hello and welcome to chapter 33 environmental emergencies of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the physiology of environmental injuries you will have learned the proper assessment and management of general and specific types of environmental emergencies including hypothermia local cold injuries such as frostbite and heat exposure illnesses such as heat stroke you will learn the associated signs and symptoms and emergency treatment of drowning diving emergencies high altitude sickness lightning strikes and bites from spiders and marine life snakes scorpions and ticks okay so let's get started environmental factors such as temperature and atmospheric pressure can overwhelm the body's ability to cope with its surroundings medical emergencies can result certain populations are at a higher risk and those are children older people people with chronic illnesses young adults who over exert themselves environmental emergencies often accompany other illnesses and injuries that require treatment at the same time environmental emergencies include heat and cold related emergencies water emergencies pressure related injuries caused by diving in high altitude climbing and injuries caused by lightning and venomation caused by bites and stings factors affecting exposure so there are four factors that affect how a person deals with heat or cold the factors are physical condition age and nutrition and hydration so first we're going to talk about physical condition so patients who are ill who are in poor physical condition will not tolerate extreme temperatures well then there's age so infants children and older adults are more likely to experience temperature related illnesses infants have a poor thermal regulation at birth and do not have the ability to shiver and generate heat when needed until about 12 to 18 months of age children may not think to or be able to put on extra clothing and then you have older adults there's a loss of subcutaneous tissue which reduces the amount of insulation they have poor circulation also contributes to heat loss and medications can affect the body's thermostat putting a person at an increased risk for temperature related emergencies also high risk of for falls and laying immobile on a hot or cold surface can contribute and then there's nutrition and hydration a lack of food or water will aggravate heat or cold stress and also alcohol will change the body's ability to regulate temperature and then there's environmental conditions so air temperature humidity level and wind can complicate or improve environmental situations extremes in temperature and humidity are not needed to produce heat or cold injuries consider the environment and whether your patient is prepared for that situation so first we're going to talk about cold exposures if the body or any part of it ex is exposed to cold environments temperature regulatory mechanisms will be overwhelmed cold exposure may cause injuries to the hands and feet ears nose or the whole body there are five ways the body can lose heat the first one we're going to talk about is conduction and that's the transfer of heat from a part of the body to a colder object by direct contact and then there's convection convection is the transfer of heat to circulating air as when the coal air moves across the body there's enviro evaporation and that's that conversion of liquid to gas then radiation so that's a transfer of heat by radiant energy and then of course respiration so body heat loss as warm air in the lungs is exhaled into the atmosphere and cooler air is inhaled the rate and amount of heat loss or gain by the body can be modified in three ways you can increase or decrease in the heat production so shivering and increasing movement when cold will increase heat production and decreasing and limiting movement when hot will decrease heat production also moving to an area where heat loss can be decreased or increase so seek shelter from the wind and cold environments and seek shade in the hot environment and wear the appropriate clothing for the environment so layers of clothing provide good insulation protective clothing traps perspiration and prevents evaporation loosen or remove clothing to cool down so hypothermia cool or core temperature of the body falls below 95 degrees hypothermia occurs the body loses the ability to regulate its temperature and generate body heat so the physiology behind hypothermia is to protect against heat loss the body constricts blood vessels in the skin resulting in blue lips or fingertips the body shivers to generate heat as these mechanisms are overwhelmed body functions begin to slow down and mental status deteriorates eventually key organs such as the heart begins to slow down leading to death so the development of hypothermia it can develop quickly as with cold water immersion or air temperature does not have to be below freezing for hypothermia to occur so there's people who are at higher risk and these are homeless people and those whose homes lack heating or swimmers even in the summer or geriatric patients and ill patients who are less able to adjust to temperature extremes patients with injuries or illness such as burns shock head injury stroke generalized infections injuries to the spinal cord diabetes and hypoglycemia so there's some signs and symptoms and basically they become more severe as the body's core temperature falls hypothermia generally progresses through four stages and so see the table on 33-1 okay so you want to assess the general appearance pull back your glove and place the back of the hand on the patient's abdomen if the abdomen feels cool the patient is likely experiencing a generalized cold emergency a hypothermia thermometer registers body lower body temperatures there's first there's mild hypothermia and this occurs when the core temperature is greater than 93.2 but less than the normal 98 degrees the patient is usually alert and shivering pulse rate and respirations are usually rapid and the skin may appear red or pale or cyanotic then you have moderate hypothermia and that exists when the core temperature is from 86 degrees to 93.2 shivering will stop and muscle activity decreases eventually all muscle activity stops and mental status deteriorates then there's severe hypothermia and this occurs when the core temperature is less than 86 degrees fahrenheit as the core drops towards 85 the patient becomes lethargic and stops fighting the cold the patient appears stiff or rigid if the body temperature continues to fall below 80 degrees the pulse becomes slower and weaker the respirations slow and may become absent and cardiac dysrhythmias can occur at a core temp of less than 80 degrees all cardiopulmonary cardiorespiratory activity may cease pupillary action is slow and the patient may appear dead never assume to that a cold pulseless patient is dead so then there's local cold injuries most injuries from cold are confined to exposed parts of the body when exposed parts of the body become very cold but not frozen injuries such as frost nip and immersion foot or also known as trench foot can result when the parts become frozen though that injury is called frostbite the figure on this slide shows frostbite to the extremities and face important factors in determining the severity of the local injured cold injury are the duration of the exposure temperature to which the body part was exposed