18: Emergencias ambientales

Objetivos cognitivos (1 de 2)
4-7.1 Describa las diversas formas en que el cuerpo
pierde calor.
4-7.2 Enumere los signos y síntomas de exposición al
frío.
4-7.3 Explique los pasos para brindar atención
médica de emergencia a un paciente expuesto
al frío.
4-7.4 Enumere los signos y síntomas de exposición al
calor.
4-7.5 Explique los pasos para brindar atención de
emergencia a un paciente expuesto al calor.
 Objetivos cognitivos (2 de 2)
4-7.6 Reconocer los signos y síntomas de
emergencias relacionadas con el agua.
4-7.7 Describa las complicaciones de casi
ahogamiento.
4-7.8 Discuta la atención médica de emergencia de
mordeduras y picaduras.
• No hay objetivos afectivos para este capítulo.
 Objetivos psicomotores
4-7.9 Demostrar la evaluación y la atención médica
de emergencia de un paciente con exposición
al frío.
4-7.10 Demostrar la evaluación y la atención médica
de emergencia de un paciente con exposición
al calor.
4-7.11 Demostrar la evaluación y la atención médica
de emergencia de un paciente a punto de
ahogarse.
4-7.12 Demuestre completar un informe de atención
prehospitalaria para pacientes con
emergencias ambientales.
 Factors Affecting Exposure
• Physical condition
• Age
• Nutrition and hydration
• Environmental conditions
 Loss of Body Heat (1 of 2)
• Conduction • Radiation
– Transfer of heat from – Loss of body
body to colder object heat directly into
• Convection a colder
– Transfer of heat through environment
circulating air • Respirations
• Evaporation – Loss of body
– Cooling of body through heat during
sweating breathing
 Loss of Body Heat (2 of 2)
• Rate and amount of heat gain or loss can be
modified in three ways:
– Increase or decrease heat production.
– Move to sheltered area where heat loss is
increased or decreased.
– Wear insulated clothing.
 Hypothermia
• Lowering of the body temperature below 95°F (35°C)
• Weather does not have to be below freezing for
hypothermia to occur.
• Older persons and infants are at higher risk.
• People with other illnesses and injuries are susceptible
to hypothermia.
Signs and Symptoms
of Mild Hypothermia
• Shivering
• Rapid pulse and respirations
• Red, pale, cyanotic skin
Signs and Symptoms of More
Severe Hypothermia
• Shivering stops.
• Muscular activity decreases.
• Fine muscle activity ceases.
• Eventually, all muscle activity stops.
 Core Temperature
Less Than 80°F
• Patient may appear dead (or in a
coma).
• Never assume that a cold,
pulseless patient is dead.
 Scene Size-up

• Note weather conditions.

• Identify safety hazards
such as icy roads, mud, or
wet grass.
 Initial Assessment

• Check temperature on
patient’s abdomen.
• Mental status can be affected.
• Ensure adequate airway.
• Warmed, humidified oxygen
helps warm from inside out.
• Palpate for carotid pulse; wait
30–45 seconds.
• Transport immediately or
move to warmer location.
 Focused History and Physical
Exam

• If unconscious, do a rapid physical exam.

• If conscious, attempt to obtain SAMPLE history.
– Determine how long the patient was exposed to
the cold.
– Medications can affect the patient’s metabolism.
• Focused physical exam
– Concentrate on areas of body directly affected
by exposure.
 Baseline Vital Signs
• Can be altered by hypothermia
• Monitor for changes in mental status.
• Check for core body temperature.
 Interventions
• Move from cold environment.
• Do not allow patient to walk, eat, use any
stimulants, or smoke or chew tobacco.
• Remove wet clothing.
• Place dry blankets under and over patient.
• Handle gently.
• Do not massage extremities.
• Give warm, humidified oxygen.
 Detailed Physical Exam

• Aimed at determining degree and extent of cold

injury
• Evaluate skin temperature, texture, and turgor.
 Ongoing Assessment

• Rewarming can be harmful; monitor carefully.

