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HypothermiaFebruary 2013 CECondell Medical CenterEMS SystemSite Code: 107200E-1213

Prepared by: Sharon Hopkins, RN, BSN, EMT-PRev: 2.11.13

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ObjectivesUpon successful completion of the program the EMS

provider will be able to:

Describe the thermoregulatory mechanism. Describe the mechanisms of heat transfer. Identify risk factors that predispose a patient to an

environmental emergency. Discuss the pathophysiology of cold emergencies. Identify the normal and critically low body

temperatures.

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Objectives cont’d List and describe the various cold disorders. Describe signs and symptoms, and management of

cold disorders. Describe differences of treatment of the arrested

patient with a normal body temperature versus a cold presentation.

Actively participate in case scenario discussion. Review use of a saline lock with and without IV

tubing. Successfully complete the post quiz with a score of

80% or better.

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Background Hypothermia Body’s job is to maintain homeostasis

A constant and suitable condition in which the body functions

Normal body temperature is 98.60F (370C) Hypothermia considered a core temperature

less than 950F Unable to generate sufficient heat production to

return to a normal core temperature

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Thermoregulatory Mechanisms Body attempts to maintain/regulate the body

temperature Core temperature

Temperature of deep body tissues Varies minimally from 98.60F (370C) Can be measured via tympanic or rectal

thermometers (additional routes used in hospital) Tympanic and rectal can reflect core temperatures Peripheral body temperature measured via oral or

axillary temperatures

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Thermoregulatory Mechanisms cont’d Production and loss of heat maintained via a balance

between the nervous system and negative feedback mechanisms (an action is stopped or negated)

Hypothalamus at base of brain regulates temperature When heat is sensed, heat generating mechanisms shut off

(i.e.: stop shivering) When decrease in body temperature sensed, heat losing

mechanisms shut off (i.e.: stop sweating) Thermoreceptors located peripherally (i.e.: skin and

certain mucous membranes) and centrally (deeper tissues of body)

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Hypothalamus – Thermoregulatory Center

Sits deep in brain

Thermo-stat for body

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Thermoregulatory Mechanisms cont’d Basal metabolic rate – BMR

Metabolism that occurs when body completely at rest

Continually adjusting based on the need of the body Blood vessels constrict or dilate based on need to

conserve heat or dissipate heat Can develop a difference between peripheral and core

body temperatures Core temperature is the crucial measurement with

major organs Rectal temperatures will reflect core temperatures

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Mechanisms of Heat Transfer

Heat flows from warmer to colder substances Conduction

Direct contact Convection

Heat loss to air currents passing over body Radiation

Heat loss via infrared rays Evaporation

Change of liquid to vapor; sweat evaporation Respiration

Via convection, radiation, and evaporation via lungs

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Conduction Transfer of heat away from the warmer

surface to the cooler surface Air is poor conductor of heat

Still air is good insulator Water conducts better than dry air Example: Sitting on a cold bench at the

stadium you warm it up by your body temperature conducting to the colder bench

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Convection Heat lost to air currents passing over the body Amount of heat lost depends on temperature

difference between your body and environment plus speed which the air or water currents are moving Air in motion takes away a lot of heat

Body heat is first conducted to the air before convection occurs

Example: Blowing on your food to cool it down

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Radiation Direct emission of heat Heat radiates from the warmer body and

clothing to the cooler environment The greater the difference between the body

and environmental temperature, the greater the heat loss

Example: On a hot summer day you can see the heat radiating off the hot pavement

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Evaporation Responsible for 20-30% of heat loss Wet clothing enhances heat loss Exhaled respiratory vapors add to the heat

loss Notice how you see your breath in cold weather?

Example: Stepping out of a shower on a cold winter morning, you warm up immediately after drying off

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Review Question??? When a person is exposed to cold

temperatures and strong winds for extended period of time, heat is lost mainly through: A. Radiation B. Convection C. Conduction D. Evaporation

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Answer: B - Convection Convection occurs when heat is transferred to

circulating air (cool air moves across body surface). If person is wearing light clothing and standing in the cold, windy weather, lose heat mostly by convection.

