4-7 Environmental Emergencies

Signs and symptoms

Hypothermia

• Altered mental status.
• Slow, slurred speech.
• Exhaustion, stiffness, lack of coordination.
• Loss of sensation.
• Pupils that respond slowly, and is typically dilated.
• Normal skin color does not return during palpation (blanching).
• Early signs when the body is trying to compensate:
  • Shivering.
  • Increased breathing rate.
  • Increased pulse rate.
• Late signs when the body fails to compensate:
  • No shivering or movement.
  • Slow and shallow breathing.
  • Slow and weak pulse.
• Local cold injuries can accompany hypothermia.
• Suspect hypothermia if you note cold environment, elderly patient, those impaired with medical or trauma conditions and those on drugs and alcohol.
• The presence of wind in addition to the cold increases the chance of hypothermia and cold injuries.

Local cold injury

• Surface injuries produce a waxy skin that appears be gray or yellow but still soft to the touch.
• Deep injuries produce a waxy skin that appears white with possible blisters. The affected area is frozen solid and hard to the touch.

Hyperthermia

• Elevated core temperature.
• Muscle cramps.
• Altered mental status.
• Weakness, headache.
• Nausea or vomiting.
• Rapid, strong pulse at first, which deteriorates into thready pulse.
• Deep, rapid breathing at first, which deteriorates into shallow and weak breathing.
• Skin that is cool and moist during early stages when the body compensates.
• Skin that is hot at late stages when the body can not compensate.
• Seizures.
• Humidity in addition to heat increases the risk of heat stroke.

Bites and stings

• Symptoms of poisoning and allergy.
• Altered mental status.
• Bite or sting marks.
• Hives, flushing.
• Itching.
• Swelling.
• Breathing difficulties.

Aquatic emergencies

• Altered mental status.
• Airway obstruction from the water.
• Inadequate breathing.
• Hypoxic.
• Inadequate pulse.
• Shock.
• Cardiac arrest.
• Hypothermia from the cold water.
• Decompression sickness from coming out of a dive too fast:
  • Pain.
  • Itching of the skin with rash.
  • Severe forms can cause shock, hypoxia, bloody sputum and seizures.
• Clear or bloody discharge from the nose and ears due to the high pressure rupturing the ear drums and sinuses during a dive.

Treatment

Hypothermia

• Prevent further heat loss.
  • Remove from cold environment.
  • Remove any wet clothing and dry the patient.
  • Place the patient on an insulated surface.
  • Wrap the patient with blankets.
• Provide oxygen.
• PPV is needed.
• CPR if pulse is absent.
• Active rewarming for alert patients: heat packs in the groin, armpits, and on the chest.
• Passive rewarming for patients with altered mental status: give the body a chance to warm itself by keeping the patient in a warm environment and wrapping the patient in blankets. All hypothermia patients should receive passive rewarming.
• Rewarming should be slow and gentle - never place the patient in a hot bath or shower.
• Do not allow patients to take stimulants such as tobacco, coffee or alcohol.
• Do not rub or massage the arms or legs, because it squeezes cold blood into the heart, which can cause cardiac problems.

Local cold injury

• Remove from cold environment.
• Elevate the frozen extremity so it won't touch or rub against a surface.
• Remove any jewelry or restrictive clothing that is not frozen to the skin.
• If there's a possibility of refreezing, do not thaw.
• Thaw the affected area in water that is just above body temperature.
  • The thawing should be rapid.
  • The temperature should be just above body temperature - enough to thaw the ice rapidly but not cause any burns.
  • Keep the temperature of the water even and steady by monitoring with a thermometer and stirring.
  • After thawing, dress affected area with dry, sterile dressing. If hands or feet are involved, place dressing between fingers and toes.

Hyperthermia

• Move to a cool place.
• Apply oxygen.
• Remove as much clothing as possible.
• Cool the patient by spraying mist and fanning.
• Apply moist towels to the forehead of over any cramping muscles.
• Trendenlenberg position to promote perfusion to the head and vital organs.
• Give patient cool water to drink only if patient is alert and not vomiting.
• Drastic cooling measures for patients with hot skin.
  • Pour water over the patient's body. This helps evaporative cooling (avoid cold water that can cause vasoconstriction and shivering).
  • Cold packs to the groin, sides of the neck, in the armpits and behind the knees.
  • Fan the patient aggressively.