• Communicate conditions at scene, clothing,
changes in mental status.
 Local Cold Injuries
• Frostnip
– Freezing of the skin but not the deeper surface
• Immersion (trench) foot
– Prolonged exposure to cold water
• Frostbite
– Freezing of a body part, usually an extremity
 Emergency Care
for Local Cold Injury
• Remove the patient from
further exposure to the
cold.
• Handle the injured part
gently.
• Administer oxygen.
• Remove any wet or
restrictive clothing.
• Never rub the area.
• Do not break blisters.
• Transport.
 Warm-Water Bath
• Water temperature should be between 100-112oF.
• Recheck water temperature and stir to circulate.
• Keep body part in water until warm and sensation
returns.
• Dress with dry, sterile dressings.
 Cold Exposure and You
• EMT-Bs are at risk for hypothermia when working
in a cold environment.
• Stay aware of local weather conditions.
• Dress appropriately and be prepared.
• Vehicle must be properly equipped and maintained.
• Never allow yourself to become a casualty!
 Heat Exposure
• Normal body temperature is 98.6°F.
• Body attempts to maintain normal temperature
despite ambient temperature.
• Body cools itself by sweating (evaporation) and
dilation of blood vessels.
• High temperature and humidity decrease
effectiveness of cooling mechanisms.
 Heat Cramps
• Painful muscle spasms
• Remove the patient from
hot environment.
• Rest the cramping
muscle.
• Replace fluids by mouth.
• If cramps persist,
transport the patient to
hospital.
 Signs and Symptoms
of Heat Exhaustion (1 of 2)
• Dizziness, weakness, or fainting
• Onset while working hard or exercising in hot
environment
• In older people and young, onset may occur while
at rest in hot, humid, and poorly ventilated areas.
• Cold, clammy skin
 Signs and Symptoms
of Heat Exhaustion (2 of 2)
• Dry tongue and thirst
• Patients usually have normal vital signs, but pulse
can increase and blood pressure can decrease.
• Normal or slightly elevated body temperature
 Emergency Medical Care
• Remove extra clothing and remove from hot
environment.
• Give patient oxygen.
• Have patient lie down and elevate legs.
• If patient is alert, give water slowly.
• Be prepared to transport.
Signs and Symptoms of Heatstroke
• Hot, dry, flushed skin
• Change in behavior leading to unresponsiveness
• Pulse rate is rapid, then slows.
• Blood pressure drops.
• Death can occur if the patient is not treated.
 Care for Heat Stroke (1 of 2)
• Move patient out of the hot
environment.
• Provide air conditioning at a
high setting.
• Remove the patient’s clothing.
• Give the patient oxygen.
• Apply cold packs to the
patient’s neck, armpits, and
groin.
 Care for Heat Stroke (2 of 2)
• Cover the patient with wet towels or sheets.
• Aggressively fan the patient.
• Immediately transport patient.
• Notify the hospital of patient’s condition.
• You are dispatched to the Green Valley Mobile
Home Park for a sick person.
• An older woman found her husband on the couch
not responding.
• You note that it is very hot with no source of
ventilation. You are the Provider
• The man is on the couch and conscious but
disoriented.
• Patent airway, breathing shallow at 22 breaths/min
• Skin is red, hot, and dry.
• What medical emergency could the patient be
experiencing? You are the Provider (continued)
 Scene Size-up

• Do environmental assessment.
• Protect yourself from heat and biological hazards.
• ALS may need to give IV fluids.
• Your partner applies high-flow oxygen via
nonrebreathing mask; you call for ALS backup.
• Rapid, thready pulse; low BP; sluggish pupils;
temp 104°F
• No signs of traumatic injury
• You remove constricting clothing, jewelry.
• You move patient into ambulance.
• Is this patient a priority?
You are the Provider (continued)
 Initial Assessment