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Respiration As you breathe, you inhale ambient air

In cold climates, this can cool the core When you exhale you lose moisture and with it goes

heat Heat is lost with ventilations via the processes of

convection, radiation, and evaporation via lungs Expired air usually 98.60F (370C) and 100%

humidified

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Heat Conserving Mechanisms Vasoconstriction

Via sympathetic nervous system Skin pale, cool

Piloerection – goose bumps Evolutionary remnant

Increased heat production Shivering Chemical thermogenesis (heat generation by body) Increased thyroxine release

rate of cell metabolism

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Predisposing Risk Factors Age

Especially young children and older adults Less developed heat-generating mechanisms

General health/ predisposing medical conditions Hypothyroidism, diabetes, Parkinson’s, malnutrition

Presence of fatigue Increases poor decision making skills

Duration of exposure Coexisting weather conditions

Wind chill Altitude Humidity level

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Risk Factors cont’d Certain medications that interfere with heat-

generating mechanisms Narcotics Alcohol Phenothiazines Barbiturates Antiseizure meds Antihistamines Antipsychotics Sedatives antidepressants, Pain meds like aspirin, acetaminophen, NSAIDS

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Body Temperature Levels

Normal 96 – 1000F (37.80C) Mild hypothermia 90 (320C) – 950F (350C) Severe hypothermia – below 900F (<320C) Below 860F cardiac resuscitation possible;

more favorable above 860F (300C)

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Complications Anticipated Dehydration from cold diuresis Hypoglycemia Decreased CNS electrical activity Coagulopathy disorders – clotting problems Non-cardiogenic pulmonary edema Cardiac dysrhythmias

Atrial fibrillation common VF at 820F (<280C) Asystole at 680F (<200C)

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Fluid Balance Cold induced vasoconstriction increases fluid thru

kidneys Respond with diuresis Tubules reabsorb less water increasing more diuresis

Fluid shifts intravascular space extravascular space intracellular space

Reverses on rewarming so intravascular volume may increase 30% above normal volume

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Cold or Heat Emergencies Difficult to determine mechanism of injury by

appearance of wounds– cold or heat exposure? Obtaining history very important Field treatment does not differ for wound care

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Pathophysiology In response to exposure to cold and wet

environments, blood vessels vasoconstrict Vasoconstriction results in a decreased blood flow to

tissues especially in the periphery Ears, nose, fingers, toes

Cellular waste is not cleared and builds up Dehydration occurs easily in the cold especially if

physically active Injuries can occur at freezing AND non-freezing

temperatures

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Stages of Hypothermia Shivering

Body’s attempt to generate heat Begins around 94-970F (34.4 -360C) Does not function around 84-880F (29-310C)

Mild hypothermia – 93-970F Conscious but displaying poor judgment and irrational

behavior B/P, HR, RR to retain & generate heat

Cools more by inhaling cold air and exhaling moisture and heat with ventilations

Skin may be red, pale, or cyanotic

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Stages of Hypothermia cont’d Moderate hypothermia – 86-92.90F

Cognitive abilities declined; does not respond to painful stimuli

Progressive muscular rigidity B/P, HR, RR leading to cardiac dysrhythmias

Severe hypothermia – core below 860F Unconscious; no response to pain VS barely or non-detectable

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Review Question??? What does shivering in the presence of

hypothermia indicate? A. Musculoskeletal system damaged B. Nerve endings are damaged causing loss of

muscle control C. Body is trying to generate more heat thru

muscular activity D. Thermoregulatory system has failed and body

temperature is falling

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Answer: C – Generating more heat Shivering in presence of hypothermia

indicates that body is trying to generate more heat (thermogenesis) through muscular activity

In early hypothermia, shivering is voluntary attempt to produce heat

As hypothermia progresses, shivering is involuntary

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Frostnip Skin freezing but deeper tissues unaffected Usually affects ears, nose, fingers Usually not painful until rewarming Skin pale, cold to touch May report loss of feeling and sensation to

injured areas.

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2 weeks

Initial insult

4 weeks

Progression of Frostbite Damage

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Trench Foot 1st noted in Napoleon’s army 1812 Particular problem in trench warfare during

winters WW I, WWII, Vietnam War, Falkland’s War 1982

Has even occurred at winter festivals 1998, 2007, 2009, 2012

Can lead to gangrene and amputation

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Trench Foot Feet are cold and wet while wearing

constrictive footwear Temperatures do not need to be freezing

Has occurred in 600F temperature with 13 hour exposure

Keeping feet cold and wet for extended periods is the key causative factor

Excessive sweating is a contributory factor Prevention – keep feet warm and dry!!!