and the wind velocity during that exposure consider underlying factors as well so exposure to wet conditions inadequate isolation insulation from colder wind restricted circulation from tight clothing or shoes or circulatory disease and fatigue or poor nutrition alcohol or drug abuse hypothermia diabetes cardiovascular disease and age patients with hypothermia should also be assessed for frostbite and other local cold injuries frost nip and immersion foot so frost nip after prolonged exposure to a cold to the cold skin may freeze while deeper tissues are unaffected usually affects the ears and nose and fingers and usually not painful so the patient often is unaware that a cold injury has occurred then there's immersion foot and occurs after prolonged exposure to cold water common in hikers and hunters who stand for a long time in the river like signs and symptoms are pale cool skin skin on the foot may look wrinkled but um can also remain soft and loss of feeling and sensation in that injured area frostbite the most serious local cold injury because the tissues are actually frozen freezing permanently damages cells and gangrene which is permanent damage or cell death requires surgical removal of that dead tissue the exposed part will become inflamed tender to touch and unable to tolerate exposures to cold signs and symptoms are most frostbitten parts are hard and waxy the injured part feels firm to frozen as you gently touch it blisters and swelling may be present the depth of the skin damage will vary with superficial frostbite only the skin is frozen but with deep frostbite deeper tissues are often frozen so let's talk about the assessment of these cold injuries next and we the management of hypothermia in the field regardless of the severity consists of stabilizing the abcs and preventing further heat loss scene size up so note the environmental conditions we need to understand what the wind chill is whether it's wet or dry and then ensure the scene is safe for you and other responders identify safety hazards such as icy roads mud or wet grass and then use appropriate standard precautions look for indicators of that mechanism of injury and then our primary assessment so of course the first thing we're going to do is form that general impression we're going to perform a rapid scan to determine whether a life threat exists and if so we want to treat that and if the chief complaint is simply being cold quickly assess the patient's core temperature evaluate the patient's mental status quickly using afu scale and then the airway breathing in circulation if you believe the patient is in cardiac arrest proceed directly to the circulation step by providing high quality chest compressions then address airway breathing ensure that the patient has adequate airway and is breathing if your patient's breathing is slow or shallow ventilation with the bvm may be necessary warm humidified oxygen helps warm the patient from the inside out then palpate for the carotid pulse you want to wait for up to 60 seconds to decide if the patient is pulseless the american heart association recommends that cpr to be started on a patient who has no detectable pulse or breathing so perfusion will be compromised based on the degree of cold the patient is experiencing and bleeding may be difficult to find because of the slow moving circulation and thick clothing then there's your transport decision so complications can include cardiac dysrhythmias and blood clotting abnormalities all patients with hypothermia require immediate transport rough handling of hypothermic patients may cause a cold slow or weak heart to fibrillate and the patient to lose any pulse if transportation delayed protect the patient from further heat loss when it comes to the history taking of course we're going to investigate the chief complaint we want to obtain that medical history and be alert for specific signs and symptoms as well as any permanent pertinent negatives sample history so if possible find out how long your patient has been exposed to the environment exposures may be short or prolonged medications and underlying medical problems may have to and may have an impact on the way the cold affects the patient's metabolism the patient's last oil intake and what the patient was doing prior to the exposure will help determine the severity of the cold problem then it's our secondary assessment so the physical findings we want to focus on the severity of the hypothermia and assess the areas of the body directly affected by the cold exposure as well as the degree and extent of damage pay special attention to skin temperatures textures and turgor then there's the vital signs it may be altered by the effects of the hypothermia and can be an indicator of its severity respirations may be slow and shallow resulting in low oxygen levels in the body low blood pressure and a slow pulse may indicate moderate to severe hypothermia and evaluate for changes in mental status using the apu scale determine a core body temperature using a hypothermia thermometer and that's based on your local protocol then your reassessment of course you're going to repeat the primary reassess the vitals in chief complaint monitor the patient's level of consciousness and vital signs rewarming can lead to cardiac dysrhythmias and then you're going to communicate all of the information you've gathered to and give it to the receiving facility so let's talk about management of these cold emergencies all right so we want to move the patient from the cold environment to prevent further heat loss and to prevent further damage to the feet do not allow that patient to walk remove any wet clothing and place dried blankets over and under the patient if available give the patient warm humidified oxygen handle the patient gently do not massage extremities do not allow the patient to eat or use any stimulants such as coffee tea soda or tobacco when it comes to mild hypothermia the patient's going to be active and alert and responding appropriately we want treatment it should involve passing rewarming place the patient in a warm environment and remove the wet clothing apply heat packs and water hot water bottles to the groin axillary and cervical regions turn up the heat too high in the patient compartment of the ambulance and give warm fluids by mouth if the patient is able to swallow moderate or severe hypothermia do not try to actively rewarm the patient rewarming may cause a fatal cardiac dysrhythmia local protocols may dictate the appropriate type of rewarming strategies based on the patient's body temperature the goal is to prevent further heat loss you want to remove the patient immediately from that cold environment remove the wet clothing cover the patient with the blanket and transport handle the patient very gently to decrease the risk of ventricular fibrillation if you cannot get the patient out of the cold immediately move the patient out of the wind and away from contact with any object that will conduct heat away from the body place blankets and waterproof protective cover on the patient and cover the head and neck with a towel always remember that even an unresponsive patient may be able to hear you okay so emergency care for local cold injuries um so this includes the following steps so remove the patient from the cold for their injury handle the injured part gently and protect it from injury and remove