[Music] spe [Music] let's start with environmental em em gencies so this will cover only heat and cold related in in um emergencies so let's start with heat there are two heat challenges we have dehydration induced by heat which we call heat exhaustion and then there's also uh true medical emergency which is heat stroke difference between the two is in the severity in heat exhaustion as already mentioned this is simply dehydration caused by extreme heat by extreme heat we have two conditions here it can be either non-exertional meaning heat waves say temperatures hit three digits in summer uh or it could also be exertional wherein the patient is running a Marathon or doesn't have to be a marathon could be a rally outside under three digit temperatures or just a ordinary day but have been out in the sun too long without adequate hydration either way the patient becomes dehydrated due to extreme heat we call it heat exhaustion so manifestations will be what manifestations of dehydration okay so heart rate's high blood pressure is low mucous membranes are dry oor okay moist clammy skin okay so dehydration basically and Labs will show the same high hematocrit high hemoglobin High bu and creatinin the temperature of course will be 102.5 or higher the this typically does not reach uh 103 okay so around 102.5 101 around that uh area but the patient here is is um responding to heat reduction mechanisms meaning once we take them out of the Sun or we fan them for instance or we give cool conferences the patient temperature responds the temperature drops that's the difference in heat stroke that's the different story please read on your own chart 67-- 6 this is now prevention how to uh prevent uh heat stroke and also heat exhaustion there are self-explanatory mean you know keeping hydrated what would be the best fluids in this case if you're outside side and it's hot would water be the best option or okay so hard water will be better something like Gatorade Vitamin Water things like that those uh Beyond water you know things that contain electrolytes okay because they're better absorbed and of course they're healthier okay um I mean they're more beneficial compared to just plain water in case you get more prevention or avoiding heat exhaustion heat stroke uh questions the answers will be here uh meaning who are at risk for heat stroke or heat exhaustion they are of course the very young very old people who work outside meaning utility workers um First Responders including cops um nurses also if you're in the home health field okay so you are also at ex increased risk now people with chronic conditions especially those that affect the very systems that we need to compensate meaning uh drugs that affect our kidneys our heart and our lungs because we need these two three organs to compensate right during dehydration or during um extremes of temperature so patients taking tranquilizers or other CNS depressants you know the those taking Xanax or lorazapam Alprazolam or anticholinergics because these cause drying yeah uh diuretics same thing and then beta blockers as well the thing with beta blockers is what what does the drug do it blocks the compensatory response yeah meaning what do we need when we're dehydrated we need we need the sympathetic response yeah we need adrenaline we need epinephrine but then when you're taking beta blockers what is the effect you're suppressing them which is not good uh people who are homeless for instance or with mental health disorders okay they're especially at risk they're not really in the right mind to not take shelter or make the best judgments for instance the elderly very common so even though they are institutionalized doesn't mean they're not at risk for heat exhaustion or heat stroke how often do nursing home patients actually ask for fluids like hey do you can you get me some juice some water no especially those with Advanced moderate to severe dementia they are no longer aware right they have agnosia so they don't have the sensory perception that you and I do they don't have they don't feel thirst uh you give them food or water they don't know what to do with that because they don't know what it is they have agnosia they can't recognize they see that it's water but they don't know what to do with that glass of water or you give them a plate of food yeah that looks like food but they don't know what to do with food okay that's called agnosia and we have natural disasters as well let's say the grid comes down he no power then of course air conditioning is gone and then that puts our institutionalized uh P population at at risk so that's just not for long-term care that also includes prisons yes s mental health facilities or assisted living facilities or uh ju institutions you know all the institutionalized um facilities assessment the patient with heat stroke again the difference between heat stroke and heat exhaustion yes both all heat stroke patients start with heat exhaustion but then with heat exhaustion the patient no longer responds to heat loss mechanisms he they may still sweat but most people with heat stroke no more sweating what is the purpose of sweating why do we sweat when it's too hot so we call that there are three we have three heat loss mechanisms yeah we have evaporation we have radiation we have conduction uh oh four actually we have convection yeah so they no longer respond to any of those