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Trench Foot Exposure followed by blistering

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Frostbite Freezing of tissue,

usually skin, when blood vessels contract

Blood flow and oxygen is reduced to affected body tissues

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Frostbite There are three degrees of cold injury Classified by depth of injury and clinical presentation

Frostnip Superficial frostbite Deep frostbite

Ice crystals form; expand and damage surrounding tissue

Damage dependent on length of exposure and depth of damage If frozen tissue dies, would lead to amputations

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Frostbite Normal sensation is lost; area becomes numb Color change noted in tissues Most affected are body parts farthest from the

core Nose, ears, fingers, hands, feet, and toes

Highest risk population Children, elderly, those with circulation problems

Majority of cases in adults 30-49 year-old

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Frostbite Don’t break blisters

Serve as protective bandaging

Treat as a burn Can’t tell if wounds

are from cold or heat exposure without knowing the history

Frostbite on a climber -parts of digits eventually needed amputation

Is this a problem???

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Preparing Site for Treatment Any constrictive jewelry or other pieces

MUST be removed As extremities/digits swell, any circumferential

articles will further constrict blood flow Any article removed from patient MUST be

documented that they were removed Document what you did with the articles

Given to patient/significant other? Turned over to ED staff?

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Pain Management Rewarming is a VERY PAINFUL!!! process

Once started, rewarming must continue regardless of the pain the patient is experiencing

Superficial frostbite is rewarmed over approximately 20- 40 minutes

Deep frostbite may take an hour to rewarm Constantly reassess pain levels and document

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Dressing Application Use fluffy, loosely wrapped dressings Separate digits with gauze

Do not want skin on skin – may become stuck together and separating will cause more tissue damage

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Adult Hypothermia/Cold Emergencies Adult Routine Medical Care (Region X SOP) Frostbite

Move patient to a warm environment Rapidly rewarm frozen areas (of frostbite) with warm

water if available (1000 – 1080F) OR Hot packs wrapped in a towel (not with direct contact to

fragile tissue) Handle skin like a burn

Light, dry sterile dressing; skin surfaces not to rub together

Elevate and immobilize Manage pain appropriately

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Rewarming Shock Hazard of rewarming extremities

Drop in core temperature if extremities rewarmed pushing colder blood into core

Recommended to rewarm thorax only and not hands or feet with hot packs

Occurs due to peripheral reflex vasodilation Cooled blood returns to core and metabolic acid

(wastes) from extremities May have paradoxical drop in core temperature

further worsening hypothermia

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Pain Management Region X SOP Fentanyl 0.5 mcg/kg IVP/IN/IO

May repeat in 5 minutes Same dose as initial dose Max total dosing of 200 mcg

FYI - A 450 pound patient would get 200 mcg by 2 doses Synthetic narcotic Less cardiovascular side effects than experienced with

Morphine Availability of IN route is advantage

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Basic Principles to Interventions Move the patient to a warmer environment

Get out of the elements of wind, wetness, and cold – prevent further heat loss

Remove any wet clothing Do not allow any body part to refreeze after

warming A freeze, thaw, refreeze cycle is more damaging to tissue

than prolonged freezing alone Do not massage tissues Do not allow patient to walk

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Systemic Hypothermia SOP Avoid rough handling and excess activity Apply heat packs to axilla, groin, neck, thorax Assess for presence of pulse

If present, continue assessment If absent, cannot withdraw resuscitative efforts

until warmed

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EKG Changes in Hypothermia Prolongation of the PR interval; then QRS;

then QT interval J waves (Osborn waves) can occur at any

temperature less than 900F (32.30C) Most frequently seen in Lead II and V6 As temperature drops, J wave increases

Can be confused with ST elevation indicating acute MI

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J wave (Osborne waves) – Development in Hypothermia

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Severe Hypothermia Signs and symptoms

Absence of shivering Dysrhythmia Loss of voluntary muscle control Decrease blood pressure Undetected pulse and respirations Cardiac arrest

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Systemic Hypothermia SOP cont’d No pulse

Begin CPR Evaluate extremities – can they be flexed? If no,

Follow appropriate cardiac protocol based on rhythm noted If defibrillation required, limit to one shock Do not administer medications – they will

not circulate effectively

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Systemic Hypothermia SOP cont’d No pulse

Begin CPR Evaluate extremities – can they be flexed? If yes,

Follow appropriate cardiac protocol based on rhythm noted If defibrillation required, repeat as core temp rises To administer medications – extend time between

medications Distribution slowed in the cold state

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Active vs Passive Rewarming Passive

Using person’s own heat generating abilities Moving to warm environment Blankets Dry clothing

Active Applying warming devices externally

Hot packs or heating pads placed in areas with superficial blood flow Neck, arm pits, groin

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Question Which of the following is NOT an example of

passive rewarming? A. Removing cold, wet clothing B. Administration of fluids by mouth C. Turning up heat in ambulance D. Covering patient with a blanket

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Answer: B – Fluid by mouth Passive rewarming involves allowing a

patient's body temperature to rise gradually and naturally.