Bites and stings

• Open and maintain airway.
• Suction.
• Oxygen.
• PPV if needed.
• Epinephrine for anaphylaxis.
• Remove any lodged stingers by gently scraping it with a card, along the direction of the stinger, not against. Do not pinch the stinger with fingers or tweezers as it will squeeze more poison into the wound.
• Wash the affected area with sterile saline solution. Do not scrub.
• Remove any restrictive clothing or jewelry as soon as possible. They may cut off circulation if swelling occurs.
• Lower injection site below the level of the heart.
• Keep the patient calm and at rest.
• Follow medical direction if a tourniquet is needed.

Aquatic emergencies

• Stabilize spine because spinal injury may have occurred when patient fell into the water.
• Float the patient by securing on a backboard.
• Give rescue breaths if not breathing.
• Suction as needed.
• Give oxygen. Especially for decompression sickness.
• PPV as needed.
• CPR as needed.

Medical conditions and mechanisms

• Hypothermia: the body regulates the core temperature and try to keep it at 37 °C. When the core temperature falls, the body compensates by shivering, goose bumps, and increasing heart rate, breathing and metabolic activity. The body loses thermal control once the core temperature drops to 35 °C (95 °F). From this point on, heart rate, breathing and metabolic activity slows down. This leads to inadequate circulation and breathing. The patient may go into cardiac arrest.
• Local cold injury: also called frost-bites, is when a part of the body tissue freezes, causing tissue damage and possibly cutting off circulation. Often occurs on exposed areas such as the hands, feet, ears, nose and cheeks. Prolonged exposure to the cold environment will eventually lead to hypothermia.
  • Early or superficial cold injury: freezing to the surface only. Skin remains soft to the touch, but a waxy gray or yellow color.
  • Late or deep cold injury: freezing beneath into the tissues. Affected area is frozen solid and hard to the touch. Skin is white and waxy and may have blisters.
• Hyperthermia: the opposite of hypothermia, when the body has more heat than it can regulate.
  • Heat cramps: when the body loses too much salt from sweating, the muscles cramp or experiences spasms. This is first stage of hyperthermia and the least severe.
  • Heat exhaustion: when the body is maximized on heat dissipating functions such as sweating and vasodilation of vessels beneath the skin, circulation to the vital organ decreases, especially if more sweat comes out than can be replaced by drinking. This is the second stage of hyperthermia.
  • Heat stroke: when the body's heat dissipating functions break down from overload. Body heat increases from loss of regulation, which causes damage to brain cells. This is the last stage of hyperthermia and the most severe.
• Decompression sickness: when you come out of a dive too fast, nitrogen bubbles form in your blood. This causes embolisms to form in blood vessels, which obstruct circulation compress or stretch blood vessels and nerves, and cause coagulation. The body responds with an allergic reaction.
• People coming out of a diving while holding their breath can rupture their lungs, causing arterial gas embolism, where air enters the blood stream.
• Barotrauma: divers experiencing too much pressure, or have weakened areas due to infection, can have their eardrums or sinuses rupture during a dive.

Terms

• Immersion hypothermia: hypothermia from immersing in water.
• Urban hypothermia: hypothermia to those who have a predisposition to the illness such as the elderly, those on alcohol, and those impaired by medical or physical conditions.
  • External: cold from being without shelter.
  • Internal: cold from being in a shelter not adequately heated.
• Blanching: normal skin color does not return during palpation.
• NEHS (nonexertional heat stroke): heat stroke without exertion. Occurs to the elderly or those who are not used to heat waves.
• EHS (exertional heat stroke): heat stroke from exertion such as exercising or strenuous activity.
• Myexdema Coma: occurs when patients with hypothyroidism have hypothermia.
• Feathering: fern pattern of on the skin of patients struck by lightning.