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Environmental Conditions

Environmental Conditions. Opening Case. Environmental Conditions. 45-Year-Old — Hypothermia. Pt found in cold water lake In water for about 40 minutes. SICK?. Sick or Not-yet-sick?. Why?. or. NOT YET SICK?. Hx. Hx: Diabetes Meds: Unknown All: Unknown. PE.

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Environmental Conditions

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  1. Environmental Conditions

  2. OpeningCase Environmental Conditions

  3. 45-Year-Old—Hypothermia Pt found in cold water lake In water for about 40 minutes

  4. SICK? Sick or Not-yet-sick? Why? or NOT YET SICK?

  5. Hx • Hx: Diabetes • Meds: Unknown • All: Unknown

  6. PE • HEENT: Pupils dilated • CHEST: No chest rise • ABD: Unremarkable • EXT: Pale, cold • VS: BP 0, HR 0, RR 0, SaO2 0

  7. Tx Scene time: 31 minutes • Pt removed from water after EMS arrival • LBB to heated ambulance • EKG: asystole

  8. Tx (continued) • Removed clothes • IV and ET • Epi 1 mg per MD orders • EKG: wide complex PEA • Lights and siren to trauma center

  9. Intubated on arrival Coarse breath sounds bilaterally Skin cyanotic, cold, and mottled Asystole; CPR ongoing Pupils fixed and dilated; GCS 3 Emergency Department Course 1

  10. ED • Pump team consulted • Warm blankets and lights, warm IV fluids • Skin cool to periphery, but patient warm centrally • Cardiac ultrasound negative for activity 1

  11. Epinephrine x 3 Rectal temp 95°F Epinephrine Bicarb x 2 and 40 IU vasopressin Atropine Resuscitation 1

  12. Outcome No response to resuscitation Family with patient Patient pronounced dead 39 minutes after arrival

  13. Introduction

  14. Introduction • Medical conditions induced by the interactions of physical, chemical, and biological factors can place rescuers at risk

  15. Temperature-Related Illness

  16. Pathophysiology

  17. PeripheralSensors SKIN Thermoreceptors on your skin send signals to your brain using the nervous system to identify heat or cold Dendritic cell Tactile cell Sensory nerve ending

  18. Hypothalamus Body’sThermostat

  19. Thermoregulation • Radiation • Convection (wind) • Conduction (water) • Evaporation

  20. Central Thermoreceptors Hypothalamus Spine Abdominal Organs

  21. HormonalThermoregulation Thermogenesis

  22. Hypothalamus

  23. Hypothalamus • Pituitary TSH-RH

  24. Hypothalamus • Pituitary • Thyroid TSH

  25. Hypothalamus • Pituitary • Thyroid • Adrenal medulla Thyroxine (T4)

  26. Epinephrine • Hypothalamus • Pituitary • Thyroid • Adrenal Medulla Increased heart rate Vasoconstriction Increased metabolism Glycolysis

  27. Thermogenesis • Muscular • Muscular activity • Shivering • Metabolic • Process nutrients • Carbohydrates • Fats • Proteins • Glycolysis

  28. Which group is at greatest risk for heat illness? • Athletes • Construction workers • Professional drivers • Landscapers

  29. Which group is at greatest risk for heat illness? • Athletes • Construction workers • Professional drivers • Landscapers

  30. Predisposing Factors

  31. Predisposing Factors • Patient’s age • Predisposing medical conditions • Use of prescription and over-the-counter medications • Use of alcohol or recreational drugs • Previous rate of exertion

  32. Heat-Related Illness

  33. Heat-Related Illness • Heat cramps • Caused by the fluctuations in sodium content of the muscles • Causes intermittent muscle cramping of the most-worked muscles

  34. Heat-Related Illness • Heat Edema • Unacclimatized individuals, especially the elderly, can develop foot and ankle edema in hot environments • Usually resolves after acclimatization in a few days

  35. Heat-Related Illness • Heat syncope • Results from peripheral vasodilation, causing a drop in cerebral perfusion • This lack of perfusion causes syncope

  36. Heat-Related Illness • Prickly heat • An acute inflammatory skin disorder that occurs in tropical environments

  37. Heat-Related Illness • Heat exhaustion • A result of intravascular volume depletion, brought on by heat stress • Signs include malaise, weakness, fatigue, headache, nausea, vomiting, vertigo

  38. Heat-Related Illness • Heat stroke • The body’s compensatory mechanisms for handling environmental heat stress fail • Two types of heat stroke: exertional and classical

  39. Exertional Healthy Younger Exercise Sporadic occurance Diaphoresis usually present Hypoglycemia Disseminated intravascular coagulation Rhabdomyolysis Acute renal failure Marked lactic acidosis Hypocalcemia Classical Predisposing factors or medications Older Sedentary Heat wave occurrence Anhidrosis (lack of sweating) Normoglycemic Mild coagulopathy Mild creatinine kinase elevation Oliguria Mild acidosis Normocalcemic Unusual Characteristics of Heatstroke Source: From Table 135-1 in B. Yarbrough, and S. Vicario, “Heat Illness,” In Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed., J. Marx, R. Hockberger, and R. Walls, eds. (St. Louis, MO: Mosby, 2002), p 2004.

  40. A football player is clumsy and confused. He feels “light headed” and is sweating profusely. His body temperature is 39.8°C (103.6°F). You should • Remove the patient to an air-conditioned building and encourage him to drink a salt-containing sport drink. • Cool the patient with water or by fanning, administer a bolus set to deliver 250 milliliters of normal saline over an hour, and transport. • Remove the patient’s clothing and apply ice or cold packs to the neck, groin, and armpits; administer a pressor and transport. • Immerse the patient in ice water, administer a bolus set to deliver 1000 milliliters of normal saline over 30 minutes, and transport.

  41. A football player is clumsy and confused. He feels “light headed” and is sweating profusely. His body temperature is 39.8°C (103.6°F). You should • Remove the patient to an air-conditioned building and encourage him to drink a salt-containing sport drink. • Cool the patient with water or by fanning, administer a bolus set to deliver 250 milliliters of normal saline over an hour, and transport. • Remove the patient’s clothing and apply ice or cold packs to the neck, groin, and armpits; administer a pressor and transport. • Immerse the patient in ice water, administer a bolus set to deliver 1000 milliliters of normal saline over 30 minutes, and transport.

  42. Cold-Related Illness

  43. A patient is hypothermic when the body temperature drops below ___ degrees.

  44. Cold-Related Illness • Hypothermia • Occurs when the core temperature drops below 35°C / 95°F • Two types of hypothermia • Primary • Secondary

  45. Cold-Related Illness • Mild hypothermia • The body’s physiologic adaptations are maximally effective in an attempt to keep the body temperature normal • Active external rewarming techniques can be used

  46. Cold-Related Illness • Moderate hypothermia • Compensatory mechanisms begin to fail • Signs and symptoms include increasing mental status changes, slowing of pulse and respirations, and decline in blood pressure • Treatment includes active and passive external rewarming

  47. Cold-Related Illness • Severe hypothermia • Clinical signs can mimic the appearance of death • Perform CPR on patients in cardiac arrest • Defibrillation is generally unsuccessful • ACLS medications should be avoided

  48. Street Secret “No one is dead until he or she is warm and dead”

  49. Local Cold Injury • Local cold injuries include • Freezing • Nonfreezing syndromes

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