Remove wet clothing Turn up heat in ambulance Cover with a blanket Drinking warm fluid is active rewarming

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Induced Hypothermia in ROSC Research indicates controlled induction of

hypothermia could be protective to the brain and other organs

General consensus is to cool patient to 32 – 34 0C for 12-24 hours (89.6 – 93.20F)

Patient can be placed on ventilator while being cooled and taken to the cath lab Cooling does not interfere with these interventions

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SOP- ROSC Hypothermia Induction Indications

Any patient after out of hospital cardiac arrest Remains unconscious and unresponsive ROSC greater than 5 minutes Able to maintain systolic B/P>90 with or without

vasopressors Airway secured Presumed cardiac etiology

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SOP- ROSC Hypothermia Induction Relative Exclusions

Major head trauma or traumatic cardiac arrest Recent major surgery within 14 days Systemic infection Coma from other causes such as drug induced or overdose Active bleeding Hypothermia is not recommended for isolated respiratory

arrest Suspected hypothermia already present 340C/93.20F

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SOP- ROSC Hypothermia Induction

If patient meets inclusion criteria with no relative contraindications, induce pre-hospital therapeutic hypothermia

Place ice packs in axilla and around neck and groin

Place an ice pack over the IV/IO site If shivering, contact Medical Control for

possible medication order

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Cooling after ROSC Ice paks place under neck, in armpits, in groin

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Marine Corps “COLD” Protection Principle & Preventive Measures C – clothing free of dirt & oil

Insulation capability declines O – avoid overheating that causes you to

sweat wetting clothing L – layer correctly to trap air between layers

Avoid constrictive clothing D – keep clothing dry

Wet clothing means wet skin

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Review of Initiating IV Access Under Routine Medical Care, IV access is

established based on patient's condition If stable, may establish saline lock

Develop habit of always adding the saline lock/extension tubing to the IV catheter Exact saline lock device may be different

depending on where you replace your supplies They all work on the same principle

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Establishing Saline Lock Equipment

IV start pack IV catheter Saline lock Saline flush IV bag if

indicated

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IV Site Prep Skin prep applicator contains antiseptics

chlorhexidine and isopropyl alcohol Cleanse site for 30 seconds Allow to air dry for 30 seconds

Do not blot or wipe away antiseptic FYI – some hospitals have a policy to

automatically change in-field IV sites Consider IV’s started in less than the best,

cleanest conditions

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Benefit Saline Locks/Extension Tubing Gain IV access in case of patient deterioration If IV tubing connected, easier on the patient for staff

to change the IV tubing avoiding manipulation of the IV catheter at the site of insertion Reduces the incidence of irritation that could lead to

phlebitis at the site IV can be started with or without use of the saline

lock – some ED staff prefer the additional length of tubing the saline lock provides

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Mechanical Skills Using Equipment Personnel preference starting IV with saline lock Place IV catheter

Then add individual pieces to the line Saline lock, flush, remove syringe, attach IV tubing

OR Attach saline lock to IV tubing; prime the whole line; then

attach to IV catheter

Neither way is more right/wrong than other Just another way to get to the same end result

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Adding IV Bag of Fluid – 1 Method Pre-connect saline lock to IV tubing Spike IV bag Run through IV tubing AND saline lock as one unit Keep cap on distal end of tubing to keep tip sterile Initiate IV Connect primed IV tubing, with saline lock attached,

to IV catheter Check for patency and adjust IV flow rate Secure tubing

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IV Start with Saline Lock – Alternate Method Spike IV bag and run out IV tubing, set aside

Keep cap on distal end of tubing to keep tip sterile Flush saline lock; can leave flush syringe attached Initiate IV Connect saline lock to IV tubing Flush the line and check for infiltration, remove

syringe Swab port and connect primed IV tubing to saline

lock; confirm IV flow rate Secure tubing

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IV Don’ts Don’t add gauze under the tape - increases the

risk of infection Don’t leave site wet with blood if possible Do not leave large loops of tubing that could

be inadvertently pulled

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IV Tips Cover insertion site with op-site type product

Site can be observed for changes Entire catheter tip should be inserted up to hub

