Chapter 33. Environmental Emergencies. Introduction. The human body functions best when all body systems operate in balance, a concept known as homeostasis.
Environmental factors such as temperature and atmospheric pressure can overwhelm the body's ability to cope with its surroundings. A variety of medical emergencies can result, particularly in children, older people, people with chronic illnesses, and young adults who overexert themselves. These can lead to mental status changes, functional changes, and possible death. Environmental emergencies can occur in any setting, and often accompany other illnesses and injuries that require treatment at the same time. For example, a trauma patient with hypothermia is at a higher risk of death than a patient with a normal body temperature.
As an emergency medical technician, you can save lives by recognizing and responding properly to these emergencies, most of which require prompt... treatment at the scene and in the hospital. In this chapter you will learn how the body regulates core temperature and the ways in which heat loss can occur.
The various forms of heat, cold, and water-related emergencies are described, including how to diagnose and treat hypothermia, frostbite, and hyperthermia. You'll also learn about pressure-related emergencies or dysbarism injuries caused by diving and high-altitude climbing, injuries caused by lightning. and envenomation, caused by bites and stings, factors affecting exposure. The following four factors will affect how a person deals with a cold or hot environment.
These can be used as prevention strategies for those who work or play in extreme environmental temperatures. Consider these factors during the assessment of your patient to determine whether he or she was prepared for a cold or hot environment. A hiker prepared for a warm summer hike in the foothills will present and respond to treatment differently than a traveler stranded in a hot vehicle because the radiator boiled over.
Physical Condition Patients who are ill or in poor physical condition will not be able to tolerate extreme temperatures as well as those whose cardiovascular, metabolic, and nervous systems are all functioning well. For example, An athlete in peak physical condition performs better and is less likely to experience injury or illness than someone with a less active lifestyle. Exertion also plays a role. For instance, a brisk walk will generate body heat when you are out in the cold but will also produce heat when it is not needed, such as walking on a hot asphalt road because your vehicle ran out of gasoline.
Age Children and older adults are more likely to experience temperature-related illness. Infants have poor thermoregulation, the body's ability to maintain normal temperature, at birth and do not have the ability to shiver, and generate heat when needed until about 12 to 18 months. An infant's surface area-to-mass ratio is larger than an adult's, so infants heat up and cool down faster.
When you get cold, you put on a sweater, A small child may not think to do this or may have difficulty finding and putting one on. On the other end of the spectrum, older adults have a loss of subcutaneous tissues as they age, reducing the amount of insulation they have. Poor circulation also contributes to increased heat loss. This is why older people often wear extra layers of clothing. Medications can also affect an older person's body thermostat, putting him or her at increased risk for temperature-related emergencies.
Finally, older patients are also at high risk for falls, and lying immobile on a hot or cold surface can rapidly lead to overexposure. 3. Nutrition and Hydration. Your body needs calories for your metabolism to function.
Staying well hydrated provides water as a catalyst for much of this metabolism. A lack of food or water will aggravate both hot and cold stress. provide fuel to burn, creating heat during the cold.
and water provides sweat for evaporation and removing heat. Alcohol use may increase fluid loss and place the patient at greater risk for temperature-related emergencies. 4. Environmental Conditions Factors such as air temperature, humidity level, and wind can complicate or improve environmental situations.
A light breeze helps you stay cool when it is hot outside, but a cold wind when it is cold outside can be uncomfortable. Extremes in temperature and humidity are not needed to produce hot or cold injuries. Many hypothermia cases occur at temperatures between 30 degrees Fahrenheit, minus 1 degree Celsius, and 50 degrees Fahrenheit, 10 degrees Celsius. Most heat stroke cases occur when the temperature is above 80 degrees Fahrenheit, 26.7 degrees Celsius, and the humidity is 80% or higher. When evaluating your patient's condition, consider the environment and whether your patient is prepared for that situation.
Older patients may turn the heat down in the winter or neglect to use air conditioning in the summer because of cost concerns. Some people may not open windows in a heat wave for fear of burglars. An understanding of the environmental conditions may help in your treatment decisions, and give you an idea about how the patient will respond to your care. Cold Exposure Normal body temperature is 98 degrees Fahrenheit, 36.7 degrees Celsius.
Complicated regulatory mechanisms keep this internal temperature constant, regardless of the ambient temperature, the temperature of the surrounding environment, if the body, or any part of it. exposed to cold environments these mechanisms may be overwhelmed cold exposure may cause injury to individual parts of the body such as the feet hands ears or nose or to the body as a whole because heat always travels from a warmer place to a cooler place body heat tends to move into the environment heat loss can occur in the following five ways conduction is the transfer of heat from a part of the body to a colder object or substance by direct contact, such as when a warm hand touches cold metal or ice, or is immersed in water with a temperature of less than 98 degrees Fahrenheit, 36.7 degrees Celsius. Heat can also be gained if the object or substance being touched is warm.
Convection occurs when heat is transferred to circulating air, such as when cool air moves across the body surface. A person who stands outside in windy. Winter weather and wears only lightweight clothing is mainly experiencing heat loss by convection.
A person can gain heat if the air moving across the person's body is hotter than the temperature of the environment, such as in deserts or industrial settings like foundries, but it is more common to see a rapid heat gain in spas and hot tubs where the water temperature may be well above body temperature. Evaporation is the conversion of any liquid to a gas, a process that requires energy, or heat. Evaporation is the natural mechanism by which sweating cools the body. This is why swimmers coming out of the water feel a sensation of cold as the water evaporates from their skin.
People who exercise vigorously in a cool environment may sweat, and feel warm at first, but later, as their sweat evaporates, they can become cold. Radiation is the transfer of heat by radiant energy. Radiant energy is a type of invisible light that transfers heat.
Radiation causes heat loss, such as when a person stands in a cold room. Heat can also be gained by radiation, for example, when a person stands by a fire. Respiration causes body heat loss as warm air in the lungs is exhaled into the atmosphere, and cooler air is inhaled. In warm climates, the air temperature can be well above body temperature, causing an individual to gain heat with each breath. The rate and amount of heat loss or gain by the body can be modified in three ways.
Also, people often have a natural urge to move around when they are cold. When a person is hot, he or she tends to reduce the level of activity. thus reducing heat production.
Move to an area where heat loss is decreased or increased. The most obvious way to decrease heat loss from radiation and convection is to move out of a cold environment, and seek shelter from the wind. The same holds true for a patient who is too hot. Simply moving the patient into the shade can reduce the ambient temperature by 10 degrees or more. If you cannot move the patient, Create shade and increase air movement by fanning the patient.
Wear the appropriate clothing for the environment. To avoid heat loss in cold environments, wear layers of clothing that provide good insulation, such as wool, down, and synthetic fabrics. Protective clothing traps perspiration, and prevents evaporation, which prevents cooling.
Keep the head, hands, and feet covered, and remove wet clothing if possible. To encourage heat loss in hot environments, wear lightweight, loose-fitting clothing, particularly around the head and neck. Hypothermia When the entire body temperature falls, the condition is called hypothermia.
Hypothermia means low temperature. It is diagnosed when the core temperature of the body, the temperature of the heart, lungs, and vital organs, falls below 95 degrees Fahrenheit, 35 degrees Celsius. The body can usually tolerate a drop in core temperature of a few degrees. However, below this critical point, the body cannot regulate its temperature, and generate body heat.
Progressive loss of body heat then begins, to protect itself against heat loss. The body normally constricts blood vessels in the skin. This results in the characteristic appearance of blue lips and or fingertips.
As a secondary precaution against heat loss, the body tends to create additional heat by shivering. As cold exposure worsens, and these mechanisms are overwhelmed, many body functions begin to slow down and mental status deteriorates. Eventually, the functioning of key organs such as the heart begins to slow.
Untreated, this can lead to death. Hypothermia can develop either quickly, as when someone is immersed in cold water, or gradually, as when a person is exposed to the cold environment for several hours or more. Recall that the temperature does not have to be below freezing for hypothermia to occur. In winter, hypothermia at temperatures well above freezing may develop in people experiencing homelessness, and those whose homes lack heat. Even in summer, swimmers who remain in the water for a long time are at risk of hypothermia.
Like all heat and cold-related conditions, hypothermia is more common among young and old people and those with illness, who are less able to adjust to temperature extremes. Patients with injuries or illness, such as burns, shock, head injury, stroke, generalized infection, injuries to the spinal cord, diabetes, and hypoglycemia, are more susceptible to hypothermia, as are patients who have taken certain drugs or consumed alcohol. Signs and Symptoms Signs and symptoms of hypothermia generally become more severe as the core temperature falls.
Hypothermia generally progresses through four stages, as shown in Table 33-1. Although there is no clear distinction among the stages, the different signs and symptoms of each will help you estimate the severity of the condition. When you assess a patient in the field, you should be able to distinguish between mild and severe hypothermia.
To assess the patient's core body temperature, Pull back on your glove and place the back of your hand on the patient's skin at the abdomen. This area of the body is usually well protected and will give you a quick, general idea of the patient's core temperature. If the skin feels cool, the patient is likely experiencing a generalized cold emergency.
If you work in a cold environment, and or depending on local protocols, you may carry a hypothermia thermometer, which registers lower core temperatures. It must be inserted in the rectum for an accurate reading. Regular thermometers will not register the temperature of a patient who has significant hypothermia. Mild hypothermia occurs when the core temperature is greater than 93.2 degrees Fahrenheit, 34 degrees Celsius, but less than the normal 98 degrees Fahrenheit, 36.7 degrees Celsius.
The patient is usually alert and shivering in an attempt to generate more heat through muscular activity. The patient may jump up and down and stamp his or her feet. Pulse rate and respirations are usually rapid.
The skin in light-skinned people can be red, but may eventually appear pale, then cyanotic. People in a cold environment may have bluish lips or fingertips because of the body's constriction of blood vessels at the skin to retain heat. Moderate hypothermia exists when the core temperature is 86 degrees Fahrenheit to 93.2 degrees Fahrenheit.
30 degrees Celsius to 34 degrees Celsius. When the core temperature is less than 90 degrees Fahrenheit, 32.2 degrees Celsius, shivering stops and muscular activity decreases. At first, small, fine muscle activity such as coordinated finger motion ceases. Eventually, as the temperature falls further, all muscle activity stops, and mental status deteriorates. Severe hypothermia is considered to be a core temperature of less than 86 degrees Fahrenheit, 30 degrees Celsius.
As the core temperature drops toward 85 degrees Fahrenheit, 29.4 degrees Celsius, the patient becomes lethargic and usually stops fighting the cold. The level of consciousness decreases, and the patient may try to remove his or her own clothes. Poor coordination and memory loss follow. along with reduced or complete loss of sensation to touch, mood changes, and impaired judgment.