any wet or restrictive clothing from the patient especially over the injured part there's if there's no chance of re-injury or if the transport to the ed will be significantly delay delayed consider active rewarming if local protocols allow consult medical control if available with frostnet contact contact with a warm object may be all that is needed immersion foot remove wet shoes boots and socks re-warm the foot gradually protecting it from further cold exposure cover the affected loosely with dry sterile dressing never rub or massage injured tissues rubbing can cause further damage and do not re-expose the injury to cold when it comes to frostbite which is late or deep cold injuries remove the clothing from the injured part cover the injury loosely with dry sterile dressing do not break blisters or rub or massage the area do not apply heat or we re-warm the part and do not allow the patient to stand or walk on a frostbitten foot when you're rewarming in the field if prompt hospital care is not available the medical control and medical control instructs you to begin rewarming in the field use a warm water bath immersion immerse the frostbite part in water with a temperature between 102 to 104 degrees dress the area with sterile dry dressing and including between the injured fingers and toes and expect the patient to report severe pain never attempt to rewarm if there's any chance that the part may freeze again so cold exposure in you you are at risk for hypothermia yourself if you work in a cold environment if cold weather search and rescue is possible in your area then you should receive survival training and precautionary tips stay on top of the weather forecast and make sure proper clothing is available and wear it whenever appropriate so your vehicle must also be properly equipped and maintained all right so now let's talk about heat exposure and in a hot environment or during vigorous physical activity the body tries to rid itself of heat sweating and dilation of blood vessels removal of clothing and relocation to a cooler environment will help with heat exposure hyper thermia is a core temperature above at or above 101 degrees fahrenheit risk factors of heat illness include high air temperature and that reduces the radiation high humidity it reduces evaporation lack of accumulation or acclimation to the heat or vigorous exercise and you're going to have loss of fluid and electrolytes with vigorous exercise okay so there's three forms of heat emergencies and that's heat cramps heat exhaustion and heat stroke and also you could have all three forms that may be present in the same patient okay so persons at a greater risk for heat illness are the same ones um basically with the cold illnesses and so we have children especially newborns and infants geriatric patients patients with heart disease copd diabetes dehydration and obesity and patients with limited mobility so alcohol and certain drugs also make a person more susceptible to heat illnesses because they cause dehydration and decrease the ability to sweat first we're going to talk about the heat cramps and that's a painful muscle spasm that occurs after vigorous exercise do not occur when only when it's hot outside the exact cause is not well understood but occasionally it occurs in leg or in abdominal muscles okay so next we're going to talk about heat exhaustion and it's also called heat collapse so some causes are hypovolemia as a result of the loss of water and electrolytes from heavy sweating also high humidity decreases the amount of evaporation that can occur and exertion in poorly ventilated areas signs and symptoms are dizziness weakness or syncope nausea vomiting and headache cold clammy skin with a ashen pot pallor dry tongue and thirst normal vital signs pulses may be rapid and weak and then normal or slightly elevated body temperature such as it could be as high as 104 degrees fahrenheit when it comes to heat stroke that's least common but the most serious cause of heat exposure and it occurs when the body is subjected to more heat than it can handle and more normal mechanisms for getting rid of the excess heat are overwhelmed if left untreated it always results in death typical onset situations so during vigorous physical activity or outdoors in a closed poorly vented human space during heat waves in buildings without significant air conditioning or with poor ventilation and children left unattended in a locked car on a hot day signs and symptoms are hot dry flesh skin so the patient may still be sweating even with the heat stroke okay so rapid rise and body temperature up to 106 degrees change in behavior unresponsiveness and seizures and rapid weak pulse that becomes weaker increased respiratory rate and then actually perspiring will stop when we're assessing heat emergencies with the scene size up we want to perform an environmental assessment remember that in a heat emergency it may be secondary to a medical or trauma emergency if the patient's unconscious has an altered mental status or requires intravenous fluids to treat for shock consider calling advanced life support assistance look for indicators of a mechanism of injury protect yourself from the heat or biological hazards and stay hydrated and use appropriate standard precautions including gloves and eye protection then you're going to do your primary assessment and you're going to start it by forming the general impression you want to observe how the patient interacts with you and the environment a heat emergency may be the primary or secondary condition so perform a rapid scan avoid tunnel vision and assess the patient's mental status using the avpu scale then of course is the airway and breathing and unless the patient is unresponsive the airway should be patent so nausea and vomiting may occur position the patient to protect the airway as necessary the patient's unresponsive be cautious of how you open the airway and consider spinal immobilization if trauma is possible so if the patient's unresponsive insert an oral airway and provide back valve mass ventilations then there's circulation so if adequate assess the for perfusion and bleeding assess the patient's skin condition and treat for shock by removing the patient from the heat and positioning the patient to improve circulation so if the patient's bleeding damage or bandage according to protocol and if the patient has any signs of heat stroke provide rapid transport next is that history taking so of course investigate the chief complaint and be alert for signs and symptoms then sample history so note the activities conditions or medications that may predispose a patient to dehydration or heat related problems and determine your patient's exposure to heat or humidity and activities prior to the onset of the symptoms and then of course there's that secondary assessment the patient is unresponsive perform a secondary assessment on the entire body if the patient is conscious perform an assessment to the specific area of the body assess the patient from muscle cramps or confusion examine the patient's mental status and take vital signs pay special attention to the patient's skin temperature trigger and level of moisture gently pinch the skin on the forehead or back of the hand and perform a careful neurologic examination then of course you want to check the vital signs so patients who are hyperthermic will be tachycardia and to