• The more altered the mental status, the more

severe the exposure.
• Keep airway patent.
• Oxygen may decrease nausea.
• Hot, dry, or moist skin may indicate elevated core
temperature.
• Treat for shock aggressively.
• If any signs of heatstroke, transport immediately.
• You set A/C on high, remove patient’s clothing,
apply cool packs.
• Patient’s wife states that husband came in after
working outside 2 hours. Complained he was hot
and dizzy.
• She made him a sandwich and went to the
neighbor’s for a few minutes. You are the Provider
(continued) (1 of 2)
• He has an allergy to milk and cats.
• Takes Lasix twice a day and a medication
for high BP.
• Do you expect this patient’s blood pressure
to be high?
You are the Provider
(continued) (2 of 2)
 Focused History and Physical Exam

• Note activities/medications that may make patient

susceptible to heat-related problems.
• Determine exposure and activities prior to
symptoms.
• Assess for muscle cramps, confusion.
• Examine for mental status, skin temperature,
wetness.
 Baseline Vital Signs
• May be tachycardic or tachypneic
• In heat exhaustion, patient may have normal skin
temp; may also be cool and clammy.
• In heat stroke, patient will have hot skin.
 Interventions
• Remove from hot environment.
• Give cool fluids by mouth.
• Cover with sheet and soak with cool water.
• Set A/C on high.
• Place ice packs on groin and axillae.
• Fan aggressively.
 Detailed Physical Exam

• Pay attention to skin temperature, turgor, wetness.

• Turgor = skin’s ability to resist deformity
• In dehydration, skin will tent when pinched on back
of hand.
• Perform careful neurologic exam.
• ALS is 25 minutes away. You are the Provider (continued)

• You choose to rendezvous.

• En route, you:
– Elevate the patient’s legs.
– Cover patient with wet sheet.
– Fan him.
– Reassess.
• What actions should you take during transport
to the hospital?
 Ongoing Assessment

• Watch for deterioration.

• Reassess vital signs every 5 minutes.
• Do not cause shivering.
• Document weather conditions and activities prior to
emergency.
 Drowning and Near Drowning
• Drowning
– Death as a result of suffocation after
submersion in water
• Near drowning
– Survival, at least temporarily, after suffocation
in water
Drowning Process
 Spinal Injuries in Submersion
Incidents
• Suspect spinal injury if:
– Submersion has resulted from a diving mishap or
long fall.
– Patient is unconscious.
– Patient complains of weakness, paralysis, or
numbness.
 Spinal Stabilization in Water
• Turn the patient supine.
• Restore the airway and begin ventilation.
• Secure a backboard under the patient.
• Remove the patient from the water.
• Cover the patient with a blanket.
 Resuscitation Efforts
• Hypothermia can protect vital organs from hypoxia.
• Documented case of a survivor of a 66-minute cold
water submersion
• Diving reflex may cause heart rate to slow.
 Diving Problems
• Descent problems
– Usually due to the sudden increase in pressure on
the body as the person dives
• Bottom problems
– Not commonly seen
• Ascent problems
– Air embolism and decompression sickness
 Signs and Symptoms
of Air Embolism (1 of 2)
• Blotching
• Froth at the mouth and nose
• Severe pain in muscle, joints, or
abdomen
• Dyspnea and/or chest pain
 Signs and Symptoms
of Air Embolism (2 of 2)
• Dizziness, nausea, and vomiting
• Dysphasia
• Difficulty with vision
• Paralysis and/or coma
• Irregular pulse or cardiac arrest
 Decompression Sickness
(The Bends)
• Occurs when bubbles of gas
obstruct blood vessels
• Can result from rapid ascent
• Most common symptom is
abdominal and/or joint pain.
• Symptoms may develop
after hours.
• Treatment is BLS and
hyperbaric chamber.
 Scene Size-up