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Infection Control The main risk factor for infections is the

presence of a medical device in a patient Field environments usually less than optimal

compared with healthcare facilities related to sterility of equipment

Hand hygiene is the first step in infection control Handwashing before and after every patient Clean gloves used for invasive skills

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Routes of Infection with Catheter Use Migration of organisms on patient’s skin from

site of insertion, along catheter, to catheter tip Contamination of equipment via direct contact

Improperly cleaned hands/glove use Improper handling of equipment Contaminated injection ports not cleaned prior to

use for injection Contamination of IV solution – rare occurrence

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Infection Prevention Have you contaminated the IV catheter? Have you kept the distal tip of the IV tubing

covered? If you rip your tape early, where did you put

it? Are you sure the side of the cot is clean??? Are you sure the side rails of the cot are clean all

the way around???

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Scenario Discussions Participate in discussions of the following

cases Determine your general impression Decide on treatment/interventions you would

initiate Review outcomes

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Scenario #1 24 year old male found unresponsive outdoors Ambient temperature late afternoon – 450F

Cloudy 71% humidity Winds calm

Background information: Unknown length of time down O-O-O Monitor showed ventricular fibrillation Patient worked as a full arrest

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Scenario #1 – Time of year - January Found by passer-by unresponsive laying face

down in mud 200´ off road Rolled over prior to EMS arrival Found cold, pale, apneic, pulseless, pupils

fixed and non-reactive O-O-O

What would you do if this were your call?

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Scenario #1 - Narrative “Moved to ambulance; c-collar and back board

applied; clothes removed; CPR started with active warming process”

“Rapid trauma assessment no trauma found”

What else do you need/want to know for assessment information that would help guide decision making for care of this patient? Do extremities flex or not?

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Scenario #1 Skills as listed in Image Trend

BVM Airway clearing Spinal immobilization Warming with hot packs Defibrillation x5 King airway IO access lower left extremity Medications: Epinephrine, Amiodarone, Narcan

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Scenario #1 – Questions Hypothermic patient – Could extremities be flexed? BVM – What rate??? Airway cleared – Why? What method? Spinal immobilization – What method/equipment? Hot packs – Where were they placed? Defib- When was each individual one delivered? King airway – What size? Placement confirmed? IO access – What length and size needle? Was

patient banded?

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Scenario #1 - Medications VF per monitor

Epinephrine 1;10,000 – 1 mg IO Epinephrine 1;10,000 – 1 mg IO Amiodarone 300 mg IO Epinephrine 1;10,000 – 1 mg IO Epinephrine 1;10,000 – 1 mg IO Narcan 2 mg IO

What do you think of the medication order for VF?

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Scenario #1 Follow-up Patient was resuscitated, admitted to ICCU Patient regained consciousness

Protected by hypothermia and sedation of self-administered drugs

Patient survived to discharge Awake, oriented, able to care for self (eat, dress, walk)

Unbelievable but true!!!

And a VERY lucky gentleman

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Scenario #2 43 year old female developed chest pain 7/10

while at work History hypertension VS: B/P 153/100; P – 86; R-16; SpO2 99% RA Unable to establish IV Given 4 baby ASA to chew Administered 1 NTG sl due to the pain Then obtained 12 lead EKG

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Scenario #2 – Any ST elevation?

II, III, aVF

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Scenario #2 Were the interventions appropriate? How would you have handled the call?

If unable to obtain IV access, need to contact Medical Control prior to administration of NTG

Need to obtain a 12 lead EKG prior to NTG Need to review for ST elevation

If ST elevation in II, III, aVF (inferior leads), need to contact Medical Control prior to administration of NTG

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Scenario #2 In the field, no negative effects from NTG

dose In the ED, 12 lead EKG was normal Taken to cath lab based on EMS 12 lead During procedure, might have seen distal

blockage that resolved Catheter maneuvers may have dislodged a clot

and reopened a vessel Patient to undergo further testing

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Scenario #3 A 19 year-old female had walked several

miles in a frozen field Feet are white, hard, and cold to touch You determine that she has frostbite in both

feet

What would you do if this were your call?