The patient becomes less communicative, experiences joint or muscle stiffness, and has trouble speaking. The patient begins to appear stiff or rigid. If the core temperature continues to fall to 80 degrees Fahrenheit, 26.7 degrees Celsius, vital signs slow, the pulse becomes slower and weaker, and respirations become shallow or absent. Cardiac dysrhythmias may occur as the blood pressure decreases.
At a core temperature of less than 80 degrees Fahrenheit, 26.7 degrees Celsius, all cardiorespiratory activity may cease. Pupillary reaction is slow, and the patient may appear dead. However, never assume that a cold, pulseless patient is dead. Patients may survive severe hypothermia if proper emergency care is provided. It is critical that you perform an extended pulse check, up to a full minute.
Assess at the carotid or femoral pulse. A patient in apparent cardiac arrest from hypothermia should not be considered dead until aggressive rewarming has been attempted. along with resuscitation.
Remember the saying, no one is dead unless they are warm and dead. It is important to note that patients who have died from a cause other than hypothermia will be cold to the touch, however, there will be additional, obvious signs of death such as rigor mortis. The warm and dead rule does not apply to such patients.
Local cold injuries. Most injuries from cold are confined to exposed parts of the body. The extremities.
particularly the feet and hands, and the ears, nose, and face are especially vulnerable to cold injury. When exposed parts of the body become very cold but not frozen, injuries such as frostnip and immersion foot, also called trench foot, can result. When the parts become frozen, the injury is called frostbite.
If possible, determine the duration of the exposure, the temperature to which the body part was exposed, and the wind velocity during exposure. These important factors will help you determine the severity of a local cold injury. You should also investigate these potential underlying factors. Exposure to wet conditions.
Inadequate insulation from cold or wind. Restricted circulation from tight clothing or shoes or circulatory disease. Fatigue. Poor nutrition. Alcohol or drug abuse.
Hypothermia. Diabetes. Cardiovascular disease.
age. In hypothermia, blood is shunted away from the extremities to maintain the core temperature. This shunting of blood increases the risk of local cold injury to the extremities, ears, nose, and face. Thus, the patient with hypothermia should also be assessed for frostbite or other local cold injury.
The reverse is also true. Remember, both local and systemic cold exposure injuries can occur in the same patient. Frostnip and Immersion Foot.
After prolonged exposure to the cold, the skin may freeze whereas the deeper tissues are unaffected. This condition, which often affects the ears, nose, and fingers, is called frostnip. Because frostnip is usually painless, the patient often is unaware that a cold injury has occurred.
Immersion foot occurs after prolonged exposure to cold water. It is particularly common in hikers or hunters who stand for a long time in a river or lake. With both frostnip and immersion foot, the skin is pale, blanched, and cold to the touch.
Normal color does not return after palpation of the skin. In some cases, the skin of the foot will be wrinkled, but it can also remain soft. The patient reports loss of feeling and sensation in the injured area.
Frostbite Frostbite is the most serious local cold injury because the tissues are actually frozen. Freezing permanently damages cells, although the exact mechanism by which damage occurs is unknown. The presence of ice crystals within the cells may cause physical damage. The change in the water content in the cells may also cause changes in the concentration of critical electrolytes, producing permanent changes in the chemistry of the cell.
When the ice thaws, further chemical changes occur in the cell. causing permanent damage or cell death called necrosis or gangrene if Gangrene occurs the dead tissue may need to be surgically removed sometimes by amputation Following less severe damage the exposed part will become inflamed tender to touch and unable to tolerate exposure to cold Frostbite can be identified by the hard waxy feel of the affected tissues The injured part feels firm to frozen as you gently touch it If the frostbite is only skin deep, it will feel leathery or thick instead of hard. Blisters and swelling may be present.
In dark-skinned people, changes may be more subtle and harder to appreciate. Maintain a high index of suspicion for potential frostbite in these patients if the exposure to cold has been substantial and the tissues feel abnormal. In light-skinned people with a deep injury that has thawed or partially thawed, the skin may appear red or white, or it may be mottled, and cyanotic, purple and blue.
As with a burn, the depth of skin damage will vary. With superficial frostbite, only the skin is frozen. With deep frostbite, the deeper tissues are frozen as well. you may not be able to tell superficial from deep frostbite in the field even an experienced surgeon in a hospital setting may not be able to tell for several days after exposure and injury assessment of cold injuries management of hypothermia in the field regardless of the severity of the exposure consists of stabilizing the airway breathing and circulations and preventing further heat loss scenes size up typically Your scene assessment begins with information provided by dispatch.
Note environmental conditions. Air temperature, wind chill, and whether it is wet or dry are important aspects of scene size-up and will likely affect the patient. Ensure that the scene is safe for you and other emergency responders. Identify potential safety hazards, such as wet grass, mud, or icy streets.
Cold environments may present special challenges both for you and your patient. Consider special hazards such as avalanches. Use appropriate standard precautions, and consider the number of patients you may have.
Summon additional help, such as a search and rescue team, as quickly as possible. As you observe the scene, look for indicators of the mechanism of injury. For example, if you find a vehicle in a secluded ditch off the highway, and the vehicle's roof and hood are covered with fresh snow, then you may assume that the patient was in a motor vehicle crash.
and has been exposed to the cold for a long period of time. Primary assessment. In a cold emergency, your patient's chief complaint may be only that he or she is cold, or the cold may be an additional complication of an existing medical injury or trauma. Perform a rapid examination to determine whether a life threat exists, and if so, treat it. If the chief complaint is simply feeling cold, quickly assess the patient's core temperature by placing the back of your hand on the abdomen.
Evaluate the patient's mental status quickly using the awake and alert verbal stimuli pain unresponsive scale. An altered mental status indicates the intensity of the cold injury. Consider spinal immobilization based on your scene size up in the chief complaint. Your assessment should account for the physiologic changes that occur as a result of hypothermia.
If you believe the patient is in cardiac arrest, proceed directly to see an airway, breathing, and circulation. providing high-quality chest compressions, then address airway and breathing, and b. afterward.
Ensure that the patient has an adequate airway, and is breathing. If your patient's breathing is low or shallow, ventilation with a bag mask device may be necessary. Use warmed and humidified oxygen if it is available, because it helps to warm the patient from the inside out. If you cannot feel a radial pulse, gently palpate for carotid pulse. and wait for up to 60 seconds before you decide whether the patient is pulseless.
Even a pulse rate of 1 or 2 beats per minute indicates cardiac activity, and cardiac activity may spontaneously recover once the body core is warmed. However, there is evidence that cardiopulmonary resuscitation, when correctly done, will increase blood flow to the critical parts of the body. For this reason, Some authorities recommend starting cardiopulmonary resuscitation on a patient with hypothermia, and no pulse. The American Heart Association recommends that cardiopulmonary resuscitation be started if the patient has no detectable pulse or breathing. Remember, for a patient with hypothermia, this may require a prolonged pulse check of up to 60 seconds.
Perfusion will be compromised based on the severity of the cold exposure. Your assessment of the patient's skin will not be helpful in determining shock. Assume that shock is present and treated appropriately. Bleeding may be difficult to find because of the slow moving circulation and thick clothing.
If the scene size up, mechanism of injury, or chief complaint suggests the potential for bleeding, look for it carefully. Remembering internal bleeding will not be visualized. Even mild hypothermia can have serious consequences and complications.
including cardiac dysrhythmias and blood clotting abnormalities. Therefore, all patients with hypothermia require rapid transport for evaluation and treatment. Assess the scene for the safest way to quickly move your patient from the cold environment. As you package your patient for transport, work quickly, safely, and gently. Rough handling of a patient with hypothermia may cause a cold, slow, weak heart to twitch or fibrillate.
If transportation is delayed, protect the patient from further heat loss. History taking. After the life threats have been managed during the primary assessment, investigate the chief complaint.
Obtain a medical history. and be alert for injury-specific signs and symptoms as well as any pertinent negatives. Obtaining a patient's history in these situations may be difficult. If possible, find out how long your patient has been exposed to the cold environment, either from the patient or bystanders.
Exposures may be short or prolonged in duration. For example, A patient may have acute hypothermia from sudden immersion in cold water or hypothermia that developed over the course of hours during an expedition. Your sample history can provide important information affecting both your treatment in the field and the treatment your patient will receive in the hospital.
Recall that medications and underlying medical conditions may have an impact on the way cold affects the patient's metabolism. The patient's last oral intake and activity prior to the exposure will help to determine the severity of the cold injury. Secondary Assessment The secondary assessment is used to uncover injuries that may have been missed during the primary assessment.
In some instances, such as a critically injured patient or a short transport time, you may not have time to conduct a secondary assessment. Focus your physical examination on the severity of hypothermia. Assessing the areas of the body directly affected by cold exposure and the degree of damage.
Is the whole body cold, hypothermia, or just parts, frostbite? These determinations will affect your treatment decisions. For example, a patient who stops shivering but remains in a cold environment will experience a rapid decrease in body temperature, a sign of severe hypothermia, and a life-threatening emergency. Determine the degree and extent of cold injury.
as well as any other injuries or conditions that may not have been initially detected. The numbing effect of cold, both on the brain and on the body, may impair your patient's ability to tell you about other injuries or illnesses. Therefore, a careful examination of your patient's entire body will help you avoid missing important clues to your patient's condition.
Keep in mind that vital signs may be altered by the effects of 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 also indicate moderate to severe hypothermia.
Carefully evaluate your patient for changes in mental status using the awake and alert verbal stimuli pain unresponsive scale. Determine core body temperature using a hypothermia thermometer. If local protocols allow, pulse oximetry will often be inaccurate due to the lack of perfusion in the extremities.
Reassessment. Repeat the primary assessment. Reassess vital signs and the chief complaint.
Has the patient's condition improved with the interventions? Identify and treat changes in the patient's condition. Keep a close eye on your patient's level of consciousness and vital signs. As the body rewarms, the sudden redistribution of fluids and the release of built-up chemicals can have harmful effects, including cardiac dysrhythmias.
Be vigilant even if the patient's condition appears to be improving. Review all treatments that have been performed. In a cold-related emergency, depending on your local protocols, your treatment may only include oxygen delivery.
Reassess oxygen delivery, and continue to provide for a warm environment by removing any wet or frozen clothing. Do not remove any clothing frozen to the patient's skin. Communicate all of the information you have gathered to the receiving facility, which may be essential in evaluating and treating your patient in the hospital.
Your documentation should always include the patient's physical status, the conditions at the scene, information gathered from bystanders, and any changes in the patient's mental status during treatment and transport. General management of cold emergencies. In most cases, move the patient from the cold environment to prevent further heat loss.
To prevent further damage to the feet, do not allow the patient to walk. Remove any wet clothing, and place dry blankets over and under the patient. If available, give the patient warm, humidified oxygen if you have not already done so as part of the primary assessment. Always handle the patient gently so that you do not cause any pain or further injury to the skin.
