Chapter 38 Environmental Conditions

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Objectives

Describe the physiology of thermoregulation Discuss risk factors, pathophysiology, assessment findings, and management of:

Hyperthermic conditions Specific hypothermic conditions Frostbite Submersion Drowning

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Objectives

Identify mechanical effects of gases on the body Discuss risk factors, pathophysiology, assessment findings, and management of:

Diving emergencies High-altitude illness

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Scenario
You respond to an athletic field at 3:00 p.m. for a person down. It is hot and humid. You know that the college football team started practice this week. Your patient is an unconscious 21-year-old, 230 pound male. His skin is wet and very hot. Vital sign assessment reveals: BP 82/64 mm Hg; HR 136/min; R 28/min. As you administer oxygen, he has a grand mal seizure.

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Discussion

What factors point to a heat-related emergency on this call? What other emergencies should you rule out? Describe additional assessments that should be done

Outline your priorities of care based on your current information

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Environmental Conditions

Environmental emergency

Medical condition caused or exacerbated by weather, terrain, atmospheric pressure, or other local factors Many from physical exposure to environmental elements

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Thermoregulation

Regulatory center Peripheral thermoreceptors Central thermoreceptors

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Thermoregulation

Body temperature increased or decreased by:

Regulation of heat production Thermogenesis Regulation of heat loss Thermolysis

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Regulating Heat Production

Muscular

Baseline muscular activity Exertion Shivering

Metabolic

Processing of food and nutrients Carbohydrates (sugars and starches) Fats Proteins Glycogen

Endocrine

Role of hormones in basal metabolic rate

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Regulating Heat Loss

Heat lost through skin, lungs, excretions

Skin most important Major sources of heat loss Radiation Conduction Convection Evaporation

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Maintenance of Thermoregulation

Hyperthermic compensation

Increased heat loss Vasodilation of skin vessels Sweating Decreased heat production Decreased muscle tone and voluntary activity Decreased hormone secretion Decreased appetite

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Maintenance of Thermoregulation

Hypothermic compensation

Decreased heat loss Peripheral vasoconstriction Reduction of surface area by body position (or clothing) Piloerection (not effective in humans)

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Maintenance of Thermoregulation

Hypothermic compensation Increased heat production

Shivering Increased voluntary activity Increased hormone secretion Increased appetite

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External Environmental Factors

May contribute to a medical emergency

Climate Season Weather Atmospheric pressure Terrain

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Predisposing Factors

Patients age Predisposing medical conditions Prescription and over-the-counter medications Alcohol or recreational drugs Rate of exertion
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Hyperthermia

Thermoregulatory mechanisms overwhelmed by: Environmental conditions

Heat stress Excessive exercise in moderate to extreme environmental conditions Older adults or ill or debilitated patients

Failure of thermoregulatory mechanisms

Either may result in heat illness

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Heat Cramps

Brief, intermittent muscular cramps Muscles fatigued by heavy work or exercise

Rapid change in extracellular fluid osmolarity from sodium and water loss

Muscle cramps Cool, rest, fluids

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Heat Exhaustion

More severe form of heat illness

Temperature elevation (<103 F [39 C])

Mental status changes Nausea, headache Sweating Management

Remove from heat Oral or IV fluids

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Heat Stroke

Thermoregulatory mechanisms fail

Body temperature >105.8 F [41 C]) Multisystem tissue damage Physiological collapse

Medical emergency
Two types

Classic heat stroke Exertional heat stroke

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Classic Heat Stroke

High temperatures and humidity Risk factors

Age Infants, elderly Chronic illness Diabetes, heart disease, alcoholism Medications Psychotropics, diuretics, antihypertensives

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Exertional Heat Stroke

Young, healthy patients Athletes, military recruits

Vigorous exercise in high heat

Inadequate hydration No acclimation
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Heat StrokeAssessment

Confusion, coma, seizures Skin flushing Dry skin (25% sweat) Tachycardia, hypotension Pulmonary edema Other systems affected
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Heat StrokeManagement

Move to cool location Maintain airway, oxygen, ventilation Active cooling

Fan wet skin

IV fluid: 500 mL over 15 min

For hypotension

Medications as prescribed

Sedation, seizure control

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Hypothermia

CBT less than 93.2 F [34 C] May result from:

