DOT National Standard EMT-Intermediate/85 Refresher

1. Welcome! DOT National Standard EMT-Intermediate/85 Refresher

2. MEDICAL EMERGENCIES • Allergic reaction • Possible overdose • Near-drowning • ALOC • Diabetes • Seizures • Heat & cold emergencies • Behavioral emergencies • Suspected communicable disease

3. HEAT EMERGENCIES heat cramps heat exhaustion heat stroke Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx MEDICAL EMERGENCIES

4. perspective • When the external temperature rises to >95F, the body can no longer radiate heat to the environment & becomes dependent on evaporation for heat transfer • As humidity increases, the potential for evaporation heat loss decreases • Sweat that drips from the skin does not provide any cooling benefit and only exacerbates dehydration

5. perspective • As a result, the combination of high temperature & high humidity essentially blocks the two main mechanisms that the body uses to dissipate heat

6. perspective • The body tends to maintain its core temperature between 96.8-100.4F • Native thermal regulation mechanisms begin to fail at core temp. of <95F & >104F

7. Physiologic response to heat stress occurs through 4 primary mechanisms • Dilatation of blood vessels, particularly the skin • Increased sweat production • Decreased heat production • Behavioral heat control

8. s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives • HEAT CRAMPS • Painful, involuntary, spasmodic contractions of skeletal muscles, usu. those of the calves (thighs & shoulder can happen too) • These cramps usually occur in individuals who are sweating profusely & replace fluid losses w/ water or other hypotonic solutions • They may occur during exercise or, more commonly, during a rest period after several hours of vigorous physical activity

9. s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives • Pts w/ severe heat cramps may have hyponatremia and hypochloremia

10. Treatment • Scene Size Up • ABCs & spinal immobilization • Secondary Assessment |Diagnostics-Monitoring-Management | Verbal Survey • Cooling: • Remove pt from hot environment to a cool area if possible • Remove constricting and warm clothing • If ALOC or severe symptoms, begin evaporative cooling • Don’t let cooling delay transport • Check glucose PRN

11. Treatment • Fluid and salt replacement (PO or IV) & rest in a cool environment • For mild cases: 0.1% to 0.2% saline solution can be given PO. Two 10-grain (650mg) salt tablets dissolved in a quart of water provides a 0.1% saline solution • Commercially available sport drinks can be used • More severe symptoms should be treated w/ IV rehydration w/ NS

12. Perspective • Pathophysiology • Epidemiology • PE & Diagnostic Findings • S/S • Differential considerations • Tx

13. Questions? • References • Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. • Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. • Wolfson, Allan B. ed. , Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.

14. Welcome! DOT National Standard EMT-Intermediate/85 Refresher

15. MEDICAL EMERGENCIES • Allergic reaction • Possible overdose • Near-drowning • ALOC • Diabetes • Seizures • Heat & cold emergencies • Behavioral emergencies • Suspected communicable disease

16. HEAT EMERGENCIES heat cramps heat exhaustion heat stroke Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment MEDICAL EMERGENCIES

17. perspective • When the external temperature rises to >95F, the body can no longer radiate heat to the environment and becomes dependent on evaporation for heat transfer • As humidity increases, the potential for evaporation heat loss decreases • Sweat that drips from the skin does not provide any cooling benefit and only exacerbates dehydration

18. perspective • As a result, the combination of high temperature and high humidity essentially blocks the two main mechanisms that the body uses to dissipate heat

19. perspective • The body tends to maintain its core temperature between 96.8-100.4F • Native thermal regulation mechanisms begin to fail at core temp. of <95F and >104F

20. Physiologic response to heat stress occurs through 4 primary mechanisms • Dilatation of blood vessels, particularly the skin • Increased sweat production • Decreased heat production • Behavioral heat control

21. s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives • HEAT EXHAUSTION • Water depletion • Sodium depletion

22. s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives • HA • N/V • Malaise • Dizziness • Muscle cramps • Tachycardia • Orthostatic hypotension