Rough handling of a patient with moderate to severe hypothermia may cause the heart to go into ventricular fibrillation, which may not respond to defibrillation. This condition is characterized by uncontrollable twitching without effective pumping action by the heart. Do not massage the extremities.
Do not allow the patient to eat or to use any stimulants, such as coffee, tea, soda, or tobacco products. Stimulants are vasoconstrictors. which may further impair circulation to affected areas.
If the patient is alert, shivering, responds appropriately, and the core body temperature is between 90 degrees Fahrenheit to 95 degrees Fahrenheit, 32.2 degrees Celsius to 35 degrees Celsius, then the hypothermia is mild. Begin passive rewarming slowly, which includes placing the patient in a warm environment, removing wet clothing, and applying heat packs or hot water bottles to the groin. axillary, and cervical regions.
Turn the heat up high in the patient compartment of the ambulance. To avoid burns, do not place heat packs directly on the skin. If possible, you may give warm fluids by mouth, as allowed by local protocols, assuming that the patient is alert and can swallow without difficulty. However, when the patient has moderate or severe hypothermia, Active rewarming is best accomplished in the emergency department utilizing aggressive strategies to introduce heat into the body's core.
Such therapies might include warm intravenous fluids, lavage with warm fluids, and rewarming blood outside the body before reintroducing it. Extracorporeal rewarming. Rewarming the patient too quickly, or from the extremities rather than the core may cause a fatal cardiac dysrhythmia or other significant complications.
For this reason, Local protocols may dictate the appropriate type of re-warming strategies based on the patient's core body temperature. With a patient with moderate or severe hypothermia, your goal is to prevent further heat loss. Remove the patient immediately from the cold environment, place the patient in the ambulance, remove wet clothing, cover the patient with blankets, and transport.
Remember to handle the patient 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 a waterproof protective cover on the patient.
Remember that body heat loss easily occurs around the head and neck, both of which can be covered with a towel. Regardless of the nature or severity of the cold injury, remember that even an unresponsive patient may be able to hear you. Some patients have reported hearing a provider pronounce them dead, a provider who forgot the saying, no one is dead unless they are warm and dead. Emergency care of local cold injuries. The emergency treatment of local cold injuries in the field should include the following steps.
Consult medical control, if available. With Frostnip, contact with a warm object may be all that the patient needs. You can use your hands or the patient's own body. For example, have the patient tuck his or her hands into the armpits.
During rewarming, the affected part will often tingle and become red and light-skinned people. With immersion foot, remove wet shoes, boots, and socks, and rewarm the foot gradually, protecting it from further cold exposure. Next, cover it loosely with a dry, sterile dressing. Never rub or massage injured tissues, which could cause further damage.
Do not re-expose the injury to cold. With a late or deep cold injury, such as frostbite, remove any jewelry from the injured part, and cover the injury loosely with a dry, sterile dressing. Do not break blisters or rub or massage the area. Do not apply heat or rewarm the part.
Unlike with frostnip and trench foot, rewarming of the frostbite extremity is best accomplished in the emergency department. You can cause further injury to fragile tissues by attempting to rewarm a frostbite in part. Never apply something warm or hot, such as the exhaust from the ambulance engine or, even worse, an open flame.
Do not allow the patient to stand or walk on a frostbitten foot. Evaluate the patient's general condition for the signs or symptoms of systemic hypothermia. Support the vital functions as necessary and provide rapid transport to the hospital if prompt hospital care is unavailable And medical control instructs you to begin rewarming in the field use a warm water bath immerse the frostbite in part in water with a temperature between 104 degrees Fahrenheit and 105 degrees Fahrenheit 40 degrees Celsius and 41 degrees Celsius Check the water temperature with a thermometer before immersing the limb and recheck it frequently during the rewarming process.
The water temperature should never exceed 105 degrees Fahrenheit, 41 degrees Celsius. Stir the water continuously. Keep the frostbite in part in the water until it feels warm and sensation has returned to the skin.
Dress the area with dry, sterile dressings, placing them also between injured fingers or toes. Expect the patient to report severe pain. Never attempt re-warming if there is any chance that the part may freeze again before the patient reaches the hospital. Some of the most severe consequences of frostbite, including gangrene and amputation, have occurred when parts thawed, and then were allowed to re-freeze. Cover the frostbitten part with soft, padded, sterile cotton dressings.
If blisters have formed, do not break them. Remember, you cannot accurately predict the outcome of a case of frostbite early in its course. Even body parts that appear gangrenous may recover following proper treatment.
Cold exposure and you. As an emergency medical technician, you are also at risk for hypothermia if you work in a cold environment. If cold weather search and rescue operations are a possibility in your assigned areas, you should receive survival training, and precautionary tips.
Become familiar with local conditions. Be aware of existing, and potential weather conditions. and monitor changes that are forecast for the area.
Make sure to wear proper clothing whenever appropriate. Your vehicle, too, must be properly equipped and maintained for a cold environment. You cannot help others if you do not protect yourself. Never allow yourself to become a victim.
Heat Exposure Recall that normal body temperature is 98 degrees Fahrenheit, 36.7 degrees Celsius. In a hot environment or during vigorous physical activity, the body will try to rid itself of the excess heat. The two most efficient methods to decrease heat are sweating, and evaporation of the sweat, and dilation of skin blood vessels, which brings blood to the skin surface to increase the rate of heat radiation.
In addition, a person who becomes overheated can remove clothing, and seek a cooler environment. Ordinarily, the heat-regulating mechanisms of the body work well. and people are able to tolerate significant temperature changes. When heat gain exceeds heat loss, hyperthermia can result.
Hyperthermia is a high core temperature, usually 101°F, 38.3°C, or higher. When the body's mechanisms to decrease body heat are overwhelmed, and the body is unable to tolerate the excessive heat, a heat emergency develops in the patient. Higher temperature can reduce heat loss by radiation.
High humidity reduces heat loss through evaporation. The inability to acclimate, adjust, to the heat is a risk factor. Another risk factor is vigorous exercise, during which sweat loss can exceed 1 liter per hour, causing loss of fluid and electrolytes. A heat emergency can take the following three forms. Heat cramps, heat exhaustion, heat stroke.
All three forms may be present in the same patient because untreated heat exhaustion may progress to heat stroke. Heat stroke is life-threatening. People at greatest risk for a heat emergency are children, geriatric patients, patients with heart disease, chronic obstructive pulmonary disease, diabetes, dehydration, and obesity, and those with limited mobility.
Older people, newborns, and infants exhibit poor thermoregulation. Newborns and infants often wear too much clothing, alcohol and certain drugs, including medications that dehydrate the body or decrease the ability of the body to sweat, also make a person more susceptible to heat emergencies. When you are treating someone for a heat emergency, always obtain a medication history. Heat cramps Heat cramps are painful muscle spasms that occur after vigorous exercise.
They do not occur only when it is hot outdoors. They may be seen in factory workers, and even well-conditioned athletes. The exact cause of heat cramps is not well understood.
It is known that sweat produced during strenuous exercise, particularly in a warm environment, causes a change in the body's electrolyte balance. The result may be a loss of essential electrolytes from the cells. Dehydration may also play a role in the development of muscle cramps.
Large amounts of water loss can result from excessive sweating. This loss of water may affect muscles that are being stressed and cause them to spasm. Heat cramps usually occur in the leg or abdominal muscles. When the abdominal muscles are involved, the The pain and muscle spasm may be so severe that the patient appears to have an acute abdominal condition.
If a patient with the sudden onset of abdominal cramps has been exercising vigorously in a hot environment, suspect heat cramps. Heat exhaustion. Heat exhaustion, also called heat prostration or heat collapse, is the most common heat emergency. exposure, stress, and fatigue are causes of heat exhaustion. which is caused by hypovolemia as the result of the loss of water and electrolytes from heavy sweating.
Recall that for sweating to be an effective cooling mechanism, the sweat must be able to evaporate from the body. Otherwise, the body will continue to produce sweat, with further loss of body water. People standing in the hot sun, and particularly those wearing several layers of clothing, such as sports fans or parade watchers, may sweat profusely but experience little body cooling.
The sweat-soaked clothing will actually begin to trap heat, increasing body temperature. High humidity will also decrease the amount of evaporation that can occur. The heat index provided in figure 33-6 shows how high humidity increases the effects of ambient temperature.
For example, if the temperature is 90 degrees Fahrenheit, 32.2 degrees Celsius, with 86% humidity. The effect of the atmosphere on a person is the same as being in an environment of 105 degrees Fahrenheit, 40.6 degrees Celsius. People working or exerting themselves in poorly ventilated areas are unable to release heat through convection.
Thus, people who work or exercise vigorously and those who wear heavy clothing in a warm, humid, or poorly ventilated environment are particularly susceptible to heat exhaustion. The signs and symptoms of heat exhaustion and those of associated hypovolemia are as follows. Dizziness, weakness, or syncope signifying a change in level of consciousness with accompanying nausea, vomiting, or headache. Muscle cramping may also be present, including abdominal cramping.
Onset while working vigorously or exercising in a hot, humid, or poorly ventilated environment and sweating heavily. Onset, even at rest, in the older and infant age groups and hot, humid. and poorly ventilated environments or extended time in hot, humid environments.
People who are not acclimatized to the environment may also experience onset at rest, cold, clammy skin with ash and pallor, dry tongue and thirst. Normal vital signs, although the pulse is often rapid and weak, an indication for use of pulse oximetry, and the diastolic blood pressure may be low. Normal or slightly elevated body temperature. On rare occasions, as high as 104 degrees Fahrenheit, 40 degrees Celsius.
Heat stroke. Heat stroke, the least common but most serious heat emergency, occurs when the body is subjected to more heat than it can handle, and normal mechanisms for getting rid of the excess heat are overwhelmed. The body temperature then rises rapidly to the level at which tissues are destroyed. Untreated heat stroke always results in death.
Heat stroke. Heatstroke can develop in patients during vigorous physical activity or when they are outdoors or in a closed, poorly ventilated, humid space. It also occurs during heat waves among people, particularly geriatric patients, who live in buildings with no air conditioning or with poor ventilation. It may also develop in children who are left unattended in a locked vehicle on a hot day. Many patients with heatstroke have hot, dry, flushed skin because their sweating mechanism has been overwhelmed.
However, in the course of heat stroke, the skin may be moist or wet due to exertion by the patient. Keep in mind that a patient can have heat stroke even if he or she is still sweating. This presentation is often seen in endurance athletes, military personnel, or emergency providers who wear personal protective equipment, such as firefighters, special weapons and tactics team members, or hazmat workers. The body temperature rises rapidly in patients with heat stroke.