Decrease in heat production Increase in heat loss Combination

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HypothermiaPathophysiology

Vasoconstriction Sympathetic discharge Shivering, tachycardia Shivering stops: Rapid cooling Respiration, pulse, BP decrease ECG changes Respiratory and cardiac arrest

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Hypothermia

Progression of signs and symptoms

Mild Core temperature 93.2-96.8 F (34-36 C) Moderate Core temperature 86-93 F (30-34 C) Severe Core temperature below 86 F (30 C)

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HypothermiaRisk Factors

Outdoor enthusiasts Older adults, young children Medical/psychiatric illness Trauma Medications

Alcohol, antidepressants Antipyretics, phenothiazines

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HypothermiaManagement

High index of suspicion Evacuate to warmth

Remove cold, wet clothes

Cover with warm blankets Rapid transport
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HypothermiaManagement

Passive rewarming

Move to warm environment and remove wet clothes Radiant heat Forced hot air Warm IVF Warmed oxygen Lavage Cardiopulmonary bypass

Active external rewarming

Active internal rewarming

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Mild HypothermiaTreatment

Passive rewarming Warm drinks

With sugar

External hot packs No alcoholic beverages Warm, heated oxygen

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Moderate Hypothermia Treatment

Cant shiver or perform tasks Passive rewarming first Keep patient at rest External rewarming

Cover warm packs to prevent burns

Transport for evaluation

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Severe Hypothermia

Support airway, ventilation and circulation

Passive and external rewarming

Oxygen

If ventricular fibrillation - start CPR and shock once

Rapid transport

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Considerations in Hypothermia

Assess for vital signs for 30-45 sec If presence of pulse questionable - start CPR Intubate Sinus bradycardia may be protective

Pacing usually not indicated If T>30C increase time between doses

Withhold IV drugs until T>30C

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Frostbite

Localized injury Freezing of body tissues Pathophysiology Predisposing factors

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Frostbite Classification/Symptoms

Superficial frostbite (frostnip)

Minimal tissue loss

Deep frostbite

Significant tissue loss even with appropriate therapy

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Superficial Frostbite

Some freezing of epidermal tissue Initial redness followed by blanching Diminished sensation

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Deep Frostbite

Freezing of epidermal and subcutaneous layers White appearance Hard (frozen) to palpation Loss of sensation Management
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Frostbite
Edema and blister formation 24 hrs after frostbite injury in area covered by tightly fitted boot

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Frostbite
Gangrenous necrosis 6 wks after frostbite injury

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Drowning

Fifth-leading cause of unintentional death 85% male, dont know how to swim

Drowning

Process that results in primary respiratory impairment Caused by submersion/immersion in liquid Liquid/air interface at airway prevents breathing
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Submersion Incident - Pathophysiology

Wet vs. dry drowning

Fluid in posterior oropharynx stimulates laryngospasm Aspiration occurs after muscular relaxation Suffocation occurs with or without aspiration Aspiration presents as airway obstruction

Fresh versus saltwater considerations

No difference in prehospital treatment

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Progression of a Drowning Incident

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Drowning

Hypothermic considerations

Common concomitant syndrome May be organ protective in cold water submersion Treat hypoxia first Treat all submersion patients for hypothermia

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Factors that Affect Clinical Outcome

Water temperature Length of submersion Cleanliness of water Age of patient

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Submersion IncidentManagement

ABCs Trauma considerations

Spinal precautions if MOI suggests injury

Postresuscitation complications

Adult respiratory distress syndrome (ARDS) or renal failure often occurs postresuscitation Symptoms may not appear for 24 hrs

Transport all submersion patients

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Diving Emergencies

Incidence Medical emergencies caused by:

Mechanical effects of pressure Barotrauma Air embolism Breathing of compressed air Decompression sickness Nitrogen narcosis

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Mechanical Effects of Pressure

Basic properties of gases

Increased pressure dissolves gases into blood Oxygen metabolizes; nitrogen dissolves

Boyle's law Dalton's law

Henry's law
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Boyles Law

When pressure is doubled, volume of gas is halved PV = K

P = Pressure V = Volume K = Constant

Trapped gases expand as pressure decreases

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Daltons Law

Pressure from each gas in a mixture of gases is the same as it would be if that gas alone occupied the same volume Pt - PO2 + PN2 + Px