23. s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives • Temperature may be normal or elevated (usually not above 104F) • No signs of CNS impairment

24. Treatment • Scene Size Up • ABCs & spinal immobilization • Secondary Assessment |Diagnostics-Monitoring-Management | Verbal Survey • Cooling: • Remove pt from hot environment to a cool area if possible • Remove constricting and warm clothing • If ALOC or severe symptoms, begin evaporative cooling • Don’t let cooling delay transport • Check glucose PRN

25. Treatment • Oral fluids • Frequent small amounts of water w/ 1/4 tsp of salt or sport drink • Adults: Give a total of 1-L • 1mo-14yrs: 10ml/kg to max of 1-L • IV • Adults: 1-L LR/NS bolus, then maintenance rate (120ml/hr) • Pediatrics: 20ml/kg LR/NS bolus (max 1-L), then maintenance rate (2ml/kg/hr) • All ages: if still symptomatic after initial bolus, give second bolus

26. Treatment • Seizures - GO TO PROTOCOL: Seizures • Many factors alter the body’s ability to regulate temperature: age extremes, heart disease, medications (diuretics, beta blockers), antihistamines, alcohol, type and amount of fluid replacement, dehydration, acclimatization, humidity, altitude

27. Treatment • Judicious fluid replacement: in elderly pts, overzealous fluid replacement may be detrimental • Cooling measures • Evaporative cooling: the most effective. Spray or wipe skin with water and evaporate water with air using fan, fanning or wind. Applying a moist cloth that retains moisture (cotton) is effective • Immersion: the next most effective but potentially dangerous. Use only if you can not provide evaporative cooling.

28. Treatment • Immerse pt in cool/cold water for 10 minutes, remove pt and recheck temperature. Be cautious! Keep pt’s head out of the water. • It is difficult to protect an airway and manage a seizing pt in a stream! • Also it is easy to make the pt hypothermic using this method. Cool only to goal temperature of 102.5F. Cooling will continue after you stop. • If first attempt not successful then continue with 5 minute cycles, rechecking temperature 5 minutes after each immersion

29. Treatment • Adjunctive measures: placing ice or cool towels in areas of high blood flow (neck veins, armpits, groin) works but is much less effective • AVOID cooling below 102.5F and stop if pt starts shivering (hypothermic overshoot). Shivering increases body temperature and reflects overcooling • Transport any pt w/ signs of severe heat exhaustion or heat stroke.

30. Differential Dx • Drug OD (amphetamines, antihistamines, tricyclic antidepressants, ASA) • Alcohol withdrawal • Sepsis, febrile illness • DKA • Meningitis, encephalitis • Thyroid storm (hyperthyroidism) • Cerebral hemorrhage • Medication reaction (antipsychotics, e.g., Haldol) • Status epilepticus

31. Pathophysiology • Epidemiology • Physical Exam Findings • Diagnostic Findings • Signs and Symptoms • Differential considerations • Treatment

32. Questions? • References • Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. • Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. • Wolfson, Allan B. ed. , Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.

33. Welcome! DOT National Standard EMT-Intermediate/85 Refresher

34. MEDICAL EMERGENCIES • Allergic reaction • Possible overdose • Near-drowning • ALOC • Diabetes • Seizures • Heat & cold emergencies • Behavioral emergencies • Suspected communicable disease

35. HEAT EMERGENCIES heat cramps heat exhaustion heatstroke Pathophysiology Epidemiology Physical Exam Findings Diagnostic Findings Signs and Symptoms Differential considerations Treatment MEDICAL EMERGENCIES

36. perspective • When the external temperature rises to >95F, the body can no longer radiate heat to the environment and becomes dependent on evaporation for heat transfer • As humidity increases, the potential for evaporation heat loss decreases • Sweat that drips from the skin does not provide any cooling benefit and only exacerbates dehydration

