Em today 2014 firefighter down (1)

+

Firefighter Down!Special Consideration for the Resuscitation of the Downed Firefighter

Christopher Watford, Michael Herbert

+License

This work is released as Free Open Access Meducation! #FOAM

This work is licensed under a Creative Commons Attribution-

ShareAlike 4.0 International License.

You are free to:

Share: copy and redistribute the material in any medium or format

Adapt: remix, transform, and build upon the material for any purpose, even

commercially.

We cannot revoke these freedoms as long as you follow the license terms.

Under the following terms:

Attribution: you must give appropriate credit, provide a link to the license, and

indicate if changes were made. You may do so in any reasonable manner, but not in

any way that suggests the licensor endorses you or your use.

ShareAlike: if you remix, transform, or build upon the material, you must distribute

your contributions under the same license as the original.

No additional restrictions: you may not apply legal terms or technological

measures that legally restrict others from doing anything the license permits.

Watford, Herbert - Firefighter Resuscitation - EM Today 2014

2

+Who Are These Guys?

Christopher Watford, BS, NRP

Lieutenant, Leland Fire/Rescue

Paramedic, New Hanover EMS

Senior Editor, EMS 12-Lead Blog

Lead Software Engineer, GE

Nuclear

Michael Herbert, BA, NREMT-P

Clinical Educator, Advanced

Circulatory

FF/Paramedic, Leland

Fire/Rescue


3

+Conflict of Interest Disclosure

Christopher Watford

None

Michael Herbert

Employed by Advanced Circulatory

as a clinical educator.

Advanced Circulatory is the

manufacturer of the ResQPOD and

ResQGARD.

Advanced Circulatory has had no

financial or editorial input into this

presentation or its contents.


4

+Disclaimer

This presentation and our opinions do

not reflect the views or opinions of our

employers.

We’re not speaking for them, we’re

speaking for us.


5

+Why Listen to Us?

We are not the experts.

We encourage you to question our assumptions

We encourage you to question our assertions.

We would like you to ask for our references.

We would like your feedback on our proposed solution to a problem.


6

+Objectives

Understand the epidemiology of Firefighter fatalities

Define physiological changes during stress

Define physiological changes during firefighting

Define risks during firefighting

Understand pathophysiology of HCN exposure

Define barriers to treatment during Firefighter resuscitation

Understand treatment goals during Firefighter resuscitation


7

+

Captain

David HeathNew Hanover County

Fire Rescue

Watford, Herbert - Firefighter Resuscitation - EM

Today 2014

8

+Epidemiology

CDC/NIOSH Fire Fighter Fatality Investigation and Prevention Program

“Each year an average of 100 fire fighters die in the line of duty. To address this continuing national occupational fatality problem, NIOSH conducts independent investigations of fire fighter line of duty deaths. This web page provides access to NIOSH investigation reports and other fire fighter safety resources.”


9


10


11

+Fatality Etiologies

Medical: 1105 (44%)

Heart Attack: 957

CVA: 59

Heat Exhaustion: 9

Other Medical: 80

Trauma: 1384 (56%)

Crushed: 390

MVC: 345

Struck by Vehicle: 145

Asphyxiation: 218

Burns: 118

Electrocution: 22

Drowning: 19

Other Trauma: 108


12

+Trauma Fatalities

Collapsing structures most common

traumatic etiology

Motor vehicle collisions second most

common

Being struck by a vehicle also common!

Asphyxiation likely if trapped or lost


13

+Trauma Fatalities (en route)

Rollovers very common

Too fast, high center of gravity,

inexperience, weather

Intersection collisions common

Too fast, driving without due regard

Overuse of lights and sirens?


14

+Trauma Fatalities (on scene)

Working an MVC is one of the most dangerous jobs a firefighter or EMS provider will do.

Spend more time blocking the scene

Backers are even more important on busy fire scenesNumerous fatalities from apparatus

repositioning


15

+Trauma Fatalities (overhaul)

Structure collapse during overhaul is a

real concern

Toxic gasses during overhaul too

Electrocution rare, but happens


16

+Medical Fatalities

Heart Attacks are the number one cause of line of duty deaths in fire fighters.Autopsies of firefighters include findings such

as: cardiomegaly, hypertrophy, severe CAD, etc.