kidney so falling blood pressure indicates that the patient is going into shock in heat exhaustion the skin temperature may be normal or cold and clammy in heat stroke the skin is hot and then use monitoring devices in the secondary assessment so check the patient's temperature with a thermometer depending on your protocol and in patients with a heat related emergency pulse ox is also indicated and then we're going to do the reassessment we want to watch carefully for deterioration patients with symptoms of a heat stroke should be transported immediately in a cool ambulance passively cooled with removal of clothing and actively cooled by spraying the patient with water and fanning you want to monitor vital signs at least every five minutes and evaluate the effectiveness of your interventions be careful not to over cool the patient you want to inform the staff at the receiving facility early on that your patient is experiencing a heat stroke because additional resources may be required document environmental conditions and the activities the patient was performing prior to your onset then for management of these heat emergencies so when it comes to heat stroke or heat cramps we're going to take the following steps with heat cramps we're going to remove the patient from that hot environment and loosen any tight clothing administer high flow oxygen and have the patient sit or lie down until the cramps subside we want to replace fluids by mouth and cool the patient with water spray or mist and add convection by manually or mechanically fanning the patient when the heat cramps are gone the patient may resume activity the best preventative and treatment strategy is hydration by drinking water so if the cramps do not go away after these measures transport the patient to the hospital when it comes to heat exhaustion we want to treat the patient with heat exhaustion by following the steps and skill drill 33-1 when it comes to heat stroke recovery from heat stroke depends on the speed with which treatment is administered emergency treatment has one objective and that's to lower the body temperature by any means available you want to take the following steps when treating a patient with a heat stroke move the patient out of that hot environment and into the ambulance set the air conditioning to maximum cooling and remove the patient's clothing you want to administer high flow o2 and assist ventilations if indicated you want to provide cold water immersion if possible spray the patient with cool water and fan him or her to quickly evaporate the moisture on the skin aggressively and rapidly fanning the patient exclude other causes of altered mental status and check blood glucose levels if possible transport immediately to the hospital and notify the patient or hospital of the arriving heat stroke patient do not over cool this patient and call for advanced life support assistance if the patient begins to shiver okay so next we're going to talk about drowning so drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid some agencies may still use the term near drowning to refer to patients who survive at least temporary 24 hours after suffocation in water risk factors include alcohol consumption pre-existing seizure disorders geriatric patients with cardiovascular disease or unsupervised access to water and that's for children drowning is often the last in a cycle of events caused by panic in the water it can happen to anyone who is submerged in water for even a short period of time struggling towards the surface or the shore the person becomes fatigued and exhausted which leads him or her to sink even deeper drowning also occurs in buckets puddles and bathtubs and places where the person is not completely submerged so what happens is the patient will get a laryngospasm so inhaling very small amounts of fresh water or salt water can cause the muscles of the larynx and vocal cords to spasm this is supposed to prevent water from entering the lungs in severe cases progressive hypoxia occurs until the patient becomes unconscious spinal injuries and submergent incidents and so we're going to assume that spinal injury exists with the following conditions so anytime there's a submersion has resulted from a diving mishap or significant fall also the patient is unconscious and has no information available to rule out the possibility of a neck injury or if the patient is conscious but complains of weakness paralysis or numbness to the arms or legs most spinal injuries and diving incidents oft affect the cervical spine we want to stabilize the suspected injury while the patient is still in water we need to follow the steps in skill drill 33-2 okay so when it comes to safety we have to ensure the safety of the rescue personnel and request additional resources for a water rescue the basic wool rule of water rescue is reach throw and row and then go do not attempt a swimming rescue unless you're trained and experienced in these techniques if you work in an area near lakes rivers or ocean you should have pre-rage plan for water rescue when it comes to recovery techniques if the person is not floating or visible in the water an organized rescue effort is necessary specialized personnel are required in that with a snorkel mask in scuba gear resuscitation efforts so hypothermia can protect vital organs from lack of oxygen there is the diving reflex and this is the slowing of the heart rate it's caused by submersion in cold water it may indic may cause immediate bradycardia and that's a slow heart rhythm the person may be able to survive for an extended period of time underwater thanks to a lowering of the metabolic rate associated with hypothermia local protocols often dictate that resuscitative efforts continue for up to an hour after submersion while stimul simultaneously rewarming the patient when it comes to diving emergencies there are many serious water-related injuries and they're associated with diving with or without dive or scuba gear medical emergencies related to scuba diving techniques and equipment are becoming increasingly common separate them into three phases so when it comes to diving there's the descent emergencies bottom emergencies and then ascent emergencies so first we're going to talk about the descent emergencies and this is caused by a sudden increase in pressure on the body as the person dives deeper into the water the lungs sinus cavities middle ear teeth and the area surrounding by the diving mask are the most commonly affected usually pain caused by the squeeze problems forces the diver to return to the surface to equalize pressures and the problem clears up by itself now divers who continue pain particularly in the ear after returning to the surface should be transported to the hospital because there could be a peripherated tympanic membrane and that's a ruptured eardrum cold water will enter the middle ear through the ruptured eardrum and the diver may lose his or her balance and orientation the diver may not or may shoot to the surface and run into ascent problems so let's talk about some emergencies at the bottom and those rarely occur and they're usually caused by faulty connections in the dive gear such as inadequate mixing of oxygen and carbon monoxide in the air the diver's breathing or accidentally feeding poisonous carbon monoxide into that breeding apparatus it can cause drowning or a rapid ascent required emergency