mechanisms he they continue to increase the body temp temperature uh plus they are dehydrated at the same time now because of this the brain cannot tolerate temperatures over 104° since these patients temperatures rise 105 or higher there will now be confusion so does this complicate the patient's prognosis yes because now can they still have the presence of mind or the Consciousness to get out of the Heat or do some interventions to to cool themselves not anymore so the the bizarre behavior the mental status changes here the acute confusion increases mortality with heat stroke again this tells you here usually anhydrosis okay usually don't no more sweating but there are still heat stroke patients that still sweat so it's not really a diagnostic finding does that make sense meaning you can't just say oh that's heat stroke because there's no more sweat okay so that's not really the defining um diagnosis it's really the mental status changes the other manifestations here are related to the dehydration the electrolyte imbalances uh which has that hypotension Taki cardia T management first step is uh of course take the patient out of the heat okay uh cool them uh at the site so let's say most of these cases are outside uh with a few exceptions if they're in a nursing home but either way you start cooling the patient that's our first intervention and depending on the patient's mental status if they're still conscious and can follow commands then we give them uh cool liquids to drink uh if not then we'll have to wait for EMTs to establish an IV access and then we give them IV fluids yes depending on the patient's uh blood pressure so what do you think a good question so what do you think the first IV fluid ordered will be will it be ISO a hypo or hypertonic solution okay we start with ISO which are give me examples of iso Saline or LR okay so those two will be your first choice maybe one liter of that and then afterwards will depend on the patient's Labs uh usually if it's a true dehydration from heat exhaustion then it will be hypotonic solution 45% will be administered so as far as cooling how do we cool the patient so first is evaporation yeah so we take off the clothes of course the clothes May either be wet from sweating or it could be dry or whichever is the case we remove clothing to allow for radiation and evaporation and then we get we do conduction okay we put coal compresses don't use ice okay just coal compresses and then we have um convection you can use fans or put them in an air conditioned room for instance okay so those are our heat loss uh mechanisms so you got sorry um the problem with ice um as long as it's not in the whole body okay so yeah so just the um the what do we call those um yeah the um hot points is that the I think that's a term so only in these areas okay but we don't need to um the yes submerge the patient in ice because that can actually trigger shivering and then now we got more heat production um when we say ice though these are ice packs okay we do not uh submerge the patient in ice okay so we can do uh typically we don't need to do internal methods of cooling by internal I'm referring to cool IV fluids or putting in rectal tubes and then instilling uh uh cool water into the rectum or putting in an NG tube and then putting cool water into the stomach or inserting a Foley and then putting cool water into the bladder those are internal cooling methods uh it's not really necessary for for heat stroke okay they usually respond to external cooling the rest of the interventions will depend on the degree of dehydration if the patient has severe hypokalemia for instance then they may go into cardiac arrest and which case we do a CLS which is not covered by the textbook now the seizures may follow because of severe heat the brain cannot to at like I said earlier temperatures above 104 so at that point febr seizures will occur because of increased interanal pressure uh because what happens to the blood vessels in the brain if you have a high temperature will there be Vaso dilation or vasil constriction vasal dilation so what happens to the volume of blood in the brain if you have Vaso dilation increases right so what happens to intracranial pressure Rises and then seizures will follow doctors May Institute uh preventive um meaning prophylactic seizure precautions meaning they they will order uh latam which is KRA so they know the patients at risk for higher risk for seizures rather than waiting for the seizure to happen we will administer anti-seizure medications okay so we'll do that ahead of time sometimes the doctor May order U benzo aines as well prevent seizures yes once the temperature uh goes over 1 104 so 105 or higher um we Institute uh seizure prophylaxis okay we already said fluids of NS or LR are these patients in Aki prenal intrarenal or postrenal pre very good so since they are in Aki we put in a Poley to monitor um urine output plus uh if it's exertional um hypothermia or heat stroke you know if it's exertional heat stroke most likely there is muscle damage now from let's say it was a marathon of some sort so there's also rabdo mysis which can cause intrarenal Aki okay so we already talked about anti-convulsant medications again that could either be leviter acetam or they could also order benzo dipin again U Aki management including dialysis if necessary electrolyte replacement okay so diazapam or Lam