It may rise to 106 degrees Fahrenheit, 41.1 degrees Celsius, or more. As the body core temperature rises, the patient's level of consciousness decreases, resulting in unconsciousness. Often, the first sign of heat stroke is confusion or a change in behavior.
However, the patient often becomes unresponsive quickly and seizures may occur. The pulse is usually rapid and strong at first, but as the patient becomes increasingly unresponsive, the pulse becomes weaker and the blood pressure falls. The respiratory rate increases as the body attempts to compensate. An important and classically described sign of heat stroke is when the patient no longer perspires, which means the body has lost its thermoregulatory mechanism.
If you are perspiring in the environment, your patient should also be perspiring. If any one of these signs is present, suspect heat stroke and act accordingly. Assessment of heat emergencies. Scene size up.
As part of your scene size up, perform an environmental assessment. How hot is it outside? How hot is it in the room where your patient is located?
How well is the patient tolerating the heat? Dispatch may report the call initially as a medical or trauma emergency. The heat emergency may be secondary.
Always look for hazards as well as clues as to what may have caused your patient's emergency. If the patient is unconscious, has an altered mental status, or requires intravenous fluids to treat shock, consider calling for advanced life support assistance as long as doing so does not delay access to aggressive cooling techniques. As you observe the scene, Look for indicators of the mechanism of injury.
For example, you arrive on the scene at a shopping mall to find an older man with a decreased level of consciousness inside a parked vehicle on a warm, humid, sunny day. The mechanism of injury for this patient is sitting in a warm environment under direct sunlight with no ventilation. Heat emergencies commonly occur in the context of athletic events and practices, often with athletic trainers present.
In those instances, You may find the patient submerged in a cold water immersion bath inside the athletic training room. It is harmful to allow heat to persist for any amount of time. Therefore, cooling prior to transport is indicated if facilities such as an ice bath are available.
If the patient is placed in a cold water immersion bath on your arrival, monitor the patient and the water, and assist as necessary. Do not remove the patient until the temperature has normalized to the appropriate level. between 101°F and 102°F, 38.3°C and 38.9°C.
Do not overcool the patient. Overcooling can lead to shivering, which generates more heat. Monitor the patient closely. Finally, if you anticipate a prolonged scene time, protect yourself from the heat, and remember to stay hydrated. Use appropriate standard precautions.
including gloves and eye protection. Long-sleeved shirts and long pants may be uncomfortable in warm weather. However, they can help protect you from being splashed by blood or other body fluids. Primary assessment.
As you approach your patient, observe how the patient interacts with you and the environment. This will help identify the patient's degree of distress. Introduce yourself and ask about the chief complaint. A heat emergency may be the primary problem or it may simply be aggravating a medical or trauma condition.
Remember, prolonged heat exposure may stress the heart, causing a heart attack. Use this initial interaction to guide you in assessing for immediate life threats and related problems. Perform a rapid scan and avoid tunnel vision. Assess the patient's mental status using the awake and alert verbal stimuli pain unresponsive scale. Heat stroke is a life-threatening emergency.
Gather clues about his or her mental status to identify the severity of your patient's condition. The more altered the patient's mental status is, the more serious the heat emergency. Assess the patient's airway and breathing and treat any life threats. Unless the patient is unresponsive, the airway should be patent. Nausea and vomiting, however, may occur.
Position the patient to protect the airway as necessary. If the patient is unresponsive, be cautious of how you open the airway. Consider spinal motion restriction if trauma is a possibility.
If your patient is unresponsive, insert an airway and provide bag mask ventilations. If circulation is adequate, assess the patient for perfusion and bleeding. Assess the patient's skin condition carefully. Treat the patient aggressively for shock by removing the patient from the heat and positioning the patient to improve circulation. If your patient has any signs of heat stroke, provide rapid transport.
History taking. After the life threats have been managed during the primary assessment, investigate the chief complaint. Obtain a medical history, and be alert for specific signs and symptoms such as the absence of perspiration, decreased level of consciousness, confusion, muscle cramping, nausea, and vomiting. Obtain a sample history.
Patients with inadequate oral intake or who are taking diuretics may have difficulty tolerating exposure to heat. Remember, many medications used by geriatric patients affect how well they tolerate heat. Be thorough in your questioning. Determine your patient's exposure to heat and humidity and activities prior to the onset of symptoms. Secondary assessment.
The secondary assessment is used to uncover injuries that may have been missed during the primary assessment. In some instances, such as a critically injured patient or a short transport time, you may not have time to conduct a secondary assessment. If your patient is unresponsive, Perform a secondary assessment of the entire body looking for problems or explanations as to what is wrong.
Obtain the patient's vital signs to help understand the severity of the emergency. If the patient is conscious, perform an assessment of specific areas of the body. Heat exposure has significant effects on the metabolism, muscles, and cardiovascular system.
Assess the patient for muscle cramps or confusion. Examine the patient's mental status. and take the patient's vital signs. Perform a detailed examination if circumstances and time permit. Pay special attention to the patient's skin temperature, turgor, and level of moisture.
Skin turgor is the ability of the skin to resist deformation. It is tested by gently pinching skin on the abdomen or back of the hand. Normally the skin will quickly flatten out.
If the patient is dehydrated, the skin will remain tented. Poor skin turgor. Perform a careful neurologic examination. Patients with hyperthermia will often have tachycardia and tachypnea. As long as they maintain a normal blood pressure, their bodies will compensate for the fluid loss.
Once their blood pressure begins to fall, it indicates they are no longer able to compensate for fluid loss, and are going into shock. Your assessment of the patient's skin will help determine the severity of the emergency. For example, in heat exhaustion. The skin temperature may be normal or may even be cool and clammy. However, in heat stroke, the skin is hot.
Check the patient's body temperature with a thermometer, depending on protocol. Your unit equipment may include disposable or oral thermometers with disposable covers, infrared digital skin thermometers, or tympanic ear thermometers. You may not use these devices routinely, so become familiar with how they work. In patients with a heat-related emergency, monitoring of pulse oximetry is also useful.
Reassessment. Watch your patient's condition carefully for deterioration. Remove your patient as quickly as possible from the hot environment.
Patients with heat cramps or exhaustion usually respond well to passive cooling and fluids by mouth. Patients with symptoms of heat stroke should be transported immediately in a cool ambulance, passively cooled with clothing removal. and actively cooled by spraying the patient with water and fanning to enhance evaporation. Any decline in level of consciousness is an ominous sign.
Monitor the patient's vital signs at least every five minutes. Evaluate the effectiveness of your interventions. Be careful not to overcool a patient who is experiencing a heat emergency, but the risk of failing to reverse heat stroke by active cooling far exceeds the risk of overcooling. Remember. Heatstroke is uniformly fatal if not reversed rapidly and effectively.
Inform the emergency department staff as soon as possible that your patient is experiencing heatstroke, because additional resources may be required. Document the environmental conditions and the activities the patient was performing prior to the emergency in your patient care report. Consider other possibilities of the altered mental status, such as traumatic brain injury, alcohol consumption, or a low blood glucose level. Management of heat emergencies.
Heat cramps. Take the following steps to treat heat cramps in the field. 1. Promptly remove the patient from the hot environment, including direct sunlight.
Loosen any tight clothing. 2. Administer high flow oxygen if the patient shows signs of hypoxia or respiratory distress. 3. Rest the cramping muscles.
have the patient sit or lie down until the cramps subside for replace fluids by mouth give water or a diluted half strength balanced electrolyte solution such as a sports drink In most cases, plain water is the most useful. Do not give salt tablets or solutions that have a high salt concentration. 5. Cool the patient with cool water spray or mist, and add convection to the cooling method by manually or mechanically fanning the patient. When the heat cramps are gone, the patient may resume activity. For example, an athlete can return to play once the heat cramps have disappeared.
However, Heavy sweating may cause the cramps to reoccur. The best strategy for treatment and prevention is hydration by drinking enough water. If the cramps do not go away after these measures, transport the patient to the hospital. If you are uncertain that the patient's cramps were caused by the heat or you note anything out of the ordinary, contact medical control or transport the patient to the hospital.
Heat Exhaustion To treat the patient with heat exhaustion, Follow the steps in skill drill 33-1. 1. Promptly remove the patient from the hot environment, preferably into the back of the air-conditioned ambulance. If outdoors, move out of direct sunlight.
Remove any excessive layers of clothing, particularly around the head and neck. Step 1. 2. Administer high flow oxygen if indicated. If this was not already done as part of the primary assessment.
If the patient has an altered mental status, check the blood glucose level. 4. Cool the patient with misting and administration of ice packs to the trunk of the patient's body. If an ice bath or similar facility is available, provide cold water immersion to the patient if allowed per local protocol. Cold water, ice bath, immersion is recommended for patients with a core temperature of 104 degrees Fahrenheit, 40 degrees Celsius. or an altered mental status.
Encourage the patient to lie down, loosen any tight clothing, and cool the patient by manually or mechanically fanning him or her. Step 2. 6. If the patient is fully alert, encourage him or her to sit up and slowly drink up to a liter of water, as long as nausea does not develop. Never force fluids by mouth on a patient who is not fully alert, or allow drinking while supine. because the patient could aspirate the fluid into the lungs. If the patient does not become nauseated, transport the patient on the left side to prevent aspiration.
Step 3. In most cases, these measures will reverse the symptoms, causing the patient to feel better within 30 minutes. Prepare to transport the patient to the hospital, and also consider a rendezvous with advanced life support for more aggressive treatment, such as intravenous fluid therapy, and close monitoring. especially in the following circumstances.
The symptoms do not clear up promptly. The level of consciousness decreases. The body temperature remains elevated. The person is very young, is older, or has any underlying medical condition, such as diabetes or cardiovascular disease.
Perform cold water immersion or other cooling measures as available. Place the patient in a supine position and fan the patient. Step 3. If the patient is fully alert, Give water by mouth. Step 4. If nausea develops, secure and transport the patient on his or her left side. Heat stroke.
Recovery from heat stroke is only possible if treatment is administered rapidly, so you must identify this patient quickly. Emergency treatment has one objective. Lower the body temperature by any means available. Take the following steps when treating a patient with heat stroke.
Move the patient out of the hot environment and into the ambulance. 2. Set the air conditioning to maximum cooling. 3. Remove the patient's clothing.
Administer high-flow oxygen if indicated. If this was not already done as part of the primary assessment. If needed, assist the patient's ventilations with a bag mask device and appropriate airway adjunct as per your protocol.
If the patient is unresponsive and unable to protect his or her airway, consider rapid transport and cooling en route. Consult medical control if available. 5. Provide cold water immersion in an ice bath, if possible.
Cooling should begin immediately and continue en route to the hospital. If it is not possible to cool en route, and cold water immersion is available at the scene, continue cold water immersion at the scene until the core body temperature is between 101°F and 102°F, 38.3°C and 38.9°C. 6. Spray the patient with cool water and fan him or her to quickly evaporate the moisture on the skin. 7. Aggressively and repeatedly fan the patient with or without dampening the skin. 8. Exclude other causes of altered mental status, and check blood glucose level, if possible.
Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. Some agencies previously used the term near-drowning to refer to a patient who survives at least temporarily, 24 hours. after suffocation in water.
Terms such as near drowning, and wet, dry, and secondary drowning, are confusing. Although previously popular, they have no effect on care, and therefore are no longer used. According to the Centers for Disease Control and Prevention, an average of 10 people die from unintentional drownings each day. More than 25% are children younger than 14 years.
Alcohol Consumption Pre-existing seizure disorders, geriatric patients with cardiovascular disease, and unsupervised access to water are among the major risk factors. 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 toward the surface or the shore.
The person becomes fatigued or exhausted, which leads him or her to sink even deeper. Most people can only hold their breath for about a minute when submerged underwater. After that, water is inhaled and then the person coughs. Without rescue, the person continues to aspirate, becomes hypoxic, loses consciousness, and within a few minutes stops breathing, and then suffers a cardiac arrest. In cold water this process is extended.
However, drowning also occurs in buckets, puddles, bathtubs. and other places where the person is not completely submerged. Young children can drown in as little as 1 inch, 3 centimeters, of water if left unattended. Spinal injuries and submersion incidents.
Submersion incidents may be complicated by spinal fractures, and spinal cord injuries, which occur in less than 0.5% of persons who are drowning. Assume that spinal injury exists with the following conditions. The submersion has resulted from a diving mishap or fall from a significant height.
The patient is conscious but reports weakness, paralysis, or numbness in the arms or legs. You suspect the possibility of spinal injury despite what witnesses say. Most spinal injuries and diving incidents affect the cervical spine. When spinal injury is suspected, the neck must be protected from further injury.
This means that you will have to stabilize the suspected injury while the patient is still in the water. If the situation does not indicate a possible spinal injury, stabilization is not recommended. To stabilize a suspected spinal injury in water, follow the steps in Skill Drill 33-2. 1. Turn the patient supine.
Two rescuers are usually required to turn the patient safely, although in some cases one rescuer will suffice. Always rotate the entire upper half of the patient's body as a single unit, twisting only the head, for example, may aggravate any injury to the cervical spine. Step 1. 2. Restore the airway, and begin ventilation.
Immediate ventilation is the primary treatment of all drowning patients as soon as the patient is face up in the water. Use a pocket mask if it is available. Have the other rescuer support. the head and trunk as a unit while you open the airway, and begin artificial ventilation. Step 2. Prepare for vomiting.
65% of victims requiring rescue breathing vomit and 88% of those receiving chest compressions will vomit. 3. Float a buoyant backboard or spinal restriction device under the patient as you continue ventilation. Step 3. 4. Secure the trunk and head to the board or device to restrict spinal motion. Do not remove the patient from the water.
Step 4. 5. Remove the patient from the water on the backboard. Step 5. 6. Cover the patient with a blanket. Give oxygen if the patient is breathing spontaneously. Begin cardiopulmonary resuscitation if there is no pulse.
Effective cardiac compression or cardiopulmonary resuscitation is extremely difficult to perform when the patient is still in the water. Step 6. Skill drill 33-2 Stabilizing a suspected spinal injury in the water. Step 1. Turn the patient to a supine position by rotating the entire upper half of the body as a single unit.
Step 2. As soon as the patient is turned. Begin artificial ventilation using the mouth-to-mouth method or a pocket mask unless you are in a situation where there is active community transmission of aerosolized or airborne respiratory illness. Step 3. Float a buoyant backboard or appropriate device under the patient. Step 4. Secure the patient to the backboard or device. Step 5. Remove the patient from the water.
Step 6. Maintain the body's normal temperature. and apply oxygen if the patient is breathing. Begin cardiopulmonary resuscitation if breathing and pulse are absent.
Recovery techniques. On occasion, you may be called to the scene of a drowning and find that the patient is not floating or visible in the water. An organized rescue effort in these circumstances calls for providers who are experienced with recovery techniques and equipment, including snorkel, mask, and scuba gear.
Scuba gear? Self-contained underwater breathing apparatus is a system that delivers air to the mouth and lungs at atmospheric pressures that increase with the depth of the dive. Resuscitation efforts When a person is submerged in water that is colder than body temperature, heat will be conducted from the body to the water.
The resulting hypothermia can protect vital organs from the lack of oxygen. In addition, exposure to cold water will occasionally activate certain primitive reflexes. which may preserve basic body functions for prolonged periods.
If a person is found unconscious in the water, resuscitation may be beneficial to the patient's outcome, but it must be administered by a highly trained rescuer. Also, whenever a person dives or jumps into very cold water, the diving reflects slowing of the heart rate caused by submersion in cold water, may cause immediate bradycardia, a slow heart rhythm, loss of consciousness, and drowning may follow. However, 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.
For this reason, local protocols often dictate that resuscitation efforts continue for up to one hour after submersion, while simultaneously rewarming the patient. Mouth-to-mouth and mouth-to-mask resuscitation are contraindicated in situations where there is active community transmission of aerosolized or airborne respiratory illnesses such as COVID-19, smallpox, or measles. Resuscitation efforts are not initiated for unwitnessed drowning victims who are found in a state of decomposition.
Diving emergencies Many serious water-related injuries are associated with underwater dives, with or without scuba gear. Some of these injuries are related to the nature of the dive, others result from panic. Panic is not restricted to the person who is frightened by water. It can happen even to the experienced diver or swimmer. Millions of people engage in scuba diving every year in the United States.
Medical emergencies relating to scuba diving techniques and equipment are becoming increasingly common. These injuries are separated into three phases of the dive, descent, bottom, and ascent. Descent emergencies. Descent problems are usually caused by the sudden increase in pressure on the body as the person dives deeper into the water. Some body cavities cannot adjust to the increased external pressure of the water.
The result is severe pain. The usual areas affected are the lungs, the sinus cavities, the middle ear, the teeth, and the area of the face surrounded by the diving mask. Usually, the pain caused by these squeeze problems forces the diver to return to the surface to equalize the pressures, and the problem clears up by itself. A diver who continues to report pain, particularly in the ear, after returning to the surface should be transported to the hospital. A special problem may develop in a person with a perforated tympanic membrane, ruptured eardrum, while diving.
If cold water enters the middle ear through a ruptured eardrum, the diver may sustain a loss of balance and orientation. The diver may then shoot to the surface and experience ascent problems. Emergencies at the bottom.
Problems related to the bottom of the dive are rarely seen. They include inadequate mixing of oxygen and carbon dioxide in the air the diver breathes, and accidental feeding of poisonous carbon monoxide into the breathing apparatus. Both are the result of faulty connections in the diving gear. These situations can cause drowning or rapid ascent. They require emergency resuscitation and transport of the patient.
Ascent emergencies. Most of the serious injuries associated with diving are related to ascending from the bottom and are referred to as ascent problems. These emergencies usually require aggressive resuscitation. Two particularly dangerous medical emergencies are air embolism and decompression sickness. Air embolism.
The most dangerous, and most common, emergency in scuba diving is an air embolism, a condition involving bubbles of air in the blood vessels. An air embolism may occur on a dive as shallow as 6 feet, 2 meters. 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 while the external pressure on the chest decreases. As a result, the air inside the lungs expands rapidly, causing the alveoli in the lungs to rupture.
The air released from this rupture can cause the following injuries. Air may enter the pleural space and compress the lungs, a pneumothorax. Air may enter the mediastinum, the space within the thorax that contains the heart, and great vessels. causing a condition called pneumomediastinum. Air may enter the bloodstream, and create bubbles of air in the vessels called air emboli.
Pneumothorax and pneumomediastinum both result in pain, and severe dyspnea. An air embolus will act as a plug, and prevent the normal flow of blood and oxygen to a specific part of the body. The brain and spinal cord are the organs most severely affected by air embolism because they require constant supply of oxygen. The following are potential signs and symptoms of an air embolism. Blotching, mottling of the skin, froth, often pink or bloody, at the nose and mouth, severe pain in muscles, joints, or abdomen, dyspnea and or chest pain, dizziness, nausea, and vomiting, dysphagia, difficulty speaking, cough, cyanosis, difficulty with vision, paralysis and or coma.
Irregular pulse and cardiac arrest. Decompression sickness. Decompression sickness, commonly called the bends, occurs when bubbles of gas, especially nitrogen, obstruct the blood vessels. This condition results from too rapid an ascent from a dive, too long of a dive at too deep a depth, or repeated dives within a short period of time. During the dive, nitrogen that is being breathed dissolves in the blood and tissues because it is under pressure.
When the diver ascends, the external pressure is decreased, and the dissolved nitrogen forms small bubbles within those tissues. These bubbles can lead to problems similar to those that occur in air embolism, blockage of tiny blood vessels, depriving parts of the body of their normal blood supply. But severe pain in certain tissues or spaces in the body is the most common problem.
Similarly, decompression sickness can occur even after a safe dive from driving a car up a mountain or flying in unpressurized airplane that climbs too rapidly to a great height however the risk of this diminishes after 24 to 48 hours the most striking symptom is abdominal and or joint pain so severe that the patient literally doubles over or bends dive tables and diving computers are available to calculate and record the proper rate of ascent from a dive including the number and length of pauses that a diver should make on the way up. However, even divers who stay within these limits can occasionally experience symptoms of the bends. You may find it difficult to distinguish between air embolism and decompression sickness. In general, air embolism occurs immediately on return to the surface, whereas the symptoms of decompression sickness may not occur for several hours. The emergency treatment is the same for both.
It consists of basic life support including supplemental oxygen, followed by recompression in a hyperbaric chamber, a chamber or a small room that is pressurized to a level higher than atmospheric pressure. Recompression treatment allows the bubbles of gas to dissolve into the blood, and equalizes the pressures inside and outside the lungs. Once these pressures are equalized, gradual decompression can be accomplished under controlled conditions to prevent the bubbles from reforming.
Assessment of drowning and diving emergencies. Scene size up. In managing water emergencies, your standard precautions should include gloves, mask, and eye protection at a minimum.
Check for hazards to your crew. Never drive through moving water. Even a small amount can cause the vehicle to be swept away.
Use extreme caution when driving through standing water. Never attempt a water rescue without proper training and equipment. Call for additional resources early.
If your patient is still in the water, look for the best, safest means of removal. This may require additional help from search and rescue teams or special extrication equipment. Trauma and an associated need to provide spinal motion restriction must be considered when the scene is a recreational setting.
Check for additional patients based on where and how the emergency occurred. As you observe the scene, Look for indicators of the mechanism of injury. As you put together information from dispatch and your observations of the scene, consider how the mechanism of injury produced the injuries suspected.