resuscitation and transport are needed so ascent emergencies now these are the most serious injuries and usually require aggressive resuscitation there's a multiple different ones so let's talk about the air embolism first and this is the most dangerous and most common scuba diving emergency so what happens are bubbles of air in blood vessels and you have the problem starts when the diver holds his or her breath during a rapid ascent the air pressure in the lungs remains at a high level within the external pressure of the chest and it decreases so the air inside the lungs expands rapidly causing the alveoli in the lungs to rupture and this may cause a pneumothorax or an air embolism signs and symptoms of an air embolism include blotching which is modeling of the skin froth or pink or bloody um at the nose or mouth severe pain in the muscles joints or abdomen dyspnea or chest pain dizziness nausea and vomiting or dysphagia which is difficulty speaking cough cyanosis difficulty with vision paralysis or coma or irregular pulse and cardiac arrest and then there's decompression sickness and we often hear this called the bends and the bubbles of gas especially nitrogen obstruct blood vessels this results from a rapid ascent from the dive too long of a dive at it too a deep of a depth or repeated dives within a short period of time nitrogen that is being breathed dissolves in blood and tissues complications of the bends include blockage of tiny blood vessels depriving parts of the body of their normal blood supply and severe pain in certain tissues or spaces signs and symptoms inc include abnormal joint pain so severe that the patient doubles up or bends over you may find it difficult to distinguish between an air embolism or decompression sickness so an air embolism generally occurs immediately on return to the symptoms to the surface whereas signs of decompression sickness may not occur for several hours emergency treatment for both of them and it includes basic life support and recompression in a hyperbaric chamber all right so let's talk about the assessment of diving and drowning emergencies scene size up of course scene safety your standard precautions should include gloves and eye protection at a minimum never attempt a water rescue without proper training and equipment call for additional resources early and trauma and spinal immobilization must be considered in recreational settings you have to look for indicators of that mechanism of injury a primary assessment always form that general impression we're going to pay attention to chest pain dipsnia and complaints of sensory changes when the diving emergency is suspected we want to determine the patient's level of consciousness as always using that apu scale and we need to be suspicious of drugs or alcohol use so airway and breathing of course open the airway and assess the breathing in responsive patients and consider the possibility of spinal trauma and take appropriate actions we need the suction the patient if the patient's vomited and then perform ventilations with a bag valve mass ventilation for inadequate breathing in conduction with an airway adjunct okay if the patient is uh responsive provide high flow oxygen with a non-re-breathing mask auscultation and frequent assessment of breath sounds in drowning patients is a key part of your assessment when it comes to circulation it may be difficult to find a pulse you want to begin cpr and apply your aed l evaluate for shocks and adequate perfusion if the mechanism of injury suggests trauma we have to assess for bleeding and transport appropriately our transport decision so we're always going to transport patients to the hospital inhalation of any amount of fluid can lead to delayed complications lasting for days or weeks decompression sickness and air emboli must be evaluated in and treated in a recompression chamber history taking so we're going to investigate the chief complaint obtain the medical history and we want to be alert for injury-specific signs and symptoms as well as pertinent negatives we need to determine the depth of the dive the length of the time the patient was under water and the time of the signs and symptoms and any previous diving activity when it comes to the secondary assessment if the patient's responsive we want to thoroughly examine his or her lungs including breast sounds if unresponsive we have to look for hidden um life threats and possible potential for trauma even if trauma is not suspected for scuba divers look for indicators of decompression sickness or air emboli and check for signs of hypothermia we want to assess peripheral pulses skin color and dis coloration itching pain or paresthesia which is paresthesia's numbness and tingling okay vital signs so we want to check that pulse rate rhythm and quality and it may be difficult to palpate in a hypothermic patient so we want to check for both peripheral and central pulses listen over the chest for the heartbeat if pulses are weak and check for respiratory rate quality and the rhythm and listen for lung cells assess and document pupil size and inactivity or reactivity and oxygen saturation readings may produce a false low reading because of hypoperfusion and or shivering then we want to reassess so we have to repeat the primary drowning patients may deteriorate rapidly due to what happens is the pulmonary injury fluids will shift in the body and this is going to cause cerebral hypoxia and or hypothermia so you could have shifts in the lungs fluid could flood into the lungs okay cause pulmonary edema patients with a pneumo air embolism or decompression sickness may also decom decompensate quickly so we have to assess our patient's mental status constantly assess vital signs every five minutes paying particular attention to respirations and breath sounds and then of course we have to document the circumstances of the drowning we need to know the time the patient was submerged the temperature of the water the clarity of the water and the possibility of spinal injury we want to also bring all dive equipment to the hospital including a dialogue or a dive computer if available so when it talks about emergency care for these drowning or diving emergencies we have to do treatment for drowning and it begins with rescue and removal from the water so you have to mobilize and protect the patient's spine when a fall from a significant height or suspected diving injury is possible artificial ventilation should begin as soon as possible even before the patient is removed from the water the patient is not breathing remove any vomit from the airway manually or by suction and assist ventilations with a bvm or a pocket mask provide chest compressions and use the aed if the patient is in cardiac arrest administer oxygen if the patient is breathing spontaneously and treat for hypothermia when treating conscious patients who are suspected of having any air ableism or decompression sickness from scuba diving you want to follow these steps you have to remove the patient from the water and try to keep him or her calm administer oxygen and consider the possibility of a pneumo and monitor breast sounds so provide prompt transport to the emergency department or the nearest recompression facility for treatment based on local protocols other water hazards you want to pay close attention to body temperature of the person who's rescued from the cold water