• Never drive through moving water;

be cautious driving through still
water.
• Never attempt water rescue
without proper training and
equipment.
• Consider trauma and spinal
stabilization.
• Check for additional patients.
 Initial Assessment

• Pay attention to chest pain, dyspnea, complaints of

sensory changes.
• Be suspicious of alcohol use.
• Maintain airway; suction.
• If pulse cannot be obtained, begin CPR per
guidelines.
• Evaluate for shock and adequate perfusion.
• Treat trauma.
 Transport Decision
• Always transport near-drowning patients to
hospital.
• Decompression sickness and air embolism
must be treated in recompression
chamber.
• Perform interventions en route.
 Focused History and
Physical Exam

• If responsive, perform exam on lungs and breath

sounds.
• If unresponsive:
– Look for signs of trauma or complications.
– Check divers for indications of air embolism or
bends.
– Focus on pain in joints and abdomen.
– Check for signs of hypothermia; complete
Glasgow Coma Scale score.
 Baseline Vital Signs/
SAMPLE History
• Check pulse rate, quality, rhythm.
• Check peripheral, central pulses.
• Check for pupil size, reactivity.
• Determine length of time patient was underwater or
time of onset of symptoms.
• Note physical activity, alcohol/drug use, other
medical conditions.
• Determine dive parameters in history depth, time,
previous dive activity.
 Drowning Interventions
• Begin artificial ventilations as soon as possible.
• Stabilize and protect spine.
• Maintain patent airway. If there is no spinal injury,
turn patient on side to allow draining from upper
airway.
• Make sure patient is warm, especially after cold-
water immersion.
 Diving Interventions
• Remove patient from water.
• Begin BLS; administer oxygen.
• Place patient in left lateral recumbent position with
head down.
• Provide prompt transport to nearest recompression
facility.
• Administer oxygen and provide rapid transport.
 Detailed Physical Exam

• Examine respiratory, circulatory, neurologic

systems.
• Distal circulatory, sensory, and motor function tests
determine extent of injury.
• Examine for peripheral pulses, skin color, and
discoloration, itching, pain, numbness/tingling.
 Ongoing Assessment

• May deteriorate rapidly

• Assess mental status frequently.
• Document:
– Circumstances of drowning and extrication
– Time submerged
– Temperature of water
– Clarity of water
– Possible spinal injury
• Bring dive log, dive computer, and dive equipment
to hospital.
 Other Water Hazards
• Hypothermia from water immersion
• Breath-holding syncope
• Injuries from recreational equipment or
marine animals
 Prevention
• Pools should be surrounded with
appropriate enclosures.
• Alcohol involved in adult and teenage
drownings.
 Lightning
• Strikes boaters, swimmers, golfers, anyone in
large, open area
• Cardiac arrest and tissue damage are common.
• Three categories of lightning injuries
1. Mild: Loss of consciousness, amnesia, tingling,
superficial burns
2. Moderate: Seizures, respiratory arrest,
asystole (spontaneously resolves), superficial
burns
3. Severe: Cardiopulmonary arrest
 Emergency Medical Care
• Protect yourself.
• Move patient to sheltered
area or stay close to ground.
• Use reverse triage.
• Treat as for other electrical
injuries.
• Transport to nearest facility.
 Spider Bites
• Spiders are numerous and widespread in the US.
• Many species of spiders bite.
• Only the female black widow spider and the brown
recluse spider deliver serious, even life-threatening
bites.
• Your safety is of paramount importance.
 Black Widow Spider
• Found in all states except Alaska
• Black with bright red-orange marking in
hourglass shape on abdomen
• Venom poisonous to nerve tissue
• Requires patient transport as soon as possible
 Brown Recluse Spider
• Mostly in southern and central US
• Short-haired body has violin-shaped mark, brown
to yellow in color, on its back.
• Venom causes local tissue damage.
• Area becomes swollen and tender, with pale,
mottled, cyanotic center.
• Requires patient transport as soon as possible.
 Snake Bites
• 40,000 to 50,000 reported snake bites in the
US annually.
• 7,000 bites in the US come from poisonous
snakes.
– Death from snake bites is rare.
– About 15 deaths occur each year in the
US.
 Four Types of Poisonous Snakes
in the US