Primary assessment. Use your evaluation of the patient's chief complaint to guide you in your assessment of life threats and determine whether spinal motion restriction is necessary. Pay particular attention to chest pain, dyspnea, and complaints related to sensory changes when a diving emergency is suspected. Determine the patient's level of consciousness using the awake and alert verbal stimuli pain unresponsive scale.
Be suspicious of drug and alcohol use and the effects on the patient's level of consciousness. Standard measures should be taken for any patient found or injured while in the water. Begin with opening the airway and assessing breathing in unresponsive patients. Consider the possibility of spinal trauma, and take appropriate actions. The airway may be obstructed with water.
Suction according to protocol if the patient has vomited and expect that the patient is likely to vomit during your care and resuscitation. Provide ventilations with the bag mask device for inadequate breathing. Use an airway adjunct to facilitate bag mask ventilations as necessary. If the patient is responsive, Provide high-flow oxygen with a non-rebreathing mask.
If there is no risk of spinal injury, position the patient to protect the airway from aspiration in the event of vomiting. Auscultation and frequent reassessment of breath sounds in drowning patients is a key part of your assessment. You may hear diminished sounds or even gurgling sounds from water that has been inhaled.
Provide this information, and any changes in the patient's lung sounds. to the advanced life support providers who may rendezvous with your unit as well as to the receiving facility. Breath sounds are also particularly significant for patients with scuba diving injuries. While the patient's ascended to the surface, a pneumothorax or tension pneumothorax may have developed.
Check for a pulse. It may be difficult to find a pulse because of constriction of the peripheral blood vessels and low cardiac output, resulting in cyanosis. nevertheless If the pulse is unmeasurable, the patient may be in cardiac arrest. After administering five breaths, begin cardiopulmonary resuscitation and apply your automated external defibrillator according to basic life support and the International Liaison Committee on Resuscitation Guidelines. Evaluate the patient for adequate perfusion, and treat for shock by maintaining normal body temperature, and improving circulation through positioning.
The patient's skin may be cold to the touch. If the mechanism of injury suggests trauma, assess for bleeding, and treat appropriately. Even if resuscitation in the field appears successful, always transport patients to the hospital. Inhalation of any amount of fluid can lead to delayed complications lasting for days or weeks.
Patients with decompression sickness and air embolism must be treated in a recompression chamber. If you live in an area with a significant amount of scuba diving activity, you'll have transport. protocols for such cases.
Usually, the patient will be stabilized in the nearest emergency department. Perform all interventions en route. History taking.
After the life threats have been managed during the primary assessment, investigate the chief complaint. Obtain a medical history, and be alert for injury-specific signs and symptoms as well as any pertinent negatives. Obtain a sample history with special attention to the dive parameters, including depth. the length of time the patient was underwater, the time of onset of symptoms, and previous diving activity. Note any physical activity, alcohol or drug consumption, and other medical conditions.
All of these factors may have an effect on the diving or drowning emergency. Secondary Assessment The secondary assessment is used to uncover injuries that may have been missed during the primary assessment. In some instances, such as a critically injured patient or a short transport time, you may not have time to conduct a secondary assessment. If the patient is responsive, focus your physical examination on the basis of the chief complaint and the history obtained.
This should include a thorough examination of the patient's lungs, including breath sounds. Prolonged submersion typically results in an unresponsive patient. It is important to begin with a full body scan in these situations to look for hidden life threats, and potential trauma, even if trauma is not suspected.
A scuba diver with a possible medical condition should be assessed for indications of decompression sickness or an air embolism. Focus on pain in the joints, and the abdomen. Pay attention to whether your patient is getting adequate ventilation, and oxygenation.
and check for signs of hypothermia, time and personnel permitting. Complete a detailed assessment en route to the hospital. A careful examination may reveal additional injuries not initially observable. Examine the patient for respiratory, circulatory, and neurologic compromise. A careful distal circulatory, sensory, and motor function examination will be helpful in assessing the extent of the injury.
Assess for peripheral pulses. skin color and discoloration, itching, pain, and paresthesia, numbness and tingling. Check the patient's pulse rate, quality, and rhythm. Pulse and blood pressure may be difficult to palpate in a patient with hypothermia.
Check carefully for both peripheral and central pulses, and listen over the chest for a heartbeat if pulses are weak. Check the respiratory rate, quality, and rhythm and listen for breath sounds. Assess and document pupil size and reactivity.
Although it is a valuable tool, oxygen saturation readings may produce a false low reading because of hypoperfusion of the patient's monitoring finger. Shivering also can interfere with obtaining an accurate reading because of excessive movement. Reassessment. Repeat the primary assessment.
Reassess vital signs, and the chief complaint. Are the airway, breathing, and circulation still adequate? Recheck patient interventions.
Are your treatments for problems with the airway, breathing, and circulation still effective? The condition of patients who have experienced submersion in water may deteriorate rapidly because of pulmonary injury, fluid shifts in the body, cerebral hypoxia, and hypothermia. Patients with pneumothorax, air embolism, or decompression sickness may decompensate quickly.
Assess your patient's mental status constantly. assess vital signs at least every five minutes pay particular attention to respirations and breath sounds document the circumstances of the drowning and extrication the receiving facility personnel will need to know how long the patient was submerged the temperature of the water the clarity of the water and whether there was any possibility of cervical spine injury if you respond to a diving incident the receiving facility personnel will also need a complete dive profile to properly treat your patient. This information may be available in a dive log, on a dive computer, or from the patient's diving partners. If possible, bring all of the diver's equipment to the hospital. It will be helpful in determining the cause of the incident.
Be sure to document the disposition of this equipment. Emergency care for drowning or diving emergencies. Treatment for drowning begins with rescue and removal from the water. Provide spinal motion restriction when a fall from a significant height or suspected diving injury has occurred, or if this is a possibility when no information is provided.
Artificial ventilation should be provided as soon as possible. Artificial ventilation should only be performed in the water if rapid removal from the water is not possible. Spinal motion restriction must continue while artificial ventilation is being performed. If the patient is not breathing, Clear any vomit from the airway manually or with suction, and assist ventilations with a bag mask device or pocket mask.
Rolling patients onto their side or performing abdominal thrusts will not remove water from the lungs, and should not be done unless the airway is obstructed. Frothy sputum in the patient's airway does not require removal with suctioning. When resuscitating a patient who has drowned, the usual circulation, airway, and breathing order, compressions, airway, breathing. is not used. Rather, address airway and breathing concerns first, beginning with five rescue breaths, then use compressions and use the automated external defibrillators.
If the patient is breathing spontaneously, but has been submerged, administer oxygen. If this was not done as part of the primary assessment, treat all drowning patients for hypothermia by removing wet clothing and wrapping them in warm blankets. When treating conscious patients who are suspected of having an air embolism or decompression sickness from scuba diving, follow these accepted treatment steps.
Remove the patient from the water. Try to keep the patient calm. 2. Administer oxygen.
Consider the possibility of pneumothorax, and monitor the patient's breath sounds for development of a tension pneumothorax. 4. Provide prompt transport to the emergency department or to the nearest recompression facility for treatment based on local protocols. Injury from decompression sickness is often reversible with proper treatment.
However, if the bubbles block the airway, critical blood vessels that supply the brain or spinal cord, permanent central nervous system injury may result. Therefore, the key in emergency management of serious ascent problems is to recognize that an emergency exists and treat as soon as possible. Depending on local protocols, consider transport to a facility with a hyperbaric chamber if there is one near your service area.
Remember that aromatical evacuation for someone who has sustained an injury in ascending from a dive is relatively contraindicated as the decrease in air pressure may worsen the underlying decompression injury. Other water hazards Pay close attention to the body temperature of a person who is rescued from cold water. Treat hypothermia caused by immersion in cold water the same way you treat hypothermia caused by cold exposure.
Prevent further heat loss from contact with the ground. stretcher, or air, and transport the patient promptly. A person swimming in shallow water may experience breath-holding syncope, a loss of consciousness caused by a decreased stimulus for breathing. This happens to swimmers who breathe in and out rapidly and deeply before entering the water in an effort to expand their capacity to stay underwater. Whereas this technique increases the swimmer's oxygen level, the hyperventilation involved lowers the carbon dioxide level.
Because an elevated level of carbon dioxide in the blood is the strongest stimulus for breathing, the swimmer may not feel the need to breathe even after using up all the oxygen in his or her lungs. This results in drowning. The emergency treatment for a patient with breath-holding syncope is the same as that for a drowning patient.
Prevention Each year, many young children drown in residential pools. Appropriate precautions can prevent most submersion incidents. All swimming pools should be surrounded by a fence that is at least 6 feet high, with slats no farther apart than 3 inches and self-closing gates.
The most common problem is a lack of adult supervision. An incident can occur when a child is unattended for only a few seconds. Half of all teenage and adult drownings are associated with alcohol use. As a health care professional, You should be involved in public education efforts to make people aware of the hazards of swimming pools and water recreation.
High Altitude High altitudes can cause dysbarism injuries. Dysbarism injuries are any signs and symptoms caused by the difference between the surrounding atmospheric pressure and the total gas pressure in various tissues, fluids, and cavities of the body. Altitude illnesses occur when an unacclimated person is exposed to diminished oxygen pressure in the air at high altitudes. These illnesses affect the central nervous system, and pulmonary system, and range from common acute mountain sickness to high-altitude cerebral edema, and high-altitude pulmonary edema.
Acute mountain sickness is caused by diminished oxygen pressure in the air at altitudes above 5,000 feet, resulting in diminished oxygen in the blood, hypoxia. It strikes those who ascend too high too fast and those who have not acclimatized to high altitudes. The signs and symptoms include a headache, lightheadedness, fatigue, loss of appetite, nausea, difficulty sleeping, shortness of breath during physical exertion, and a swollen face. Treatment primarily consists of stopping the ascent and descending to a lower altitude and administering oxygen if the patient is dyspneic.
However, Consider other possible causes for the same symptoms, such as hypoglycemia or carbon monoxide poisoning from a camping stove. With high-altitude pulmonary edema, fluid collects in the lungs, hindering the passage of oxygen into the bloodstream. It can occur at altitudes of 8,000 feet or greater. The signs and symptoms include shortness of breath, cough with pink sputum, cyanosis, and a rapid pulse. High-altitude cerebral edema usually occurs in climbers and may accompany high-altitude pulmonary edema.
It can quickly become life-threatening. The signs and symptoms include a severe, constant, throbbing headache, ataxia, lack of muscle coordination and balance, extreme fatigue, vomiting, and loss of consciousness. The symptoms of high-altitude cerebral edema and high-altitude pulmonary edema may overlap.
In the field, treatment for high-altitude pulmonary edema and or high-altitude cerebral edema consists of descending to a lower altitude. During the descent, begin providing oxygen, and promptly transport to an appropriate facility. For inadequate respirations, provide positive pressure ventilation with a bag mask device.