and treat hypothermia caused by immersion from cold water the same way you treat hypothermia caused by cold exposure and then there is a thing called breath holding syncope and so this is when a person swimming in shallow water and may experience a loss of consciousness and this is caused by a decreased stimulus for breathing this results in drowning and the patient is the same as that for a drowning patient the treatment is okay so prevention so appropriate precautions can prevent most immersion accidents all pull should be surrounded by a fence and most common problem in child drownings is the lack of adult supervision so half of all teenage and adult drownings are associated with the use of alcohol all right so next we're going to talk about high altitude um issues so you have uh dyspharism injuries and this is caused by difference between the surrounding atmospheric pressure and the total gas pressure in various tissues fluids and cavities of the body and then you have altitude sickness and that occurs when an unacclimated person is exposed to diminished oxygen pressures in high air at high altitudes okay so illness uh illnesses also affect the central nervous system and pulmonary system and will range from acute mountain sickness to high altitude cerebral edema and that is haste h-a-c-e once again high altitude cerebral edema and then high-altitude pulmonary edema and that is hate h-a-p-e acute mountain sickness can occur above 5000 feet and this is caused by diminished oxygen pressure in the high in the air at altitudes above 5000 feet and this results in hypoxia right so this results from ascending too high too fast or not being acclimized to high altitudes signs and symptoms include a headache light-headedness or fatigue loss of appetite nausea difficulty sleeping shortness of breath during physical exertion and possibly a swollen face so treatment primarily consists of stopping the ascent and descending to a lower altitude when it comes to hape that is high altitude pulmonary edema and this can happen above 8 000 feet what happens is fluid collects in the lungs and it hinders the passage of oxygen into the bloodstream signs and symptoms include shortness of breath pink a cough with pink sputum cyanosis and a rapid pulse and then there's haste that's high altitude cerebral edema and this can happen above 12 000 feet may accompany hate and can quickly become life-threatening signs and symptoms are severe constant throbbing headache lack of muscle chlorination and balance extreme fatigue vomiting and loss of consciousness treatment for hate or and haste occur involves descending to that lower altitude providing oxygen rapid transport and for inadequate respirations of course we're going to provide positive pressure ventilation with the bdm cpap may be helpful for a patient with respiratory distress from hate all right so next environmental emergency we're going to talk about is lightning there are an estimated 25 million cloud to ground lightning strikes each year in the us lightning is the fifth most common cause of death from an isolated environmental um phenomena targets of direct lightning strikes include people engaged in outdoor activities or anyone in a large open area many individuals are indirectly struck when standing near an object that has been struck by cardiovascular and nervous systems are most commonly injured okay so respiratory and cardio arrest are the most common caused by lightning related deaths the tissue damage pathway usually occurs over the skin rather than through it because the duration of lightning strike is short skin burns are usually superficial categories of lightning strikes include mild loss of consciousness their amnesia confusion tingling or non-specific signs and symptoms or superficial burns and then you have moderate the lightning strikes and seizures respiratory arrest dysrhythmias that spontaneously resolve or superficial burns when it comes to severe cardiopulmonary arrest let's talk about the emergency care and treatment so we want to take measures to protect ourselves from being struck by lightning move the patient to a sheltered area and then we're gonna do uh use a reverse triage so anyone who is in cardiac or respiratory arrest is there is our first try priority other people who may have been struck will not develop cardiac complications so um treatment so we want to stabilize the spine and open the airway with a jaw thrust if the patient is uh if pulses are present and we just need to assist ventilation so if a patient is in cardiac arrest so we want to use the aed as soon as possible control bleeding and transport to the nearest facility okay a patient with signs and symptoms of a lightning strike but no obvious life threats should be transported for evaluation and now we're going to talk about bites and envenomations so we have spider bites spiders are numerous and widespread in the us there are only two spiders the female black widow and the brown recluse spider that deliver serious even life-threatening bites okay so let's talk about the black widow first the black widow spider is large measures approximately two inches with the legs extended so usually black with very distinctive bright red orange marking in the shape of an hourglass on its belly his abdomen and they prefer dry dim places around buildings wood piles and among debris the vite bite is sometimes overlooked if the site becomes numb right away the patient may not even recall being bit however most black widow spreader brights cause localized pain and symptoms including agonizing muscle spasms a bite in the abdomen may cause muscle spasms so severe that they resemble an acute abdominal condition the main danger is the venom which can cause nerve tissue damage other systemic signs and symptoms include dizziness sweating nausea vomiting rashes tightness in the chest difficulty breathing and severe cramps generally the signs and symptoms subside over 48 hours a physician can administer a specific antivenom but because of high incidence of side effects its use is reserved for very severe bites older people and younger children younger than five emergency treatment consists of bls care for the patient in respiratory distress transport to the emergency possible department as soon as possible and if possible bring safely bring the spider to the hospital or take a photo of the spider with a cell phone and send it to the hospital ahead of time okay so the next spider we're going to talk about is the brown recluse spider it's a dull brown in color and about one inch long and the short haired body has a violin shaped mark brown to yellow in color on its back it lives mostly in the southern and central parts of the country but may be found throughout the continental united states they tend to live in dark areas such as corners of old unused buildings under rocks and in wood piles the venom is not neurotoxic but synotoxic it causes severe local tissue damage typically the bite is not painful at first but becomes so within hours the area becomes swollen and tender developing a pale modeled cyanotic center and possibility possibly small blister a scab of dead skin fat and debris will form and dig down into the skin producing a large ulcer that may not heal unless treated promptly transport patients with such symptoms as soon as possible these bites are rarely cause systemic symptoms and signs but when they do the