you still remember these drugs yeah from last semester and as already said this uh may be used to prevent shivering during the uh cooling process best way however is of course to prevent this from happening in the first place I worked for a rehab facility basically it's a nursing home in Florida it was called Citrus Health and Rehab it was very nice they had first of all they had wooden floors nor carpet anywhere uh it looked like a house they had puppies at the desk they were you know like emotional animals they bring the puppies to the rooms for uh a residents who cannot ambulate so they bring the they were all um that breed on the [Music] um no no they're small um York yorky yeah yeah so the um the she wasn't the manager but anyway this the one of the staff bred them and then she sold them to the facility so the facility bought the puppies and they they live the puppies live there it's a 24-hour facility so perfect so uh they um the puppies are I mean some of them are old but I mean they're puppies forever right uh so it was like that and then they had beverage carts so what the beverage cart looks like was they had it was a cart and they had um no yeah like an umbrella so it looks very festive and they had all sorts of beverages there they had water and then all sorts of juices and they literally went into to each room they're small enough to fit into the room and then they serve them uh and then of course the staff whoever was ruling that you know they had a costume you know and then very festive again so they offer drinks and that was done throughout the day so they go into patients rooms if the patient room if the patients cannot go out or they say they're bed bound and then of course there's another cart only for the de the day room so in the day room they serve beverages all day so they had very little to no uh cases of uh heat exhaustion and this is Florida very hot all year long so if you know if we had all that then we wouldn't have to deal with you know and they had uh know good reviews because the quality of life was was better for the residents uh before we go to frostbite let's do another heat related injury first this time in um another emergency so one of the complications of anesthesia particularly general anesthesia is malignant hypothermia this is rare though so what is malignant hypothermia this is a rare inherited muscle disorder this is induced by anesthetic agents what anesthetic agents they're listed here so the drugs known to cause or trigger malignant hypothermia are halothane anline isofluran there are also a few enlan also does the same and the muscle relaxant sual choline so 1 2 3 and four sual choline is not a anesthetic this is a muscle paralyzer see when we do major surgery say General using adrenal anesthesia can we allow the patient to move around on the table no you have to be completely still will the patient cooperate if they're unconscious from anesthesia no because they're not aware right so we have to paralyze the patient so we give them sual choline so the patient stops breathing no muscle will move so every muscle in the body is paralyzed that's why they are intubated okay so when we use general anesthesia you are intubated you're on a mechanical ventilator you follow okay now so there are these are the necessary drugs we need so anesthesia you know you're told to count count 10 backwards 10 9 8 and then that's it okay so in 3 seconds you're unconscious then we give you suin choline you're paralyzed then we intubate you okay put you on a ventilator and then we start cutting of course you're also given opioids because we assume you're in severe pain so you're given opioids at the same time now this is inherited so therefore comes in families this is really uh serious it's it's uh it has a high mortality so the best way to approach this really is prevention we do not screen everybody for this Gene it's expensive plus is it really fre is it really uh frequent no extremely rare who works in the O here or anywhere near the O know somebody okay so if you do know some o nurses you can ask them do you guys have a malignant hypothermia kit the answer will be yes and if you ask them where is it yeah it's somewhere there have you ever used it chances are the answer is no that's how rare this thing is okay so there's just a few people that have the gene for lack of a better term we call it they have the malignant hypothermia Gene again screening is Impractical because it's expensive and again not too many people have this Gene so prevention is in the interview so whoever is doing the pre-op checklist um which is going to be you potentially if you work in Med searge so you're going to do the anesthesia checklist so bunch of questions uh routine questions you know have you had surgery blah blah blah so when you get to Anesthesia section the first question will be have you or a family member ever had general anesthesia if the answer is yes next question that pops up will be have you or a family member ever had a reaction to general anesthesia if the answer is yes that is an alert for the anesthesiologist and what the what is the anesthesiologist usually GNA going to do are they going to use these drugs no it doesn't matter what the patient's response was to the next question which is is what was the reaction and sometimes some facilities don't even bother asking that because once the answer is yes we assume