If local protocols allow. Continuous positive airway pressure may be helpful for a patient with respiratory distress from high-altitude pulmonary edema. Lightning According to the National Weather Service, there are an estimated 25 million cloud-to-ground lightning flashes in the United States each year. On average, lightning kills between 20 and 30 people per year in the United States based on documented cases.
This number has decreased over the past several years. Although documented lightning injuries in the United States average about 300 per year, undocumented lightning injuries are likely much higher. Lightning is the fifth most common cause of death from isolated environmental phenomena.
The energy associated with lightning comprises direct current of up to 200,000 EPS and a potential of 100 million volts or more. Temperatures generated from lightning vary between 20,000 degrees Fahrenheit and 60,000 degrees Fahrenheit. 11,000 degrees Celsius and 33,000 degrees Celsius.
Most deaths and injuries caused by lightning occur during the summer months when people are enjoying outdoor activities, despite an approaching thunderstorm. Those most commonly struck by lightning include boaters, swimmers, and golfers. Any type of activity that exposes the person to a large, open area increases the risk of being struck by lightning. Whether or not lightning injures or kills depends on whether a person is in the path of the lightning discharge.
The current associated with the lightning discharge travels along the ground. Although some people are injured or killed by a direct lightning strike, many people are indirectly struck when standing near an object that has been struck by lightning, such as a tree, splash effect. The cardiovascular and nervous systems are most commonly injured during a lightning strike.
Therefore, respiratory or cardiac arrest is the most common cause of lightning-related deaths. The tissue damage caused by lightning is different from that caused by other electric-related injuries, that is, high-voltage power line injuries, because the tissue damage pathway usually occurs over the skin, rather than through it. During your assessment, look for not only the entrance wound but also the exit wound. The exit wound does not necessarily occur on the same side of the body.
Additionally, Because the duration of a lightning strike is short, skin burns are usually superficial, full thickness, third degree, burns are rare. Lightning injuries are categorized as being mild, moderate, or severe. Mild.
Loss of consciousness, amnesia, confusion, tingling, and other nonspecific signs and symptoms. Burns, if present, are typically superficial. Moderate. Seizures.
Respiratory arrest. Dysrhythmias that spontaneously resolve, and superficial burns. Severe.
Cardiopulmonary arrest. Because of the delay in resuscitation, often the result of occurrence in a remote location, many of these patients do not survive. Emergency medical care.
As with any seen response, your priority is safety. Take measures to protect yourself and your partner from being struck by lightning, especially if the thunderstorm is still in progress. Contrary to popular belief, lightning can, and does, strike in the same place twice.
Move the patient to a place of safety, preferably in a sheltered area. If you are in an open area, and adequate shelter is unavailable, it is important to recognize the signs of an impending lightning strike, and take immediate action to protect yourself. If you suddenly feel a tingling sensation or your hair stands on end, the area around you has become charged. A sure sign of an imminent lightning strike. Make yourself as small a target as possible by squatting down into a ball, with as little of your body as possible touching the ground.
If you are standing near a tree or other tall object, move away as fast as possible, preferably to a low-lying area. Lightning tends to strike objects that project from the ground, that is, trees, fences, buildings. The process of triaging multiple victims of a lightning strike is different than the conventional triage methods used during a mass casualty incident. See Chapter 40, Incident Management. When a person is struck by lightning, respiratory or cardiac arrest, If it occurs, usually occurs immediately.
Delayed respiratory or cardiac arrest is much less likely to develop in those who are conscious following a lightning strike. Most of these people will survive. Therefore, you should focus your efforts on those who are in respiratory or cardiac arrest. This process, called reverse triage, differs from conventional triage, where such patients would ordinarily be classified as deceased.
When a person is struck by lightning, It causes massive direct current shock, with the patient experiencing massive muscle spasms, tetany, that can result in fractures of long bones, and spinal vertebrae. Therefore, manually stabilize the patient's head in a neutral in-line position, and open the airway with the jaw thrust maneuver. If the patient is in respiratory arrest with a pulse, begin immediate bag mask ventilations with 100% oxygen. If the patient is in cardiac arrest. Begin cardiopulmonary resuscitation and automated external defibrillators as soon as possible and provide defibrillation if indicated.
If severe bleeding is present, control it immediately. Transport the patient to the closest appropriate facility. If cardiopulmonary resuscitation or ventilations are not required, address other injuries, that is, splint fractures, dress and bandage burns, and provide continuous monitoring while en route to the hospital.
A patient with signs and symptoms of a lightning strike, but no obvious life threats, should still be transported to the emergency department for evaluation. Bites and envenomation. This section discusses bites and stings from spiders, hymenoptera, snakes, scorpions, and ticks, and injuries from marine animals. Spider bites.
Spiders are numerous and widespread in the United States. Many species of spiders bite. However, Only two, the female black widow spider, and the brown recluse spider, are able to deliver serious, even life-threatening bites.
When you care for a patient who has had some type of bite, be alert to the possibility that the spider may still be in the area, although it is unlikely. Remember that your safety is of paramount importance. Black widow spider The female black widow spider, Latrodectus, is fairly large, measuring approximately 2 inches.
5 centimeters, long with its legs extended. It is usually black and has a distinctive, bright red-orange marking in the shape of an hourglass on its abdomen. The female black widow spider is larger and more toxic than the male.
Black widow spiders are found in every state except Alaska. They prefer dry, dim places around buildings, in woodpiles, and among debris. The bite of the black widow spider is sometimes overlooked. If the site becomes numb right away, the patient may not even recall being bit.
However, most black widow spider bites cause localized pain and symptoms, including agonizing muscle spasms. In some cases, a bite on the abdomen causes muscle spasms so severe that the patient may be thought to have an acute abdominal condition, possibly peritonitis. The main danger with this type of bite, however, is that the black widow's venom can damage nerve tissues. It is a neurotoxin.
Other systemic symptoms include dizziness, sweating, nausea, vomiting, and rashes. Tightness in the chest and difficulty breathing develop within 24 hours, as well as severe cramps, with board-like rigidity of the abdominal muscles. Generally, these signs and symptoms subside over 48 hours. If necessary, a physician can administer a specific antivenin, a serum containing antibodies that counteract the venom. but because of a high incidence of side effects, its use is reserved for severe bites, for older or feeble patients, and for children younger than 5 years.
In children, these bites can be fatal. In general, emergency treatment of a black widow spider bite consists of basic life support for the patient in respiratory distress. More often, the patient will only require pain relief. Transport the patient to the emergency department as soon as possible for treatment.
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 so that it can be definitively identified. Brown recluse spider. The brown recluse spider, Loxicils, is dull brown and, at one inch, three centimeters, smaller than the black widow.
The short-haired body has a violin-shaped mark, brown to yellow in color, on its back. Although the brown recluse spider lives mostly in the southern and central parts of the country, it may be found throughout the continental United States. The spider takes its name from the fact that it tends to live in dark areas, in corners of old, unused buildings, under rocks, and in wood piles.
In cooler areas, it moves indoors to closets, drawers, cellars, and clothing. In contrast to the venom of the black widow spider, the venom of the brown recluse spider is not neurotoxic but cytotoxic, that is, 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, mottled, cyanotic center and possibly a small blister. Over the next several days, a scab of dead skin, fat, and debris forms, and digs down into the skin, producing a large ulcer that may not heal unless treated promptly. Transport patients with such symptoms as soon as possible. Brown recluse spider bites rarely cause systemic symptoms and signs. When they do, provide basic life support and prompt transport to the emergency department.
Again, it is helpful if you can identify the spider, and either safely bring it to the hospital with the patient, or take a picture of the spider, and send it to the hospital ahead of time. Because symptoms do not typically develop for hours after the bite occurs, this is usually not possible. Hymenoptera stings. Typically hymenoptera, bees, wasps, yellow jackets, and ants. stings are painful but are not a medical emergency remove the stinger and if still present the venom sack this is best done by using a firm edged item such as a credit card to scrape the stinger and sack off the skin use ice packs to assist in controlling pain from a human opt or sting if the patient is allergic to the venom then anaphylaxis may occur the signs and symptoms of anaphylaxis are flushed skin low blood pressure and difficulty breathing that is usually associated with reactive airway sounds such as wheezes, or in severe cases, diminished or absent breath sounds.
Hives, urticaria, may develop near the site of envenomation or centrally on the body. The patient can also have swelling to the throat and tongue. Anaphylaxis is a true emergency, and can be fatal if not recognized and treated quickly.
If anaphylaxis develops, Be prepared to assist the patient in administering an epinephrine auto-injector, EpiPen. Also be prepared to support the airway and breathing should the patient experience significant respiratory compromise. Chapter 21, Allergy and Anaphylaxis, has a detailed discussion of the treatment of anaphylaxis.
Snake bites. Snake bites are a worldwide problem. According to the World Health Organization, more than 400,000 injuries from venomous snake bites are caused by snake bites. Snake bites occur annually, including at least 20,000 deaths.
However, snake bite fatalities in the United States are extremely rare, approximately 15 per year for the entire country. Of the approximately 115 different species of snakes in the United States, only 19 are venomous. These include the rattlesnake, crotalus, the copperhead, Aggistridon contortrix, the cottonmouth, or water moccasin, Agkistredom piscivorus.
and the coral snakes, Microsphovias and Micoroids urazanthus. At least one of these venomous species is found in every state except Alaska, Hawaii, and Maine. As a general rule, these snakes are timid. They usually do not bite unless provoked or accidentally injured, as when they are stepped on.
There are a few exceptions to these rules. Cottonmouths are often aggressive, and rattlesnakes are easily provoked. Coral snakes In contrast, usually bite only when they are being handled.
Most snake bites occur between April and October, when the animals are active, and tend to involve young men who have been drinking alcohol. Texas reports the largest number of bites. Other states with a major concentration of snake bites are Louisiana, Georgia, Oklahoma, North Carolina, Arkansas, West Virginia, and Mississippi.
If you work in one of these areas, You should be thoroughly familiar with the emergency handling of snake bites. Remember, almost any time you are caring for a patient with a snake bite, another snake may be in the area, and create a second victim, you. Therefore, use extreme caution on these calls and be sure to wear the proper protective equipment for the area. In general, only one-third of snake bites result in significant local or systemic injuries.
Often, envenomation does not occur because the snake has recently struck another animal, and exhausted its supply of venom for the time being. Venomous snakes native to the United States all have hollow fangs in the roof of the mouth that inject the venom from two sacks at the back of the head. The classic appearance of the venomous snake bite, therefore, is two small puncture wounds, usually about 0.5 inch apart, with discoloration and swelling, and the patient usually reports pain surrounding the bite.