Heat exhaustion fairly common during training eventsHeat exhaustion coupled with cardiovascular

risks is a dangerous mix!


17


18

+Medical Fatalities (cont.)

CVA’s are comparatively rare

Cardiomyopathies and channelopathies should be considered in younger firefighters who collapse

Do you know what medical problems your crew has? Comorbid factors may play a large role in FF fatalities

Certain Cancers are now recognized as resulting from Line of Duty incidents!


19

+ Physiological Effects

of Firefighting

Watford, Herbert - Firefighter Resuscitation - EM Today 2014 20

+Physiological Effects of Firefighting


21

+The Stress of Firefighting

Firefighters:

perform strenuous physical work

while wearing heavy personal

protective equipment (PPE)

often in hot environments and under

physiologically stressful conditions


22

+The Stress of Firefighting

Firefighting results in

significant cardiovascular

and thermal strain as a result

of:

strenuous work

heavy and insulating PPE

psychological stress

environmental extremes


23

+Physiology of Stress in Firefighting

Strenuous firefighting activities can

lead to:

Attainment of maximal HR

Elevated core temperature

Dehydration

Decreased stroke volume

Increased arterial stiffness

Alterations of myocardial function


24

+Other Stress of Fire/EMS Response

Alarm Response

“Noxious Arousal” from pager

T-wave inversion seen even in healthy

subjects


25

+Cardiovascular Effects of Note

At the Attainment of Maximal Heart Rate…

Subendocardial viability ratio (SEVR): Decreases

Index of myocardial oxygen supply and demand

Decrease in myocardial perfusion relative to cardiac workload.

Rate Pressure Product: Increases

Determines the myocardial workload

Increases significantly during firefighting activity due to the increase in myocardial oxygen consumption.


26

+Question

Is a reduced SEVR and increased RPP

related to sudden cardiac events during

firefighting?


27

+Answer

We don’t know…

More research into the effects of

firefighting is needed!


28

+Hematological and Blood Chemistry

Changes

Hemoconcentration

~15% reduction in plasma volume

Release of platelets from the spleen and lymph tissue

Platelet count increased significantly (18%)

H&H increases

Hemoglobin (Hgb) and hematocrit (Hct) revealed small but

significant increases (P<0.001)

Platelet closure time decreased significantly (15%

ADP, 20% EPI)


29

+Hematological and Blood Chemistry

Changes


30

Smith et al. 2013 - Clotting and fibrinolytic changes after firefighting activities

*Decreased Platelet closure time == Quicker Clotting

+Fibrinolytic changes


31

Smith et al. 2013 - Clotting and fibrinolytic changes after firefighting activities

+Coagulatory changes


32

Smith et al. 2013 - Clotting and fibrinolytic changes

after firefighting activities

+ Changes from Baseline

1.45

1.22

1.38

1.09

0%

25%

50%

75%

100%

125%

150%

175%

200%

FVIII TF

Coagulation

Pre Post 120Post

0%

50%

100%

150%

200%

250%

300%

350%

400%

450%

Tpa act Tpa agn

Fibrinolytic

Pre Post 120Post


33

Horn et al 2010: Effects of Fire Fighting and On Scene Rehab on Hemostasis

+Risks of SCA during Firefighting

2007 study by Kales

and coworkers clearly

demonstrated that the

relative risk of

suffering from a fatal

cardiac event was 10–

100 times greater

following fire-

suppression activities

than during non-fire

duties.


34

+Summary

Studies suggest there is an

increased risk of

thrombosis due to a

procoagulatory state,

hours after firefighting.

In effect an increased

vulnerability to myocardial

infarction after fighting fire.


35

+How do we address this?

NIOSH and NFPA stress Prevention and Detection

as the key!

Reduce modifiable risk factors

Fitness and Nutrition Programs

Smoking Cessation Programs

Screening and Detection

Annual Physicals

Assessment of Cardiovascular Risks


36

+ Chemical Exposures

during Firefighting


Bromomethane

Benzene

Sulfur Dioxide

Formaldehyde

Phosgene

Carbon Dioxide

Acetic AcidAlcohols

MethaneAmmonia

ChloromethaneOxides of Nitrogen

Hydrogen SulfidePCB’s

Furfural

Acrolein

Carbonyl Fluoride

Dioxin

Carbon Monoxide

Hydrogen Cyanide

Benzopyrine

Ethylene

Used with permission from Capt. Steve Jones – Burlington Fire

Dept

+Let’s concentrate on the “toxic

twins”…


39

+Toxic Twins

Hydrogen Cyanide Carbon Monoxide


40

+Cyanide

Extremely poisonous,

colorless chemical, with faint

almond* smell.