it could be malignan hypothermia you understand okay so therefore once the answer is yes surgery will proceed we just won't use these drugs so you may wonder why not get rid of these drugs again the condition is very rare these are the most coste effective general anesthetic agents and muscle paralyzers in the market they're the cheapest and they're widely used okay so all we can do again if the answer was what yes on the a question of have you or a family member why is it you or a family member because it's genetic okay it's inherited so it could be it could be not the patient but it could be a parent a grand Grand parent a child okay other triggers which are not really common are these medications okay but they're they're possible okay these can trigger malignant hypothermia but uh most common uh most cases that are documented are these these General anesthetics and this muscle paralyzer are we clear all right let's go now to what exactly happen so here it's a muscle disorder what happens to the muscle is they start Contracting the problem is they won't relax so the every muscle in the patient from head to toe will contract and what will happen if your muscles are Contracting let's say you do this let's see what happens to your body temp temperature when you do this okay so it's just one arm if every muscle in your body contracts what will happen whole body will generate Heat and the temperatures here can reach 111° how much temperature do you need to cook an egg one yeah 111 can it if it can cook an egg can it cook your brain yes can this cause death yes now despite the term malignant hypothermia the hypothermia actually is a late sign so if a patient dies from hypothermia that means did we do our job correctly no okay so let's go to the um pathopysiology so what happens is upon exposure to those anesthetic agents and AAL choline um suin choline that I mentioned earlier muscles start Contracting the earliest sign let's go to manifestations now the earliest sign are cardiovascular respiratory that means the heart rate is the first that will rise why did the heart rate go why did the heart rate go up what were those muscles consuming every time you contract your muscles what will they consume oxygen oxygen so once oxygen levels drop what will happen to the heart rate automatically will suddenly rise so first sign early sign tachic cardia heart rate greater than 150 is the early sign next is the Unexplained drop in oxygen levels so if oxygen levels drop what will happen to CO2 it will rise so the earliest now remember this patient is intubated yeah because this is general anesthesia so who will be the first one to notice the anesthesiologist will see this first unless the Ane anesthesiologist went for a potty break in which case circulating nurse will be uh Manning the um the anesthesia chair so it will be the the circulating nurse that will that will report this okay so nurse will report sudden tachic cardia and then they will report also the CO2 because we we intubate the patient so there will be a CO2 at the end of the at tube we call that the ntial CO2 so if the N tidal CO2 Rises that means oxygen levels drop correct can CO2 and O2 both be high at the same time no it's always paradoxical right oxygen Rises CO2 drops CO2 Rises oxygen drops so the again the earliest sign is what tachicardia and then Che so the respiratory early sign will be CO2 rise or oxygen uh decrease in oxygen the other manifestations of course once takic cardia because really if you think about it it's the hypoxemia right that uh triggered all of these so once the muscles start Contracting they consumed all of the oxygen in the body oxygen dropped CO2 Rose and then the heart rate automat ially increases and then of course blood pressure will drop and decreases oxygen I mean blood flow to the kidneys so there will be oor uh and then um if we don't do anything because once those muscles contract and never stop Contracting will those muscles survive they'll die right and then what will those muscles Again release when they're dead myoglobin right remember remember rabdo myis under heat stroke earlier so there will be rabdo here so can the patient go into Aki yes so two types of Aki here so we have prerenal plus intrarenal because of the rabdo and what will what other things will the dead muscle cells release besides myoglobin potassium okay so will there be hyperia okay so pick take your pick now where do you want to die from the um Aki from intra or preal Aki hyperemia or from hypothermia okay so the management will be of course addressing addressing those three because the patient will die from Aki they'll die from hyperemia they'll die from hypothermia cause uh brain damage and then Cardiac Arrest of course from hypokalemia I mean hyper calmia again the rise in temperature is a late sign so once the temperature rises did we do our job no because once we see the reaction we spring into action remember that malignant hypothermia kit I mentioned earlier okay so we have that kit it's on standby it's in every operating room suite they just grab the kit all they need to address malignant hypothermia are in that kit now let's examine what could be inside that sterile kit all you need to address those three so let's take it one by one so for the um well oxygen of course it will be the anesthesiologist okay so we'll increase oxygen uh can we stop surgery if possible yeah