initial treatment is bls and transport to an emergency department if possible safely bring the spider to the hospital or take a photo of the spider with a cell phone and send it to the hospital ahead of time okay so now we have bees wasps yellow jackets and ants and and these things are painful but not a medical emergency we have to remove the stinger and the venom sac using a firm edged eye item such as a credit card to scrape the stinger and sack off the skin use ice packs to assist in controlling pain from that sting okay so anaphylaxis may occur if the patient's allergic to the venom signs and symptoms include flush skin low blood pressure difficulty breathing wheezes hives or swelling of the throat and tongue and be prepared to assist the patient in administering an epipen auto injector and support the airway and breathing so the next environmental emergency we're going to talk about is snake bites so steak snake bite fatalities in the u.s are extremely rare about 15 a year for the entire country and of the approximately 115 different species of snakes native in the us only 19 are venomous so these include rattlesnakes the copperhead the cottonmouth or the water moccasin and then there's the coral snakes okay so the figure on this slide shows different poisonous steaks that are found in the united states snakes usually do not bite unless they're provoked angered or accidentally injured as when they are stepped on except for cottonmouths which are very aggressive so protect yourself from getting bitten use extreme caution on these calls and wear proper protective proper protective equipment for the area okay so only one third of the snakes result in significant local or systemic injuries venomous snakes native to the united states have hollow fangs in the roof of their mouth and that that inject the poison from two sacks uh at the back of their head okay so the classic appearance of these poisonous snake bites is two small puncture wounds usually about a half inch apart with discoloration swelling and pain non-venomous snakes can also bite usually leaving a horseshoe of tooth marks fang marks are clear indications of a poisonous snake bite this is what we're going to talk about is pit vipers okay and so pit vipers are rattlesnakes copperheads and caught mouth and they're all called pit vipers with triangular shaped flat heads they take their name from the small pits located just behind each nostril and in front of each eye the pit is a heat sensing organ okay the fangs are special hollow teeth that act much like a hypodermic needle connected to the sac containing a reserve of venom rattlesnakes they're the most common form of a pit viper and they have patterns of color often with a diamond pattern they can grow up to six feet or more in length then there's copperheads they're usually two to three foot long the red copper color cross with brown and red bands typically inhibit wood piles and abandoned dwellings and they account for most of the venomous snake bites in the eastern united states their bites are almost all never fatal but the venom can cause significant damage to tissues in the extremities and then there's cotton mouths they grow about four feet in length also called water moccasins they're oliver brown with black cross bands and a yellow under surface they are water snakes with an aggressive pattern of behavior fits fatalities from these snake bites are rare but tissue destruction from the venom may be severe the signs of envenomation by a pit viper are severe burning at the site of the injury followed by swelling and a blue discoloration so that echomosis signs are evident within five to ten minutes and they spread over the next 36 hours in addition to destroying tissues locally the venom of a pit viper can also interfere with the body's ability to clot and cause bleeding to at various distant sites okay distinct sites other signs and symptoms may or may not include weakness nausea vomiting sweating fevers and fainting vision problems changes in level of consciousness and shock if swelling has occurred use a pen to mark its edges on the skin when treating a bite from a pit viper you want to take the following steps so calm the patient place the patient in a supine position and explain that staying quiet will slow the spread of any venom through the system locate the bite area and clean it with soap and water apply ice if the bite occurs in an arm or leg consider the use of pressure immobilization bandage of the extremity then place the affected extremity below the level of the heart be alert for an anaphylactic reaction to that venom and treat with an epi auto injector as appropriate do not give them anything by mouth and be alert for vomiting if the patient was bitten on the trunk keep him or her supine and quiet and transport as quickly as possible you want to monitor the vital signs and mark the skin with a pen over the area that has swollen and note whether the swelling is spreading if there are any signs of shock where you're going to treat for it and if the snake has been killed bring it with you alternatively take a picture of the snake with a cell phone and send it to the hospital ahead of time you want to notify the hospital that the patient has been bitten by a snake if possible describe that snake and then transport appropriately if the patient knows the signs of no signs the patient shows no signs of envenomation where you're just going to perform bls as needed and place the patient place a sterile dressing over the suspected bite area and immobilize the injury site all patients with a suspected snake bite should be taken to the emergency department you want to treat the wound as you would any deep puncture wound to prevent infection all right so that was the pit vipers now we're going to talk about the coral snakes and this is a small reptile with a series of bright red yellow and black bands completely and circulating the body okay red on yellow will kill a fellow red on black venom will lack so it injects the venom with its teeth and tiny things by chewing motion leaving puncture or scratch-like wounds because of its small mouth and teeth a limited jaw expansion the coral snake usually bites its victims on a small part of the body such as a finger or toe coral snake venom is a powerful toxin that causes paralysis of the nervous system within a few hours after being bitten a patient will exhibit bizarre behavior following by progressive paralysis of eye movements and respiration successful treatment depends on positive identification of that snake and support of respiration anti-venom is available but most hospitals do not stock it emergency care of a coral snake bites are the same as a pit viper fight okay so the next thing we're gonna talk about is scorpion stings and scorpions are eight-legged arachnoids with a venom gland and a stinger at the end of their tail they are rare and live primarily in the southwestern united states and in deserts with one exception a scorpion sting is usually very painful but not dangerous causing localized swelling and discoloration the figure on this slide shows a scorpion the exception is a specific type of scorpion and the venom of this species may produce a severe systemic reaction that brings about circulatory um collapse severe muscle contractions excessive salivation hypertension convulsions and cardiac failure if you're called to care for a patient