Warm Weather EmergenciesFirework Injuries

Legal Review of Intoxicated Person

Definition and description Immersion Submersion Drowning

Immersion syndrome Sudden cardiac arrest caused by massive

vagal stimulation after sudden exposure to cold water

Postimmersion syndrome Delayed deterioration of a previous

asymptomatic or minimally symptomatic patient

Shallow water blackout Unconsciousness after submersion

Epidemiology & demographics Second leading cause of accidental death

in US Leading cause of accidental pediatric

death Teenagers second major group Elderly third highest group

Etiology Classic sequence starts with panic

Victim can no longer hold breath, reflexively takes a breath, and water enters mouth

Victim takes several violent intakes of air and water while flailing

Etiology Water intake hits posterior oropharynx

Laryngospasm Bronchospasm Severe hypoxia Acidosis Cardiac disturbances CNS anoxia Coma

Physical findings Often accompanied by trauma Cardiac disturbances common Hypothermia common

Differential diagnosis Trauma Spinal injury Cardiac disturbances Hypothermia Hypoglycemia CNS disturbances Metabolic abnormalities

Therapeutic interventions Priority is reversing hypoxia If any resuscitation is required, patient

must be transported

Complications Sudden respiratory arrest ARDS Release of fluid into alveoli Inflammation of alveoli and lung tissue Loss of surfactant Atelectasis Aspiration pneumonia Pneumothorax

Homeostasis State of equilibrium

Homeotherm Body that strives to stay within 1° of norm

Thermoregulation Thermoreceptors Brain Skin Spinal cord Abdominal viscera Great vessels

Metabolism Increases to generate heat

External mechanisms of heat and cold response Radiation Exchange heat with surroundings Convection Air movement moves heat being radiated Conduction Direct contact with an object Evaporation Heat transfer mechanisms in tandem

External mechanisms of heat and cold response Involuntary responses

Perspiration Blood vessels Metabolism Piloerection

External mechanisms of heat and cold response Voluntary responses

Seek shelter from cold or heat Add or remove insulation

Outside contributors Wind velocity Humidity

External mechanisms of heat and cold response Predisposing factors

Age Health Medical history Shock CNS insult Burns Medications Skin conditions Mental history

Measures to prevent heat and cold injury Cold

Avoid long periods of exposure Cover exposed body surfaces Layer clothing Keep clothing and body dry

Measures to prevent heat and cold injury Heat

Avoid long periods of exposure Drink plenty of clear fluids Use shade to reduce heat Avoid using diuretics Avoid using amphetamines Limit alcohol intake

Heat cramps Muscle spasms Poor fluid level Overexertion with fatigue Sodium and electrolyte loss Extended exertion in heat

Heat cramps Physical findings

Cramps in fingers Arms Legs Abdomen

Heat cramps Differential diagnosis

Tetany Other heat emergency Simple muscle cramps

Therapeutic interventions Remove from heat Oral hydration of electrolytes IV solutions – nacl or LR

Heat exhaustion Dehydration & compensated hypovolemia Sweating Sodium & electrolyte loss Vasodilation with venous pooling Extended exertion in heat

Heat exhaustion Physical findings

Rapid shallow breathing Weak rapid pulse Flushed or pale skin Cool clammy skin Heavily sweating Normal core temp which can rise to 100-105° F May present with dehydration

Heat exhaustion Differential diagnosis

Uncomplicated dehydration Hypoglycemia Infection Intoxication Fatigue

Heat exhaustion Therapeutic interventions

Similar to heat cramps Remove from heat Supine Oral hydration of fluids/electrolytes IV solutions – nacl of LR Manage core temp

Heat stroke Increase in core temp over 105°F with

decreased LOC Hypothalamic temperature regulation lost Chain reaction within tissue Cellular death of brain, kidneys, liver Hallmark is altered mental status Metabolic acidosis Hyperkalemia

Heat stroke Classic heat stroke

Long periods of heat and humidity exposure Affects very young, very old, diabetics,

alcoholism and cardiac history Risks from diuretics, psychotropics,

anticholinergics Late sign – hot red dry skin

Heat stroke Exertional heat stroke

Sudden rise in core temp during exertion All age groups susceptible Patient not fluid deprived Skin may be sweaty

Heat stroke Physical findings

Altered LOC – disorientation, combative Unconsciousness Hallucinations Seizures Core temp above 40.6°C or 105°F Ataxia Tachycardia that slows near death Tachypnea progressing to bradypnea Hypotension often lacking diastolic

Heat stroke Differential diagnosis

CVA Hypoglycemia Infection Uncomplicated dehydration Intoxication Neuroleptic malignant syndrome

Heat stroke Therapeutic interventions

Goal -cooling core temperature Goal –replenish fluid Airway management Cardiac monitoring

NFPA Statistics In 2011, 9600 firework related injuries

treated in emergency rooms 8 out of 9 (89%) of injuries involved

“consumer use” fireworks In 2011, 17,800 reported fires were started

by fireworks

26% of victims were under 15 years old Injury rates apply to a range of ages;

the greatest being 5-19 years old and 25-44 years old

Males account for 68% of firework related injuries

61% to extremities 46% to the hands or

finger 11% to the legs 4% to the wrist

34% to parts of the head including the eye (17% of the total)