because um the the bad thing about malignant hypothermia is it can occur any time it can occur right after we gave the anesthesia it could occur a few minutes after or hours into surgery or it could also occur after surgery when do you think is the best time for this to occur okay right at after anesthesia induction so as soon as we put the mask on the patient gave them the anesthesia gas if it occurs right there that would be the great okay because we haven't cut the patient yet so it will be the best time to to for this to happen but unfortunately we don't know when this will happen the first thing we'll do is grab the kit we give the drug that's in there called dantrolene sodium D dantrolene sodium is given im or IV this is a muscle relaxant this is also used in multiple sclerosis okay all other conditions that have muscle spasm so this is a potent muscle relaxant so for malignant hypothermia though this is the only FDA approved drug to stop malignant hypothermia okay so no other muscle relaxant is approved only dantrolene sodium so this is what you'll give first so the anesthesia ologist will grab this administer it to the patient this will stop the reaction however did the process already start yes the patient's muscles have already have already started Contracting so were were there al already myoglobin Ora uh myoglobin in the blood there's was there already hyp potassium yes they're already there so the other interventions we need are how do we lower potassium calcium gluconate will be in the kit what else how else can we lower potassium bicarbonate will there will be there too yeah um will there be um insulin with dextrose okay well insulin probably not but dextrose will be there so you have to grab the insulin regular insulin from the uh medicine cabinet um how else well this is severe right this is acute so those will be our interventions so those will be the first um drugs we will use um are we going to um insert a Foley if there's not already a Foley in yes we need a Foley we need to monitor uh yeah kidney function and can we start cooling the patient down yes remember over muscle here if you've seen videos if you watch YouTube hypothermia the videos You'll see is if you um raise any part of the body in this patient let's say you you lift an arm that arm will stay up that's how rigid the muscles become you raise the leg that leg will stay up even though the patient is unconscious that's how stiff the the muscles are okay so you can just imagine the amount of heat that the the muscles are generating okay and and how much oxygen they are consuming okay so it's for them to contract like that so that's all in the uh it says cart but it's actually just a you know a um a kit okay um so hopefully the patient survives okay so we um give fluids of course we start cooling the patient down now the IV fluids the saline or LR that will be infusing will be wrapped in ice we'll put ice bags around the the um IV fluid bags so that they're cool when they enter so that's internal cooling if necessary or if the uh temperature is really high uh of course we put ice already on the axilla groin but uh we will start cooling the patient down so if these measures keep the know the temperature still high above 110 we uh lavage the stomach so we put in NG tube put um cool pull water into the belly and then suck it back out then do the same in the rectum and if needed we'll also put in a three-way Poley that way we irrigate the bladder with cool water and then drain it out um at the same time so these are our internal cooling measures so we're cooling the patient outside and internally as well cuz we can't risk brain damage because the temperature again will reach 111 or higher and that's not that's not [Music] good yeah again the the triggers are these drugs listed here but extremely rare yeah a few my friends are o nurses and when I ask them they've never seen it happen extremely rare why do you think it's extremely rare also the events I mean there must be a lot of you know there has to be malignant hypothermia Gene positive patients out there but how come the cases are so low what did we do again no what did we do to prevent this we ask questions okay so the only cases that we miss would be someone who had no idea so let's say they don't I don't know my patient Sy s okay plus if you think about it if this patient let's say you had malignant hypothermia will they tell you about it I mean you survived right they they they did that yeah probably but I mean you're out of surgery will you remember no you can careless ah is that what happened okay go back to sleep right but they will put it in your allergy record what what what do you think will be listed in your list of allergies these drugs will be put in your allergy list and that you of course will be told you're allergic to these okay you have the H malignant hypothermia gen we can't use these okay so they will be in your permanent record that next time you have surgery will they use this okay hell no okay because you're lucky to have survived it right so make sure it never happens again any questions on malignant hypothermia very good children let's go [Music] to cold related now let's start with frostbite I know hypothermia first and then we'll go back as since frostbite is here let's start with that okay frostbite um who are at risk for frostbite you know what frostbite is right I mean the temperature