37. perspective • As a result, the combination of high temperature and high humidity essentially blocks the two main mechanisms that the body uses to dissipate heat

38. perspective • The body tends to maintain its core temperature between 96.8-100.4F • Native thermal regulation mechanisms begin to fail at core temp. of <95F and >104F

39. Physiologic response to heat stress occurs through 4 primary mechanisms • Dilatation of blood vessels, particularly the skin • Increased sweat production • Decreased heat production • Behavioral heat control

40. s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives • HEAT STROKE • Acute life-threatening emergency w/ mortality rates as high as 30%-80% and is universally fatal if left untreated. • The cardinal features of heat stroke are hyperthermia [>104F] and altered level of consciousness • Classic (non-exertional) heat stroke may exhibit anhidrosis • The absence of sweat is not considered a diagnostic criteria, because sweat is present in over half of pts with heat stroke

41. s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives • Virtually any neurologic abnormality may be present • Irritability • Confusion • Bizarre behavior • Combativeness • Hallucinations • Posturing • Seizures • coma

42. Treatment • Scene Size Up • ABCs & spinal immobilization • Secondary Assessment |Diagnostics-Monitoring-Management | Verbal Survey • Cooling: • Remove pt from hot environment to a cool area if possible • Remove constricting and warm clothing • If ALOC or severe symptoms, begin evaporative cooling • Don’t let cooling delay transport • Check glucose PRN

43. Treatment • Oral fluids • Frequent small amounts of water w/ 1/4 tsp of salt or sport drink • Adults: Give a total of 1-L • 1mo-14yrs: 10ml/kg to max of 1-L • IV • Adults: 1-L LR/NS bolus, then maintenance rate (120ml/hr) • Pediatrics: 20ml/kg LR/NS bolus (max 1-L), then maintenance rate (2ml/kg/hr) • All ages: if still symptomatic after initial bolus, give second bolus

44. Treatment • Seizures - GO TO PROTOCOL: Seizures • Many factors alter the body’s ability to regulate temperature: age extremes, heart disease, medications (diuretics, beta blockers), antihistamines, alcohol, type and amount of fluid replacement, dehydration, acclimatization, humidity, altitude

45. Treatment • Judicious fluid replacement: in elderly pts, overzealous fluid replacement may be detrimental • Cooling measures • Evaporative cooling: the most effective. Spray or wipe skin with water and evaporate water with air using fan, fanning or wind. Applying a moist cloth that retains moisture (cotton) is effective • Immersion: the next most effective but potentially dangerous. Use only if you can not provide evaporative cooling.

46. Treatment • Immerse pt in cool/cold water for 10 minutes, remove pt and recheck temperature. Be cautious! Keep pt’s head out of the water. • It is difficult to protect an airway and manage a seizing pt in a stream! • Also it is easy to make the pt hypothermic using this method. Cool only to goal temperature of 102.5F. Cooling will continue after you stop. • If first attempt not successful then continue with 5 minute cycles, rechecking temperature 5 minutes after each immersion

47. Treatment • Adjunctive measures: placing ice or cool towels in areas of high blood flow (neck veins, armpits, groin) works but is much less effective • AVOID cooling below 102.5F and stop if pt starts shivering (hypothermic overshoot). Shivering increases body temperature and reflects overcooling • Transport any pt w/ signs of severe heat exhaustion or heat stroke.

48. Differential Dx • Drug OD (amphetamines, antihistamines, tricyclic antidepressants, ASA) • Alcohol withdrawal • Sepsis, febrile illness • DKA • Meningitis, encephalitis • Thyroid storm (hyperthyroidism) • Cerebral hemorrhage • Medication reaction (antipsychotics, e.g., Haldol) • Status epilepticus

49. Pathophysiology • Epidemiology • Physical Exam Findings • Diagnostic Findings • Signs and Symptoms • Differential considerations • Treatment

50. Questions? • References • Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. • Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. • Wolfson, Allan B. ed. , Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.