with a suspected sting from this type of arachnoid notify medical control as soon as possible administer bls and transfer the patient as rapidly as possible and then there's tick bites so ticks are tiny insects that usually attach themselves directly to the skin they're found most often in brush shrubs trees sand dunes and other animals the bite is not painful but infectious diseases can spread through the tick saliva okay so the figure on this slide shows a tick and the characteristics bullseye rash pattern associated with lyme disease rocky mountain spotted fever this occurs within seven to ten days after a bite and that occur that symptoms are nausea vomiting headache weakness paralysis and cardiorespiratory collapse and then lyme disease so lyme disease is reported in the united states with the exception of hawaii the first symptoms are generally fever flu-like symptoms symptoms um they're associated with that bull's-eye rash that may spread to several parts of the body after more than a after a few days or weeks painful swelling of joints particularly in the knees occur and it may be confused with rheumatoid arthritis and may result in permanent disability if it is recognized and treated promptly with antibiotics the patient may recover completely tick bites occur most commonly during the summer months you want to provide any necessary supportive care and transfer the patient transport the patient for further eval in situations where access to care is delayed remove the tick by using fine tweezers to grasp the tick's head and pull straight out of the skin once the tick is removed cleanse the area with antiseptic and save the tick in a glass jar for identification do not handle the tick with your fingers the patient should follow up with their health care provider as soon as possible and then we're going to talk about injuries from marine animals so basically marine animal envenomations are responsible for more envenomations than any other marine animal you could have fire coral portuguese maniwar sea wasps sea nettles true jellyfish sea anemones and true coral and soft coral figures on this screen show examples of those on jellyfish portuguese man of war and the sea anemone the stinging cells are called neocytes so signs and symptoms very painful red lesions in light-skinned individuals lesions that extend in a line from the sight of the sting headache dizziness muscle cramps and fainting treatment so what do we want to do we want to remove the patient from that water remove the tentacles by scraping them off with an edge of a sharp stiff object such as a credit card not try to manipulate the remaining tentacles on rare occasions a patient may have a systemic allergic reaction so we want to treat such a treat the patient for anaphylactic shock we need to give basic life support and provide immediate transport to the hospital toxins from the spines of sea urchins stingrays and certain spiny fish such as a lionfish scorpion fish or stone fish are heat sensitive the best treatment is to mobilize the effective area and soak it in hot water for 30 minutes the patient still needs to be transported if you work near the ocean you should be familiar with the marine life in your area the emergency treatment of common envenomations consists of the following steps limit further discharge by avoiding fresh water wet sand showers or careless manipulation of the tentacles remove the patient or keep the patient calm and reduce motion of that affected extremity remove the remaining tentacles by scraping them off with the edge of a stiff sharp object immersion in vinegar may also help alleviate the symptoms and then provide transport to the emergency department okay so that concludes the lecture part for chapter 33 environmental emergencies now we're going to go over the review questions to see what we've learned okay so when a person is exposed to a cold temperature and strong winds for an extended period of time he or she may lose heat mostly by and what did we know that is by convection and so if this occurs when the heat is transferred by that circulating air shivering in the presence of hypothermia indicates that the it's going to be c and that's uh that shivering its body is trying to produce heat by generating it through muscle activity right all of the following examples of passive rewarming techniques except all right so it's going to be passive re-warming involves the body's temperature okay so the body and so we know administering fluids in mouth by mouth is not passive a woman with frostbite to both feet walking several miles in the frozen field her feet are white hard and cold to the touch treatment at the scene includes okay so we know we're not going to rub them we're not going to help her walk we want to probably remove the wet clothing and cover her feet in dry sterile dressings yeah because we know we're never going to rub the feet okay 30 year old male who has been playing softball on a all day in a hot environment complains of weakness nausea shortly after experiencing a sinkable episode appropriate treatment for this patient includes all of the following except we want to move them to closer colder environment give them oxygen and so we're going to do everything except for giving them something to drink right right you're assessing a 27 year old woman with a heat related emergency her skin is flushed and hot and moist and her level consciousness is decreased after moving her to cool environment managing her airway and administering oxygen what are we going to do okay so the patient's having a heat stroke after moving her to that environment we are going to cover her with wet sheets and fan her okay it's important to remove a drowning victim from the water before the laryngospasm relaxes and why is this and that is because um it's going to be even small amounts of salt or fresh water might cause that laryngeal spasm and so less water will have entered the patient's lungs if we get them out before a 13 year old is found floating face down in a swimming pool witnesses tell you that the girl was practicing diving after you and your partner safely enter the water what are we going to do and what we're going to do is rotate that body as a unit okay so we're going to rotate the entire upper half of her body as a unit shortly after ascending rapidly to the surface of the water while holding his breath the 27 year old diver begins to cough pink frothy sputum and he's talk complaining of dipsnia and chest pain what are we gonna suspect and we know that uh that's gonna be an air embolism so the signs of an air embolism okay and then finally three ambulances respond to a golf course where a group of six golfers were struck by lightning two of the golfers are conscious and alert and they have some burns the next two golfers have minor fractures and appear confused and then the last two are in cardiac arrest according to the reverse triage which group of golfers should be treated first okay and we knew uh we know that the group in cardiac arrest so c right so that reverse triage where normally um triaging um the while we're doing a triage we know that cardiac arrest is usually normally um the last people but with the reverse triage we're gonna use them first we're gonna do those first okay so this concludes chapter 33 of the environmental emergencies um thank you for listening to the chapter and hope you have a good day