so um you know below freezing of course temperature outside is 32 degrees or lower and uh somebody will be exposed you know a body part will be exposed unprotected okay so most common parts of the body will be the nose yeah so fingers the the nose the ears right those are usually the exposed body parts or if it's your cheeks then the cheeks will also be exposed your toes and hands are also equally um high risk so here feet hands nose ears now there are different degrees just like in Burns wherein we had superficial right first degree second third degree fourth degree same thing with frostbite it also has degrees so the first degree we most commonly know it as Frost nip yeah so you and I probably experienced frostnip we didn't cause any permanent damage you know when we go out let's say um temperature 10° or below you've been out like that without any gloves how do you feel okay the pant are very painful yeah the fingers get really pain painful your nose are very painful and then when you go inside away from the cold you turn red yeah you can see that your nose your hands are very red so that's what we call redness and Emma so you had experienced frostnip um of course uh the second degree third degree or fourth degree frostbite will involve uh other colors now okay um I had a patient 3 weeks ago uh he fell from the bus sustained a head injury um and then experienced frostbite he so three of his fingers on the left hand actually here the thumb the four finger and the middle finger all black right so just a few minutes after he fell because he was on the ground for a while okay while um know they called EMTs and picked him up so he had frostbite just from that one fall so you see and he was 85 years old okay so how see how fast it can go I mean how long was he there just maybe 10 15 minutes right EMS should be there at at that time already but that's how he got the frost bite okay so so that's how fast it can set in so number of factors no his mental status the temperature outside okay so perfect you know perfect combination so let's go with who are at risk is it any different from what we had for heat related injuries same so same mental health um mental health patients uh homeless people institutionalized people our uh utility workers gate First Responders oh yeah okay very good uh Sports just like the marathon athletes we had also for hypothermia or heat stroke so same same risk factors um prevention how do you prevent it so with um heat related we said no um have cover and then maintain fluids right so here you dress okay so do we dress like uh a lot or in layers okay let me ask you this how many socks should you wear with socks though think about it if you the more socks you wear what will happen to your it's okay if you're not wearing shoes or boots but once you put on multiple layers of socks and put them in a boot what will happen to circulation to your feet it actually causes constriction okay so multiple layers of clothing but there should only be one one layer of socks because the more you you wear it actually causes constriction because our boots designed to be worn like that like you have two three layers of socks they didn't design it like that okay so the fit will be different when you have one sock versus multiple okay uh What uh material will be best is cotton the best for hot and cold or is it the synthetic material bortex is now the best yeah non non cotton because what will cotton do especially in cold it'll absorb moisture and then what will happen you have wet socks CU you were wet and then exposed to cold it will freeze right so it's not really good whereas if you have gortex or similar material no moisture wicking material they do not retain moisture okay so they would be the best so you notice it right if you buy um uh ski gear what are they made of are they really is there any cotton in those things no very if they have cotton maybe 10 20% cotton everything else is Hester spandex yeah so moisture wicking material okay that's the uh modern technology now probably in the 80s 90s no we had nothing but cotton but not anymore so we've got moisture wicking technology now let's go to management so just like in heat related injuries what's the first thing you do take them out okay take them out of the cold okay get them to a warmer place uh what will we do with any wet clothing okay take them off um put War clothes on if there's anything constricting not only clothes but jewelry especially so what will happen to the frost bite again just like in Burns what did we do with the jewelry you know burn clothing we remove them yeah so remove them as early as possible uh yeah once we uh once we have that uh available okay um do you know what she's talking about that's as a warming blanket okay so we have um we have equipment in the hospital of course we don't see that in the field they're uh we we have them in the hospitals okay so we have warming equipment warm one is a be hugger which blows warm air into the yeah or we can also have um cooling blankets which double as warming blankets meaning these are same as bear Huggers but instead of blowing hot air inside we're we're circulating water inside so that water can either be cool or warm because you can adjust the temperature on the machine so you can either uh increase the temperature of the water or lower the temperature so depends on what they want to use it for cool the