing cardiac arrest. If transport is delayed, move the patient to a warm environment if at all possible
3. Provide care for shock. Provide oxygen, warmed and humidified if possible
4. Give the alert patient warm liquids at a slow rate. When warm fluids are given too quickly, the patient’s circulation patterns change. Blood is sent away from the core and instead routed to the skin and extremities. Do not allow the patient to eat or drink stimulants
5. Except in the mildest of cases (shivering), transport the patient. Continue to provide high-concentration oxygen and monitor vital signs. Never allow a patient to remain in or return to a cold environment

Question 16

Take the following precautions when actively rewarming a patient:

Answer 16

• Rewarm the patient slowly. Handle the patient with great care, just as if there were unstabilized cervical-spine injuries
• Use CENTRAL REWARMING. Heat should be applied to the lateral chest, neck, armpits, and groin. You must avoid rewarming the limbs. If they are warmed first, blood will collect in the extremities due to vasodilation (dilation of blood vessels), possibly causing a fatal from of shock. If you rewarm the trunk and leave the lower extremities exposed, you can control the rewarming process and help prevent most of the problems associated with the procedure
• If transport must be delayed, giving the patient a warm bath is very helpful. However, keep the patient alert enough so he does not drown. Do not warm the patient too quickly
• Keep the patient at rest. Do not allow the patient to walk. Since the blood is coldest in the extremities, exercise or unnecessary movement could quickly circulate the cold blood and lower the core body temperature
• Avoid any rough handling of the hypothermic patient. Such activity may set off fatal dyshythmias, especially ventricular fibrillation

Question 17

A patient who is unresponsive or not responding appropriately has….

Answer 17

Severe hypothermia

Question 18

For the patient who has severe hypothermia you should…

Answer 18

Provide passive rewarming.

• Do not try to actively rewarm the patient with severe hypothermia
• *Remove the patient from the environment, and protect him from further heat loss. Active rewarming may cause the patient to develop ventricular fibrillation and other complications. Active rewarming can be initiated after arrival at the emergency department in a more monitored setting

Question 19

For the patient with severe hypothermia you should…

Answer 19

1. Ensure an open airway
2. Provide high-concentration oxygen that has been passed through a warm-water humidifier. If necessary, you can use the oxygen that has been kept warm in the ambulance passenger compartment. If there is no other choice, you can use oxygen from a cold cylinder
3. Wrap the patient in blankets. If available, use insulating blankets. Handle the patient as gently as possible, as rough handling may cause ventricular fibrillation. Do not allow the patient to eat or drink stimulants. Do not massage his extremities
4. Transport the patient immediately

Question 20

In cases of extreme hypothermia…

Answer 20

You will find the patient unconscious with no discernible vital signs. The heart rate can slow to less than 10 beats per minute, and the patient will feel very cold to your touch (core body temperature may be below 80°F). Even so, it is possible that a patient in this condition is still alive!

Question 21

If a patient suffering from extreme hypothermia is STILL alive, provide emergency care as follows:

Answer 21

• Assess the carotid pulse for 30 to 45 seconds. If there is no pulse, start CPR immediately and prepare to apply the AED
• If there is a pulse, follow the care steps for a patient who is unresponsive or not responding appropriately as previously listed

Question 22

Why will the hospital staff NOT pronounce a patient dead until after they have rewarmed him and applied resuscitative measures?

Answer 22

Because the hypothermic patient may bot reach biological death for more than 30 minutes

Question 23

Local cooling

Answer 23

Cold-related emergencies also can result from this.
Those affecting particular (local) parts of the body, are classified as (1) early or superficial and (2) late or deep
*Local cooling most commonly affects the ears, nose, face, hands and fingers, and feet and toes. When a part of the body is exposed to an intense cold, blood flow to that part is limited by the constriction of blood vessels.
*When this happens, tissues freeze. Ice crystals can form in the skin and, in the most severe cases, gangrene (localized tissue death) can set in, which may ultimately lead to the loss of the body part

Question 24

Patient assessment early or superficial local cold injury

Answer 24

Early or superficial local cold injuries (sometimes called frostnip) are brought about by direct contact with a cold object or exposure to cold air. Wind chill and water chill also can be major factors. In this condition tissue damage is minor and response to care is good. The tip of the nose, tips of the ears, upper cheeks, and fingers (all are areas that are usually exposed) are most susceptible to early or superficial local cold injuries.