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Scenario #3 – Pick the best answer:Treatment at the scene should include:

A. Rubbing feet gently with your warm hands

B. Having her walk around to restore circulation

C. Removing her wet clothing and rubbing her feet briskly with a warm, wet cloth

D. Removing her wet clothes and covering her feet with dry, sterile dressings

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Scenario #3 – Answer D Rationale #D

To treat frostbite, remove any wet clothing Cover injured area with dry, sterile dressings Do not break any blisters Do not apply heat to rewarm area if there is any

chance of refreezing

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Scenario #3 – Explanations of wrong answers:#A - Do not rub or massage frostbitten areas

Increases tissue damage

#B – Walking on frostbitten feet increases tissue damage Ice crystals have formed in the tissues and

movement, rubbing, massaging increase damage to surrounding tissue

#C – Never rub cold injured skin; if allowed to freeze, thaw, freeze, increase in damage to tissues occurs

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Scenario #4 30 year old male who fell through the ice In water 20 minutes; exposed additional 10

minutes while getting to shore VS: 158/84; P – 120; RR – 30; SpO2 99% RA GCS 15 Denies pain IV access; cardiac monitor

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Scenario #4 Pt wearing snow mobile suit and helmet while in the

water In ambulance, clothing removed

Dried Covered with blankets Hot packs applied

Pt red, shivering Complained of no feeling in right foot; all

extremities move well

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Scenario #4 What do you think – care and documentation?

What was the ambient temperature? What did the monitor show? Was a hot pack placed over the IV site?

What does it mean when a patient shivers?

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Scenario #4 Shivering indicates the patient is still capable

of generating heat through the action of shivering Passive rewarming used patient’s own body heat

Removed from cold environment Removed wet clothing Covered with a blanket

Active rewarming Hot packs placed in the neck, armpit, and groin areas

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Scenario #5 You are called to the scene for a 27 year-old

male who immediately became unconscious after being elbowed in the chest

Upon arrival CPR is being performed; patient confirmed to be 0-0-0

With this initial rhythm, what is your action?

Ventricular fibrillation

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Scenario #5 When confirming a patient is in VF, provide CPR First action with arrival of equipment is to get

monitor on patient to view rhythm Rhythm viewed with patient presentation drives

decision making As soon as monitor is ready, stop CPR If VF/pulseless VT seen, immediately defibrillate

Immediately resume CPR after defibrillation starting with compressions

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Scenario #5 – Following Region X SOP’s First shock delivered CPR resumed; attempting to establish IV access After 2 minutes, CPR paused for max of 10

seconds to reevaluate rhythm What is your next action when seeing this on the

monitor?

Check for a pulse!!!

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Why Limit CPR Pause to <10 sec? When compressions interrupted, blood flow

drops rapidly Decrease in intrathoracic pressures Takes awhile to regenerate adequate perfusion again

Maintain a rate of at least 100 compressions per minute 30:2 in 1 man and 2 man adult CPR Once intubated, compressor stops only after 2

minutes of CPR for rhythm check Ventilations are asynchronous

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Importance of Adequate Compression Rate During CPR Lengthy pauses in CPR detrimental to blood

flow and ultimately the patient Takes a few compressions to build up enough

pressures to be effective after each pause

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Negative Effects of Hyperventilation Hyperventilation blows off CO2 Decreased CO2 causes reflexive vasoconstriction

Limits volume of oxygenated blood perfusing to the brain Excessive ventilation can result in gastric inflation

Increases risk of vomiting and aspiration Excessive ventilation rate increases intrathoracic

pressures Can compromise venous return to the heart and diminish

cardiac output Ventilate once every 5-6 seconds with BVM Ventilate once every 6-8 seconds via ETT or King

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Scenario #5 When viewing a rhythm that should generate

a pulse, including VT, NOW appropriate to check for a pulse

If no pulse, rhythm PEA, resume CPR If pulse, reevaluate patient

Responsiveness Airway/ventilation status Blood pressure 12 lead EKG

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Scenario #5 – Any ST elevation?

Sinus Tach - NO ST elevation

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Scenario #5

So why did this patient arrest? Commotio cordis – concussion of the heart

Instant cardiac arrest from a non-penetrating blow to the chest wall

Diagnosis made by exclusion of other etiologies If blow made immediately before peak of T wave, VF

can develop Improved survival rates to immediate CPR and rapid

defibrillation

See October 2012 CE for additional discussion

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Bibliography American Heart Association. 2010 Guidelines for

CPR and ECC. 2010. Bledsoe, B., Porter, R., Cherry, R. Paramedic Care

Principles & Practices, 4th edition. Brady. 2013. Siegel, M., Kraemer-Cain, J. PICC Line Care at

Home. Advance for Nurses. September 26, 2011. Region X SOP’s; IDPH Approved January 6, 2012. http://www.cdc.gov/niosh/docs/2010-115/pdfs/2010-

115.pdf http://en.wikipedia.org/wiki/Hypothermia