24 times more toxic then CO

Synergistic toxicity with CO

IDLH – 50ppm

NIOSH REL – 5ppm

OSHA PEL – 10ppm


41

+Pathophysiology of Cyanide

Histotoxic hypoxia

Inability of cells to take up or

utilize oxygen from the

bloodstream

Despite physiologically

normal delivery of oxygen to

such cells.

Inhibits cytochrome

C-oxidase


42

+Signs & Symptoms of CN toxicity

Headache

Confusion

Anxiety

Blurred vision

Loss of judgment

Increased respiratory

rate

Dyspnea

Cardiac arrhythmias

Seizures

Coma

Death

MODERATE

EXPOSURESERIOUS EXPOSURE


Dept

+Cyanide Poisoning

Cyanide exposure: Expected in those exposed to smoke in

closed-space fires

Important cause of incapacitation and death in smoke-inhalation victims

Cyanide can act independently of, and perhaps synergistically with, carbon monoxide to cause morbidity and mortality (“Toxic Twins”)


44

+Columbia Fire Department Study

Eight month study

monitoring CO and

HCN at fires.

Found extremely high

HCN levels at calls

Found no correlation

between CO and HCN

production


Dept

+Food for thought…

Air monitoring of

these firefighters at

this moment found

HCN levels to be:

38 ppm

46


Dept

+Treatment


47

+Suggested Literature Review


48

Report of the Investigation Committee into the Cyanide Poisonings of

Providence Firefighters. J. Curtis Varone, Thomas N. Warren, Kevin Jutras,

Joseph Molis, Joseph Dorsey. May 30, 2006.

+ Special

Considerations during

Resuscitation


+RIT

If the downed firefighter is inside a structure, you’ll need to effect rescue.

MAYDAY incidents are chaotic and communication will be poor.

Frequent training for RIT will improve chance of a rescue.

Consider that it may take upwards of 15 minutes to rescue a downed firefighter.


50

+Determining the Etiology

RIT has just rescued a downed firefighter.Does not appear to be breathing.

Is it trauma?Blunt? Penetrating?

Asphyxiation?

Is it medical?

Does it matter initially?


51

+Getting them out of their gear!

Extrication.We’re at an impasse until we get these

guys out of their turnout gear.

Their gear is going to be hot, wet, maybe even contaminated.

Their gear is in the way of what we need to be doing: Chest Compressions!


52

+FD-CPR

Concept began with Hilton Head Island Fire & Rescue Video showing the time delay to get firefighter out

of gear

Thanks to Capt. Tom Bouthillet for sharing their experience on Youtube

Revised with the help of input from numerous firefighters and EMS providers.

Proposed Process: FD-CPR 10 Steps to Doff Gear and perform CPR


53

+FD-CPR

VideoWatford, Herbert - Firefighter Resuscitation - EM Today 2014 54

+Treatment

CPR, CPR, and more CPR.

Consider the etiologyWas their air cylinder empty? Early adv airway.

Was their mask off? Early adv airway and consider HCN.

Did they simply collapse suddenly? Std pit crew.

Structure collapse? Check rhythm, transport decision?


55

+Your Plan?

What is your plan for:

EMS response to structure fires?

Rehab?

RIT?

Downed firefighters?

Cyanide exposure?


56

+FD-CPR References

Us: [email protected]

[email protected]

Leland Volunteer Fire/Rescue Department http://www.lelandfirerescue.com

http://www.facebook.com/lelandfirerescue

http://www.facebook.com/LelandFireRescueTraining

FD-CPR http://www.fd-cpr.com (Coming Soon!)

http://www.facebook.com/fd-cpr (Coming Soon!)