Pt = Total pressure PO2 = Partial pressure of oxygen PN2 = Partial pressure of nitrogen Px = Partial pressure of remaining gases

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Henrys Law

At constant pressure, solubility of gas in liquid is proportionate to partial pressure of gas %X = Px/Pt x 100

%X = Amount of gas dissolved in liquid Px = Partial pressure of gas Pt = Total atmospheric pressure

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Barotrauma of Descent

Squeeze

Pain Sensation of fullness HA, disorientation Vertigo Nausea Bleeding from nose or ears

Prehospital care

Supportive
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Barotrauma of Ascent

Reverse squeeze Breath holding during ascent POPS

Alveolar rupture Pneumomediastinum Subcutaneous emphysema Air embolism

Administer oxygen
Transport for possible hyperbaric care
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Air Embolism

Complication of pulmonary barotrauma

Expanding air disrupts tissues Air forced into circulatory system Air passes through left side of heart Lodges in small arterioles Blocks distal circulation

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Air Embolism

Paralysis or sensory change Aphasia Confusion Blindness Convulsions Loss of consciousness

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Air EmbolismCare

Airway, breathing, ventilation Inflate ET cuff with saline Left lateral recumbent position

Thorax elevated 15 degrees Some protocols transport supine

Air transport in pressurized cabin

Or low altitude

Hyperbaric chamber
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Decompression Sickness

Bends, dysbarism, caisson disease, and diver's paralysis Multisystem disorder Nitrogen in compressed air converts from solution to gas

Forms bubbles in tissues and blood

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Decompression Sickness

Dyspnea Itch Rash Joint pain Crepitus Fatigue

Vertigo Paresthesias Paralysis Seizures Unconsciousness

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Decompression Sickness

Symptoms 12-36 hrs after dive Prehospital care

Support vital functions High-concentration oxygen Fluid resuscitation Rapid transport for recompression

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Nitrogen Narcosis

Rapture of the deep

Nitrogen dissolved in blood

High atmospheric pressure

Impaired judgment
Slowed motor response

Euphoria
Potential memory loss
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Nitrogen Narcosis

Supportive care Assess for injuries Transport

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High-Altitude Illness

>8000 ft above sea level

Reduced atmospheric pressure Hypobaric hypoxia Associated with: Mountain climbing Aircraft or glider flight Hot-air balloons Low-pressure or vacuum chambers

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High-Altitude IllnessPrevention

Gradual ascent Limit exertion

Decrease sleeping at altitude

High CHO diet Medications

Controversial
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Acute Mountain Sickness (AMS)

Rapid ascent of unacclimatized person to high altitudes

4-6 hrs after reaching high altitude Maximal within 24-48 hrs Abates on 3rd or 4th day Gradual acclimatization

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Acute Mountain Sickness (AMS)

Headache

Nausea, vomiting
Dizziness, irritability

Dyspnea on exertion
Tachycardia or bradycardia Ataxia Altered consciousness
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Acute Mountain Sickness (AMS)

Prehospital

Oxygen Descent

Hospital

Diuretics Steroids Hyperbaric therapy

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High-Altitude Pulmonary Edema (HAPE)

Increased pulmonary artery pressure develops in response to hypoxia

Leukotrienes released Increase pulmonary arteriolar permeability Leakage of fluid into extravascular spaces 24-72 hrs after reaching high altitudes Often preceded by exercise

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HAPE

Hyperpnea Crackles, rhonchi

Tachycardia, cyanosis
Emergency care

Oxygenate Descent

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High-Altitude Cerebral Edema (HACE)

Severe acute high-altitude illness

Global cerebral signs with AMS Related to increased intracranial pressure From cerebral edema and swelling Distinctions between AMS and HACE are blurred Mild AMS to unconsciousness with HACE occurs within 12 hrs 1-3 days of exposure to high altitudes

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HACE

Urgent management to prevent

Coma Death

Airway, ventilation, circulation support Descent to lower altitude

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Conclusion
Many emergencies result from exposure to environmental elements. The paramedic must be able to recognize and manage these conditions by understanding their causative factors and underlying pathophysiology.

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Questions?

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