Cold Weather Emergencies

Presented by: Wade Scoles RRT, NREMT

Staff Education Coordinator, NW MedStar

• Most serious injuries in ambulance crashes are unrestrained medical attendants in the rear compartment.

• You are 2.6 times more likely to be injured while running “code”.

Emergency Vehicle Safety

• Exposing your patient– Bring them inside the ambulance– Keep them warm– Remove wet clothing– Cutting Coats & Snowsuits…

Cold Weather Assessment & Mngt

• Assessing skin color, temperature and perfusion

Cold Weather Assessment & Mngt

•Normal cap refill of 2-3 seconds will be longer in cold weather due to vasoconstriction

•Will not necessarily reflect hemodynamic status

Patient #1

• Typical winter conditions (more than an inch of snowfall and temperatures that dip below 20 degrees) cause death rates from heart attacks to triple among men 35 to 49 years old.

Video

• 55 year old having chest pain while shoveling snow

• Initial assessment:– Pale, diaphoretic, no resp. distress– Vital signs:

• Pulse 110, RR 16, BP 158/90, SpO2 96%

Patient #1

• Management:– Rapid transport, call for ALS if available – Monitor with AED, Oximetry– Oxygen– Nitroglycerin

• Contraindicated if BP < 100 systolic

– Aspirin

Patient #1

Patient #1

• Why is shoveling a potentially dangerous activity?– Strenuous activity in cold

weather– HR & BP increase– Body constricts vessels

when exposed to the cold

Patient #2

• Approximately 1,000 Americans fall through ice each year

Video

Patient #2

• 11 year old, cold water submersion

• Pale, cold, unresponsive, not breathing

• To resuscitate or not?

• In the water 40-45 minutes

• Water temp 33 degrees

Patient #2

• Assessing hypothermic patients– Take extra time to assess pulse & RR in

hypothermic patients– Allow for slow heart & respiratory rates– Don’t start chest compressions if severe

hypothermic patient shows any signs of life

Patient #2

• Management– Rapid transport, call for ALS if available– High quality BLS– Remove wet clothing– Begin active re-warming of truncal area while

administering BLS– May attempt defibrillation once if AED says

“Shock indicated”

Patient #2

• Management– Withhold further defib or meds until body temp

reaches >30°C (86°F)– Will need transport to facility capable of active

internal rewarming for severe hypothermia

Patient #2

• Sudden submersion into cold water triggers the Mammalian Dive Reflex

• HR & RR slows and blood flow diverts from the extremities to the core

• This slowing of metabolism and diversion of blood allows longer survival times.

• How cold must the water be, to be “protective”?– <20° C (68 °F)

Hypothermia Severity

Severity Symptoms TreatmentMild:

>34°C or 93.2°F

Shivering,

Tachycardia

External rewarming all areas

Moderate: 30-34°C or 86-93.2°F

Confusion, disorientation, apathy, bradycardia or AFib

External rewarming, truncal areas only

Severe: <30°C or <86°F

Unconsciousness, More cardiac dysrhythmias like V-Fib

Truncal external rewarming plus active internal rewarming

Profound <20°C PEA or asystole, EEG flat line at 63°F

Same as “Severe” category

Patient #3

Patient #3

• Nearby fishermen call 911 to report drunk, confused man wandering around the ice

• Upon your arrival– Pt is confused, dizzy, vomiting and C/O headache– Vitals

• Pulse 118, RR 24, BP 132/80, SpO2 97% BS clear.

• Differential diagnoses?

Patient #3

• What questions are you going to ask to determine the problem?– Drunk?– Hypoglycemia?– Stroke?– Head injury?– Carbon Monoxide Poisoning?

• Pt. states he was just fishing with his buddy, had a couple of beers and doesn’t remember anything else

Patient #3

• With bystanders help, you figure out where he was fishing and find his friend in the hut

• His friend is passed out inside

• Pulse 120, RR 12, BP 116/70, SpO2 92%

• What are your priorities?– Additional resources needed?– Secure airway– Oxygen

Carbon Monoxide

• Carbon Monoxide is colorless, odorless, tasteless gas

• CO exposure accounts for an estimated 15,000 emergency department visits and 500 unintentional deaths in the United States each year

Carbon Monoxide

Carbon Monoxide

• CO has a half-life of 4-5 hours– Oxygen can reduce that– Hyperbaric Oxygen can reduce it even more

• Hyperbaric chambers in the Northwest– WA: Spokane (Deac), Seattle (Virginia Mason),

Clarkston (Tri-State), Richland (Kadlec)– Alaska: Anchorage, Juneau, Wasilla– Montana: Billings Clinic– Idaho: Boise, Idaho Falls, Pocatello– Oregon: Portland, Hillsboro, Eugene, McMinnville

Carbon Monoxide

• Detecting CO in blood– Standard oximetry not helpful– Co-oximetry

Carbon Monoxide

% COHb Symptoms≤10 No symptoms

≤15 Mild headache

25 Nausea & serious headache

30 Nausea & vomiting intensify, confusion, lethargy

45 Unconsciousness

60 Death

Patient #4

Patient #4

• 65 year old woman rescued from house fire

• Scene safety concerns

• Patient condition– Unresponsive– No evidence of trauma or burns– HR 140, RR 12, BP 130/78, – SpO2 on Oxygen is 98%

Patient #4

• Differential diagnoses?– Head trauma, CO poisoning, Medical Event

• CO level is 12%• Patient still unresponsive• Consider Cyanide Poisoning• Management

– Secure Airway– O2– Assist respirations– Cyanokit

Cyanide Poisoning

• Cyanide may be a factor in ~4,000 fire-related deaths in the U.S. each year

• Study of smoke inhalation deaths– 87% of the fatalities had toxic levels of

cyanide

• Cyanide is commonly found in the smoke of closed-space fires– Synthetic construction materials, furniture– Natural materials like wool and cotton produce

cyanide when burned

Cyanide Poisoning

• Treatment– Hydroxocobalamin (Cyanokit)– 5 grams (diluted in 200ml) over 15 minutes– Can safely be used for suspected cyanide

poisoning as it bonds with cyanide in the body to form Vitamin B-12

Patient #5

You are called to the home of a 28 year old pregnant woman with respiratory distress

Patient #5

• 34 weeks pregnant

• 2 day history of cough, muscle aches

• Now with fever and increasing respiratory distress

• VS: HR 120, RR 24, SpO2 82%

Protect yourself

N-95 mask, gloves

Patient #5

• After Oxygen:– SpO2 87%– Still in respiratory distress

• Breath sounds:– Insp. Crackles & exp. wheezes

• Impression?– Influenza, Respiratory distress

Novel H1N1 in the US, By Age Group

Novel H1N1 U.S. Deaths, By Age Group

Flu Hospitalizations, Spokane Area

Patient #6

• 24 year-old male crashes on snowmobile

http://www.youtube.com/watch?v=UoA7jK26SOE

Patient #6

• Scene safety concerns

• Transport decision

• Helicopter safety concerns– Skids sinking into snow– White-out conditions upon landing

Patient #6

• Upon your arrival:– Pt is conscious, sitting on tailgate of truck– c/o back and neck pain– HR 80, RR20, BP hard to hear through

clothes, SpO2 97% – Skin feels cool

• Your assessment– Are you going to cut off his snowsuit?

Patient #6

• Management:– C-spine immobilization– ABCs

• How are you going to place him in C-spine precautions?

http://www.emsonline.net/head2009/skills.asp

Contact: Renee Anderson509-232-8155

1-866-630-4033andersr@inhs.org

Fax: 509-232-8168