Fang marks are a clear indication of a venomous snake bite. A snake bite with other tooth marks may be from a non-venomous snake. If you are unsure whether the snake was venomous, proceed as if it was.
especially if the patient exhibits other signs and symptoms. A person who has been bitten by any venomous snake needs prompt transport. Also, notify the hospital as soon as possible if a patient has been bitten by a pet viper or coral snake.
Some venoms can cause paralysis of the nervous system, and hospitals may not have appropriate anti-venom on hand. Pet vipers, rattlesnakes, copperheads, and cottonmouths are all pet vipers, with 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 that allows the snake to strike accurately at any warm target, especially in the dark, when it cannot see through its vertical, slit-like pupils. The fangs of the pit viper normally lie flat against the roof of the mouth, and are hinged to swing back and forth as the mouth opens.
When the snake strikes. The mouth opens wide and the fangs extend. In this way, the fangs penetrate whatever the mouth strikes.
The fangs are hollow teeth that act like hypodermic needles. They are connected to a sac containing a reservoir of venom, which in turn is attached to a poison gland. The gland itself is a specifically adapted salivary gland, which produces enzymes that digest and destroy tissue.
The primary purpose of the venom is to kill small animals. and facilitate the digestive process. In the United States, the most common form of pit viper is the rattlesnake. Several different species of rattlesnake can be identified by the rattle on the tail. The rattle is numerous layers of dried skin that were shed but failed to fall off, coming to rest against a small knob on the end of the tail.
Rattlesnakes have many patterns of color, often with a diamond pattern. They can grow to 6 feet, 2 meters, or longer. Copperheads are smaller than rattlesnakes, usually 2 to 3 feet long with the red copper color crossed with brown or red bands.
These snakes typically inhabit woodpiles and abandoned dwellings, often close to areas of habitation. Although they account for most of the venomous snake bites in the eastern United States, copperhead bites are almost never fatal. However, note that the venom can cause significant damage to tissues in the extremities.
Cottonmouths grow to approximately 4 feet in length. Also called water moccasins, these snakes are olive or brown, with black crossbands and a yellow undersurface. They are water snakes, and have a particularly aggressive pattern of behavior. Although fatalities from these snake bites are rare, tissue destruction from the venom may be severe. The signs of envenomation by a pit viper are severe burning pain at the site of the injury, followed by swelling.
and a blue discoloration in light-skinned people that signals bleeding under the skin. Bluish discoloration may be more difficult to see in dark-skinned people. These signs are evident within 5 to 10 minutes after the bite has occurred and last over the next 36 hours.
In addition to destroying tissues locally, the venom of the pit viper can interfere with the body's clotting mechanism and cause bleeding at various distant sites. This toxin affects the entire nervous system. Other systemic signs, which may or may not occur, include weakness, nausea, vomiting, sweating, seizures, fainting, vision problems, changes in level of consciousness, and shock. If swelling has occurred, use a pen to mark its edges on the skin. This will allow physicians to assess the timing and extent of the swelling with greater accuracy.
If the patient has no local signs an hour after being bitten. It is likely that envenomation did not take place. The toxicity is related to the amount of toxin injected.
A bite will affect children more than adults because there is less body mass to absorb the toxin. The same principle holds true for a small-statured adult. In treating a snake bite from a pit viper, follow these steps. 1. Calm the patient.
Assure him or her that venomous snake bites are rarely fatal. Place the patient in a supine position, and explain that staying still will slow the spread of any venom through the system. Determine the approximate time of the bite and document your time en route to a receiving facility.
This time from onset to evaluation at the facility is one of the criteria used in grading the severity of the incident, and in determining the amount of antivenin to be used. 2. Locate the bite area, clean it gently with soap and water or a mild antiseptic. Do not apply ice to the area. 3. If the bite occurred on an arm or leg, and the transport time to the hospital is anticipated to exceed 2 hours.
Consider the use of a pressure immobilization bandage of the extremity, for example, 40 to 70 mm of mercury in the arms and 55 to 70 mm of mercury in the legs, and then place the affected extremity below the level of the heart. 4. Be alert for an anaphylactic reaction to the venom, and treat with an epinephrine auto-injector, as appropriate. 5. Do not give anything by mouth, and be alert for vomiting.
Alternatively, take a picture of the snake with a cell phone, and send it to the hospital ahead of time. 10. Notify the hospital that you are bringing in a patient who has a snake bite, if possible, describe the snake. 11. Transport the patient promptly to the hospital.
If the patient shows no sign of envenomation. Provide basic life support as needed. 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, whether or not they show signs of envenomation. Treat the wound as you would any deep puncture wound to prevent infection.
Familiarize yourself with the venomous snakes in your region, as well as local protocols for handling snake bites. There may be specific hospitals where antivenin is more readily available, either in the facility or through zoos, health departments, or other services. Coral snakes.
The coral snake is a small reptile with a series of bright red, yellow, and black bands completely encircling the body. Many harmless snakes have similar coloring, but only the coral snake has red and yellow bands next to one another. As this helpful rhyme suggests, red on yellow will kill a fellow.
Red on black, venom will lack. A rare creature that lives in most southern states, and in the southwest, the coral snake is a relative of the cobra. It has tiny fangs, and inject the venom with its teeth by a chewing motion, leaving behind one or more puncture or scratch-like wounds.
Because of its small mouth and teeth and 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 of being bitten, a patient may exhibit bizarre behavior, followed by progressive paralysis of eye movements and respiration.
Often, there are limited or no local symptoms. Successful treatment, either emergency or long-term, depends on positive identification of the snake and support of respiration. Antivenin is also available for coral snake bites.
but most hospitals do not stock it. Therefore, you should notify the receiving hospital of the need for it as soon as possible. The steps for emergency care of a coral snake bite are the same as a pit viper bite.
Scorpion stings. Scorpions are eight-legged arthropods from the class Arachnida. They have a venom gland and a stinger at the end of their tail.
Scorpions are rare. They 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 exception is the centroid sculpturatus. Although it is found naturally in Arizona and New Mexico, as well as parts of Texas, California, and Nevada, it may be kept as a pet by anyone. The venom of this particular species may produce a severe systemic reaction that leads to circulatory collapse, severe muscle contractions, excessive salivation, hypertension, convulsions, and cardiac failure. Antivenin is available but must be administered by a physician. If you are called to care for a patient with a suspected sting from C.
sculpturatus, notify the receiving hospital as early as possible to facilitate the availability of this antivenin. Administer basic life support and provide rapid transport to the emergency department. Tick bites. Found most often on brush, shrubs, trees, sand dunes, or other animals, ticks usually attach themselves directly to the skin.
Only a fraction of an inch. About 3 mm long, they can easily be mistaken for a freckle, especially because their bite is not painful. Indeed, the danger with the tick bite is not from the bite itself, but from the infecting organisms that the tick carries. Two infectious diseases, Rocky Mountain Spotted Fever and Lyme disease, are transmitted to humans by ticks. Both are spread through the tick's saliva, which is injected into the skin when the tick attaches itself.
The longer a tick stays embedded, the greater the chance that a disease will be transmitted. Rocky Mountain Spotted Fever, which is not limited to the Rocky Mountains area, occurs within 7 to 10 days after a bite by an infected tick. Its symptoms include nausea, vomiting, headache, weakness, paralysis, and possible cardiorespiratory collapse. Lyme disease has received extensive publicity.
Lyme disease was originally seen only in the town of Lyme, Connecticut. According to the Centers for Disease Control and Prevention, it has now been reported in all states except for Hawaii. It occurs most commonly in the Northeast and the Great Lakes states.
Pennsylvania reported the largest number of cases from 2011 to 2013. The first symptoms are generally fever and flu-like symptoms, sometimes associated with a bull's eye rash that may spread to several parts of the body. After a few days or weeks, painful swelling of the joints. particularly the knees, occurs. Lyme disease may be confused with rheumatoid arthritis and, like that disease, may result in permanent disability.
However, if it is recognized and treated promptly with antibiotics, the patient may recover completely. Tick bites occur most commonly during the summer months, when people are out in the woods wearing little protective clothing. Do not attempt to suffocate the tick with gasoline or petroleum jelly, or burn it with a lighted match. You'll only increase the risk of infection or burn the patient. For patients in conventional emergency medical service settings with tick bites or signs and symptoms of Lyme disease, provide any necessary supportive emergency care, and transport the patient for further evaluation.
In a situation, such as wilderness emergency medical service, where access to care is delayed, remove the tick from the patient. Using fine tweezers, grasp the tick by the head. and pull gently but firmly straight up so that the skin is tented.
Hold this position until the tick releases. Special tweezers are available for this, but are unnecessary. This method will usually remove the whole tick.
Partial removal can lead to infection. Cleanse the area with antiseptic and save the tick in a glass jar or other container so that it can be identified. Do not handle the tick with your fingers.
The patient should follow up with his or her health care provider as soon as possible. Injuries from marine animals, cilenterates, including fire coral, Portuguese man-of-war, sea wasp, sea nettles, true jellyfish, sea anemones, true coral, and soft coral, are responsible for more envenomations than any other marine animals. The stinging cells of the cilenterate are called nematocysts, and large animals may discharge hundreds of thousands of them. Invenomation causes very painful, red lesions in light-skinned people extending in a line from the side of the sting.
These lesions may be more difficult to see in dark-skinned people. Systemic symptoms include headache, dizziness, muscle cramps, and fainting. To treat a sting from the tentacles of a jellyfish, a Portuguese man-of-war, various anemones, corals, or hydras, remove the patient from the water.
and remove the tentacles by scraping them off with the edge of a stiff object, such as a credit card. Do not try to manipulate the remaining tentacles. This will only cause further discharge of the nematocysts.
On very rare occasions, a patient may have a systemic allergic reaction to the sting of one of these animals. Treat such a patient for anaphylactic shock and provide rapid transport to the hospital. Toxins from the spines of urchins, stingrays, and certain spiny fish such as the lionfish, scorpionfish, or stonefish are also heat sensitive.
Therefore, the best treatment for such injuries is also to soak the affected extremity in hot water for 30 minutes. This will often provide dramatic relief from local pain. However, The patient still needs to be transported to the emergency department because an allergic reaction or infection, including tetanus, could develop.
If you work near the ocean, you should be familiar with the marine life in your area. The emergency treatment of common saline rate envenomations consists of the following steps. 1. Limit further discharge of nematocysts by avoiding fresh water, wet sand, showers, or careless manipulation of the tentacles.
Keep the patient calm, and reduce motion of the affected extremity. 2. Remove the remaining tentacles by scraping them off with the edge of a stiff object such as a credit card. Do not use your ungloved hand to remove the tentacles, because self-envenomation will occur.
Persistent pain may respond to immersion in hot water. 110°F to 115°F 43.3°F 3 degrees Celsius to 46.1 degrees Celsius, for 30 minutes. If available, immersion in vinegar may also help alleviate the symptoms.