patient or warm the patient all right so we remove clothing if the lower extremities or even the hands are involved of course we try not to use them we don't we don't want to you know put additional pressure which further compromise the circulation and then we do rapid rewarming now the rule here is if let's say if there's a chance of refreezing what I mean by that is we have a frozen hand obviously it's frostbitten if there's a chance wherein once you start rewarming meaning you thawed the extremity right it's now thawed it's not frozen anymore and then there's a chance that it could refreeze so what circumstances am I talking about let's say we're up in the mountains in the middle of ski season that's where the accident someone fell off okay so in in the buried in ice okay and then we carry them out we we dug them out and then we put them in a tent we rewarmed and then during transport so let's say the transportation was not really ideal okay so let's say it wasn't you know it was very windy and it's it's a pickup truck for instance okay so or any other condition wherein when transporting the patient you expose the patient again to freezing conditions when you've already thawed the extremity so look at state so if you steak shouldn't be frozen yeah you should be eaten fresh yeah so let's say you got a sale which what I do there's a sale in steaks I buy and bulk freeze them and then Tha them once eat what if you froze th and then refroze that state what will happen to it after the second freeze their meat is ruin yeah it doesn't taste good anymore same thing with our hands and feet so body tissues the same you've already it was frozen you thought it now you froze it again that will not recover anymore that body part is now gone see they will have to cut that off there's no more chance for recovery so here look at it's it's hot right 104 that's hot that's hot water so that's what we use 98.6 to 104 if you want to see how hot that is just put your hands in your your finger in your mouth your your mouth is about 98 99° okay so that's how hot it is how much more 104 so we do that for 32 minute spans um and by the way another rule is um we give analgesics okay because it's painful when you uh Tha a frozen body part and the pattern that we use is if if the patient's whole body so let's say it's not frostbite right so let's say it's hypothermia uh with frostbite if it if that's the case meaning it's not just one body part that's the problem is the whole body the patient is hypothermic we warm the core first we warm the trunk okay and then we warm the extremities afterwards meaning your your target is the core first the um they call it um an after drop phenomenon what does that mean if you warm the extremities first meaning the blood warms up right but if the core is still frozen once yeah once the warm blood returns to your heart meaning to your core it cools down again so therefore is it really no you'll have what we call an after drop okay so the the key there is warm the core first meaning the trunk and then you warm the extremities but this one obviously is local correct cuz this is frostbite so one body part is involved so that's why we can immerse just the that body part in the um Rew Waring bath yes the patients can go into cardiac arrests but that's more for hypothermia though not frostbite because when we say frostbite we we really uh refer to a body part usually the hands the feet the legs so now that won't have any any um uh you lose that limb but not really your life okay let's put it that way uh no massaging though okay so just handle it carefully rearm it and again once rewarmed protect it from further injury including ref freezing uh expect swelling though so control the whatever you cover it with okay not too tight if there are blisters just like in Burns don't pop them they just leave them alone then you attend to the other problems so same thing as what we discussed in malignant hypothermia since that involved muscle injury too right so in frostbite yes there's muscle injury so we expect rabdom myisis as well you expect hyper calamia Etc and since these are deep wounds then the patient will be given uh tetnus injection okay if we have just like in Burns so if you have any compartment syndrome that uh results then we do escarotomy photomy as indicated you avoid further substances or medications that will cause vasal constriction such as uh coffee tobacco okay that's it let's go to hypothermia so this one cold related injuries risk factors again the same so older adults and very young as well infants um chronic illnesses diabetes heart failure COPD kidney disease um homeless people and we have hypothyroidism spinal cord injury meaning they have decreased Mobility okay prevention we already mentioned earlier let's go to management so similar to heat related injuries what did we do remove the clothing yeah so in cold related of course obviously that's why they're cold related because the clothing are either wet or cold remove that replace them with dry warm uh material usually when we have hypothermia this is outside yeah so the patient is outside unless again in the remember in Texas when um when yeah when they had that um winter storm and um Ted Cruz went to Cancun yeah that that part you know no power and then people had um freezing temperatures okay so we had many cases there of hypothermia especially the elderly so ABCs just in