Cottonmouth
Rattlesnake

Copperhead Coral snake

 Pit Vipers
• Rattlesnakes,
copperheads, and
cotton mouths
• Store poison in pits
behind nostrils
• Inject poison to
victim through fangs
 Signs and Symptoms
of a Pit Viper Bite
• Severe burning at the bite site
• Swelling and bluish discoloration
• Bleeding at various distant sites
• Other signs may or may not include:
– Weakness – Fainting
– Sweating – Shock
 Care for Pit Viper Bites (1 of 2)
• Calm the patient.
• Locate bite and cleanse the area.
• Do not apply ice.
• Splint area to minimize movement.
• Watch out for vomiting caused by anxiety.
• Do not give anything by mouth.
Care for Pit Viper Bites (2 of 2)
• If the patient is bitten on the trunk, lay
the patient supine and transport
quickly.
• Monitor patient’s vital signs.
• Mark the swollen area with a pen.
• Care for shock if signs and symptoms
develop.
• Bring the snake to hospital if it has
been killed.
 Coral Snakes
• Small snake with red, yellow, and black bands
• “Red on yellow will kill a fellow, red on black,
venom will lack.”
• Injects venom with teeth, using a chewing
motion that leaves puncture wounds
• Causes paralysis of the nervous system
Care for Coral Snake Bites (1 of 2)
• Quiet and reassure the patient.
• Flush the area with 1 to 2 quarts of warm,
soapy water.
• Do not apply ice.
• Splint the extremity.
• Check and monitor baseline vital signs.
 Care for Coral Snake Bites (2 of 2)
• Keep the patient warm and elevate the lower
extremities to help prevent shock.
• Give supplemental oxygen if needed.
• Transport promptly. Give advance notice to
hospital of coral snake bite.
• Give the patient nothing by mouth.
 Scorpion Stings
• Venom gland and stinger found
in the tail end.
• Mostly found in southwestern US
• With one exception, the
Centruroides sculpturatus, most
stings are only painful.
• Provide BLS care and transport.
 Tick Bites (1 of 3)
• Ticks attach themselves
to the skin.
• Bite is not painful, but
potential exposure to
infecting organisms is
dangerous.
• Ticks commonly carry
Rocky Mountain spotted
fever or Lyme disease.
 Tick Bites (2 of 3)
• Rocky Mountain spotted fever develops 7 to
10 days after bite.
• Symptoms include:
– Nausea, vomiting
– Headache
– Weakness
– Paralysis
– Possible cardiorespiratory collapse
 Tick Bites (3 of 3)
• Lyme disease has now been
reported in over 35 states.
• Lyme disease symptoms may begin
3 days after the bite.
• Symptoms include:
– Target bull’s-eye pattern
– Rash
– Painful swelling of the joints
 Caring for a Tick Bite
• Do not attempt to suffocate or burn tick.
• Use fine tweezers to grasp tick by the body and
pull it straight out.
• Cover the area with disinfectant and save the tick
for identification.
• Provide any necessary supportive emergency
care and transport.
 Injuries from Marine Animals
• Coelenterates are responsible for more
envenomations than any other marine life animal
• Have stinging cells called nematocysts
• Results in very painful, reddish lesions
• Symptoms include headache, dizziness, muscle
cramps, and fainting.
 Care for Marine Stings
• Limit further discharge by minimizing
patient movement.
• Inactivate nematocysts by applying
alcohol.
• Remove the remaining tentacles by
scraping them off.
• Provide transport to hospital.