Sparklers, fountains, and novelties accounted for one-third (34%) of ER visits

More than half are thermal (burn) related

One quarter resulted in bruises or lacerations

3% of injuries occur as people are trying to escape an area of danger; sustaining a fracture or sprain

SCENE SAFETY is always the priority Assess trauma triage criteria

Burns >10% BSA of 2nd or 3rd degree should be considered

Burns with involvement to head, neck, or airway are high priority patients

Impaled objects through the abdomen or airway

Amputation of digits or extremities Spinal cord injuries associated with blunt

trauma or falls

Establish level of responsiveness Immobilize c-spine if indicated

check the neck prior to placing c-collar Airway assessment for patency Get good lung sounds if risk of inhalation,

assess work of breathing Identify and treat any life threatening

hemorrhages Check for neurological deficits

AVPU Motor & Sensory Pupils

SMO’s Code 22 (Thermal) Initial trauma care 100% Oxygen for stridor, hoarseness, or wheezing

(accelerated transport) Check for distal pulses in extremity burns Burn wound care

Use sterile gloves and mask if available Cool burns with sterile water or saline (<20% BSA) Dry sterile dressing or burn sheets for >20% BSA

Consider pain management Nitrous Oxide inhalation Morphine Sulfate 5-10mg IVP in 5mg increments every 5

minutes, if SBP>90. Do not give Morphine IM.

Secure object in place using whatever you can, however you can!

NEVER remove an impaled object unless it interferes with the patients airway, or EMS airway management

Think of “what lies below” to determine potential internal injuries, risk of hemorrhagic shock

“Intoxicated” may include Alcohol (ethanol) Illicit drugs (LSD, heroin, cocaine, GHB,

ecstasy, methamphetamine, etc.) Legally prescribed

medications(Hydrocodone, Oxycontin, Valium, etc.)

Mind altering substances such as inhaled chemicals, etc. (720 ILCS 690/ Use of Intoxicating Compounds Act)

Legal definition “The state of being poisoned; the condition

produced by the administration or introduction into the human system of a poison. But in its popular use this term is restricted to alcoholic intoxication, that is, drunkenness or inebriety, or the mental and physical condition induced by drinking excessive quantities of alcoholic liquors, and this is its meaning as used in statutes, indictments, etc.”

Black’s Law Dictionary

Medical definition Substance intoxication: “Reversible,

substance-specific, maladaptive behavioral or psychological changes directly resulting from physiologic effects on the central nervous system of recent ingestion of or exposure to a psychoactive substance, particularly alcohol”

http://medical-dictionary.thefreedictionary.com/intoxication

Both definitions refer to “alcohol” as a primary substance leading to intoxication

Both refer to a diminishment in psychomotor and cognitive function

Neither refer to any risk of harm

Assumption: There is some degree of Altered Mental Status

1. Is there a non-alcohol cause for Altered Mental Status?

2. Is there risk of harm?3. Does the individual have capacity to refuse

care?4. Is there someone who can take responsibility

for the patient?

Thorough history and physical examination

Blood glucose level Pulse oximetry EtCO2 if available

ANY history of trauma ANY suicidal threats or depression ANY significant co-ingestants ANY alcohol ingestion in the last hour ANY significant medical complaints ANY combative behavior ANY involvement of less-than-lethal

devices

ANY evidence of trauma beyond minor extremity

ANY significant derangement of blood glucose

ANY evidence of airway compromise ANY significant hypoxia/hypercarbia ANY abnormal vital signs

Is there a responsible caretaker? Is there an inherent danger in refusal? Is there a possibility of worsening BAL? Alcohol consumption history

What was consumed? What was the time period of consumption?

Trauma Rage (combative)

Airway compromise Narcotics/Co-ingestants Suicidal/Depression/Psychotic Pain (chest/abdomen/other medical

complaints) Oxygen low or CO2 high Risk of harm to self or others TASER (other less-than-lethal devices)

Ingestion recent/Extremely large (EtOH) Not normal vital signs Glucose low or high

Adult or qualified minor Alert and oriented GCS 15 Must appreciate the situation Must understand the medical

concern/diagnosid Must understand the consequences of

refusing care

EMS and the Hippocratic Oath

•We are not bound by Oath to “DO NO HARM”•As licensed agents through the Illinois Department of Public Health, and our EMS System Physicians, we are required to be competent in action and decision•Medical Control is NOT in place to defer provider risk•Regardless of Medical Control’s advice, ALL parties involved in patient care are responsible for outcome

•Using the combination of “Determining Capacity” and “Risk of Harm” will lead you to the right decision.

•This is the most subjective decision any EMS professional has to determine

•If there is ever any doubt, your best defense is to act in the best interest of the patient

You are summoned to a possible overdose. You assess and treat a 25 yr old male that is unresponsive with gasping respirations at 6/min. After administration of Narcan, the patient regains full sensorium; is alert and oriented to person, place, time, and events; admits to overdosing on heroin; and is refusing further care or transportation to a medical facility.

What lasts longer, the effects of Narcan or heroin?

What is his Determining Capacity? Are there any Risks of Harm to the

patient if he is allowed to refuse care?

Discussion……

Any Questions???