case there are other injuries or I should say cab sorry and then same effect the patients will have severe uh cardiopulmonary complications as a result um if they do go into cardiac arrest we change the rules a little bit because the how long can you do chest compressions in and let's say somebody goes into cardic arrest how long can we do CH chest compressions yeah this time though we go longer okay so if we normally do maximum 30 minutes and then we call it yeah about 30 but um most cases I mean we you know because if you look at the algorithm if it's five minutes apart five minutes apart so technically we should stop compressions around 20 minutes do you know what I'm talking about let me show you the um by the way you can do um ACLS even without your license yet so let's say after school ends you can go for ACLS um most facilities reimburse you uh for the cost if you're worried because it costs like $250 um let's look at he this one I'm just giving you an idea about how long a code will last so let's say okay so you call a code yeah patient is um unresponsive no not breathing no no no pulse so you start CPR right so let's say what time is it now 207 okay so how long uh so let's say you do two minutes okay so look at that 2 minutes compression yeah so 2 minutes and then you put the um pads on so let's say 2 minutes later we got uh V or V Tech so we shop okay so shop no matter here these are the rules so if you have shop over you do this if um here we have um Rhythm you know came back okay so this is obviously shorter but this one would be the longest so you've got two minutes here okay so two minutes two minutes that that's four another two six yeah and then but look at the medication you can give medications repeatedly every 3 to 5 minutes so let's say we go 5 minutes so after the first shock you give the first EP right so that's five minutes already and then every five minutes you can repeat the EP so that's already what 10 12 minutes yeah and then you can give a Mone here so that's 15 so all in all about 25 to 30 minutes okay uh we miss it sometimes because you know In the Heat of the Moment uh sometimes the recorder cuz there's supposed to be a recorder um I'm usually a recorder because I mean I'm in bad shape okay I can't do I can't do I can't do uh test compressions okay but um you know I'm just at the cart right I'm recording and I'm handing out what they need so you know the protocol so you know when to give Epi okay so you expect it already so once they start compression so I take out the first EP I put it put it together and then once they ask okay EP all right here you go and then I record right and then five minutes later I don't want to open anything because uh because what if the Rhythm comes back and then we stop the code right yeah we're going to waste it so anticipate okay nothing now so I start uh preparing the next one all right so I anticipate okay second EP all right and then keep recording sometimes whoever that person doing that tend to do other things and then they forget the recording okay so it should be like if you're a recorder that's your job okay so it's an important job because you're keeping time so you're telling the the providers hey um five minutes already because sometimes they forget to ask so five minutes already okay give another epic okay you hand it so it's about what 30 minutes right 25 30 minutes now in in hypothermia we extend the time Beyond 30 minutes because if the patient's hypothermic the heart was kind of well not frozen but kind of preserved because it's cool meaning the metabolic rate is is lower right so um the rule is if if the patient's temperature is below 94 no between 85 and 94° meaning hypothermic yeah they're not dead so they're only Dead one once they reach 95 or higher does that mean does that make sense meaning you're not dead until you're warm and dead does that make sense yeah so you have to be at a certain um temperature and still no heartbeat to be dead so if you're below that temperature below 95 we continue okay because you're not dead yet do you follow so we extend that's why we extend the of course you know people uh there's already five or six people who have taken turns already so if we remember the cooling measures internal cooling measures we did in malignant hypothermia okay so uh instead of using cool now we use warm so we wrap the IV fluid with uh hot water um you know har you know we we warm it with you know hot water packs and then same thing with our lavage so instead of putting cool water into the stomach we use warm water and then same thing for the rectum same thing for the bladder okay so we um we use internal and external cooling measures so here forced air warming blankets this is the Bear Hugger that Miss Nasco was referring to earlier uh and here's the uh after drop phenomenon I mentioned earlier okay um CU that cold blood from the extremities contain a lot of lactic acid so that um that can cause AR rymus okay so we what's the rule again we what's the pattern we warm the okay the core first before the extremities okay uh any questions in terms of warming the solutions do we have a specific temperature to warm it up to no just wrap it as long as it's a body temperature body temperature is what 90 98 97 yeah but um remember with with um frostbite we can go as hot as 104 okay course you don't use the microwave okay don't put IV fluid bag in the micro