**The injury, as its name suggests, is localized with clear demarcation of its limits. Patients are often unaware of the onset of an early local cold injury until someone indicates that there is something unusual about the person’s skin color

Question 25

The following are common signs and symptoms of early or superficial local cold injuries

Answer 25

• The affected area in patients with light skin reddens; in patients with dark skin, it lightens. Both then blanch (whiten). Once blanching begins, the color change can take place very quickly
• The affected area feels numb to the patient

Question 26

Patient care for Early or Superficial local cold injury

Answer 26

1. Get the patient out of the cold environment
2. Warm the affected area
3. If the injury is to an extremity, splint and cover it. Do not rub or massage the area, and do not reexpose it to the cold

Question 27

During recovery from an early local cold injury, the patient may….

Answer 27

Complain about tingling or burning sensations, which is normal. If the condition does not respond to this simple care, begin to treat for a late or deep local cold injury

Question 28

Patient assessment late or deep local cold injury

Answer 28

(Also known as frostbite) develops if an early or superficial local cold injury goes untreated. In late or deep local cold injury, the skin and subcutaneous layers of the body part are affected. Muscles, bones, deep blood vessels, and organ membranes can become frozen

Question 29

The following are common signs and symptoms of late or deep local cold injury

Answer 29

• Affected skin appears white and waxy. When the condition progresses to actual freezing, the skin turns mottled or blotchy, and the color turns from white to grayish yellow and finally to grayish blue. Swelling and blistering may also occur
• The affected area feels frozen but only on the surface. The tissue below the surface is still soft and has its normal resilience, or “bounce”. With freezing, the tissues are not resilient and feel frozen to the touch

Question 30

Initial emergency care for late or deep local cold injury - frostbite and freezing - is as follows

Answer 30

1. Administer high-concentration oxygen
2. Transport to a medical facility without delay, protecting the frostbitten or frozen area by covering it and handling it as gently as possible
3. If transport must be delayed, get the patient indoors and keep him warm. Do not allow the patient to drink alcohol or smoke because constriction of blood vessels and decreased circulation to the injured tissues may result. Rewarm the frozen part as per local protocol, or request instructions from medical direction

Question 31

Active rapid rewarming of frozen parts

Answer 31

Active rewarming of frozen parts is seldom recommended. The chance of permanently injuring frozen tissues with active rewarming is too great. Consider it only if local protocols recommend it, if you are instructed to do so by medical direction, or if transport will be severely delayed and you cannot reach medical direction for instructions

Question 32

If you are in a situation where you must attempt rewarming without instructions from a physician, you will need the following

Answer 32

Warm water and a container in which you can immerse the entire site of injury without the limb touching the sides or bottom of the container. If you cannot find a suitable container, fashion one from a plastic bag supported by a cardboard box or wooden crate

Question 33

If you are in a situation where you must attempt rewarming without instructions from a physician, follow the procedure as follows

Answer 33

1. Heat water to between 100°F and 105°F. You should be able to put your finger into the water without experiencing discomfort
2. Fill the container with the heated water, and prepare the injured part by removing clothing, jewelry, bands, or straps. Thawed areas often swell, so you need to remove potentially constricting items beforehand
3. Fully immerse the injured part. Do not allow the injured area to touch the sides or bottom of the container. Do not allow the injured area to touch the sides or bottom of the container. Do not place any pressure on the affected part. Continuously stir the water. When the water cools below 100°F, remove the affected part and add more warm water. The patient may complain of moderate pain as the affected area rewarms, or he may experience intense pain. Pain is usually a good indicator of successful rewarming
4. If you complete rewarming of the part (it no longer feels frozen and is turning red or blue), gently dry the affected area, and apply a dry sterile dressing. Place dry sterile dressings between the patient’s fingers and toes before dressing his hands and feet. Next cover the site with blankets or whatever is available to keep the area warm. Do not allow these coverings to come in direct contact with the injured area or to put pressure on the site. First try to build some sort of framework on which the coverings can be placed
5. Keep the patient at rest. Do not allow the patient to walk if a lower extremity has been frostbitten or frozen
6. Make certain that you keep the entire patient’s head as warm as possible without overheating him. Cover the patient’s head with a towel or a small blanket to reduce heat loss. Leave the patient’s face exposed.
7. Continue to monitor the patient
8. Assist circulation according to local protocols (some systems recommend rhythmically and carefully raising and lowering the affected limb)
9. Do not allow the limb to refreeze

Question 34

Hyperthermia

Answer 34

An abnormally high body temperature. If left unchecked, it will lead to death. Heat and humidity are often associated with hyperthermia