57

mailto:[email protected]

mailto:[email protected]

http://www.lelandfirerescue.com/

http://www.facebook.com/lelandfirerescue

http://www.facebook.com/LelandFireRescueTraining

http://www.fd-cpr.com/

http://www.facebook.com/fd-cpr

+References

NIOSH Fire Fighter Fatality Investigation and Prevention Program.

http://www.cdc.gov/niosh/fire/

Brandt-Rauf PW, et al. Health hazards of fire fighters: exposure assessment. Br J Indust Med. 1988; 45:606-612.

Smith DL, et al. Effect of strenuous live-fire fire fighting drills on hematological blood chemistry and psychological measures. J Therm Biol. 2001; 26:375-379.

CDC. Fatalities Among Volunteer and Career Firefighters: United States, 1994-2004. Morbidity and Mortality Weekly Report. 2006; 55(16):453-455.

Dweck MR, et al. Noxious arousal induces T-wave changes in healthy subjects. J Electrocardiol. 2006; 39:324-330.

NIOSH. Preventing Fire Fighter Fatalities Due to Heart Attacks and Other Sudden Cardiovascular Events. Publication Number 2007-133. June 2007.


58

http://www.cdc.gov/niosh/fire/

+References

Geibe JR, et al. Predictors of On-Duty Coronary Events in Male Firefighters in the United States. Am J Cardiol. 2008; 101:585-589.

Fahs CA, et al. Impact of Excess Body Weight on Arterial Structure, Function, and Blood Pressure in Firefighters. Am J Cardiol. 2009; 104:1441-1445.

Horn GP, et al. The Effects of Fire Fighting and On-Scene Rehabilitation on Hemostatis. University of Illinois Fire Service Institute. November 2010.

Estes CR, Marsh SM, Castillo DN. Surveillance of Traumatic Firefighter Fatalities: An Assessment of Four Systems. Pub Health Rep. 2011; 126:540-551.

Kunadharaju K, Smith TD, DeJoy DM. Line-of-duty deaths among U.S. firefighters: An analysis of fatality investigations. Acc Anal and Prev. 2011; 43:1171-1180.

Smith DL, et al. Effect of Live-Fire Training Drills on Firefighters’ Platelet Number and Function. Prehosp Emerg Care. 2011; 15:233-239.


59

+References

Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment stragies. Scand J Trauma Resus Emerg Med. 2013; 21(31):1-15.

IAFF. Heart Disease in the Fire Service. 2013.

http://www.iaff.org/hs/index.htm

Smith DL, Barr DA, Kales SN. Extreme sacrifice: sudden cardiac death in the US Fire Service. Extr Phys Med. 2013; 2(6):1-9.

Mbanu I, et al. Seasonality and Coronary Heart Disease Deaths in United States Firefighters. Chronobiol Int. 2007; 24(4):715-726.

Poston WSC, et al. An examination of the benefits of health promotion programs for the national fire service. BMC Pub Health. 2013; 13(805):1-14.

Yang J, et al. Sudden Cardiac Death Among Firefighters ≤45 Years of Age in the United States. Am J Cardiol. 2013; 112:1962-1967.


60

http://www.iaff.org/hs/index.htm

+References

Fent KW, et al. Systemic Exposure to PAHs and Benzene in Firefighters Suppressing Controlled Structure Fires. Ann Ccup Hyg. 2014; 58(7):830-845.

Hostler D, et al. A Randomized Controlled Trial of Aspirin and Exertional Heat Stress Activation of Platelets in Firefighters during Exertion in Thermal Protective Clothing. Prehosp Emerg Care. 2014; 18:359-367.

Hunter A, et al. Abstract 27: Fire simulation exposure causes impairment of endothelial function and increased thrombogenicity in healthy firefighters. Heart. 2014; 100(Suppl 3):A14-A15.

Kales SN, Smith DL. Sudden cardiac death in the fire service. Occup Med. 2014; 64:228-232.

Perroni F, et al. Psychophysiological Responses of Firefighters to Emergencies: A Review. Open Sport Sci J. 2014; 7(Suppl-1, M3):8-15.

Smith DL, et al. Clotting and Fibrinolytic Changes after Firefighting Activities. Med Sci Sports Exerc. 2014; 46(3):448-454.


61

Em today 2014 firefighter down (1)

Education

Transcript of Em today 2014 firefighter down (1)