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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
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Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+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
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+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.
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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.
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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.
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+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
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+
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.”
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+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
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+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
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+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?
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+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
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+Trauma Fatalities (overhaul)
Structure collapse during overhaul is a
real concern
Toxic gasses during overhaul too
Electrocution rare, but happens
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+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!
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+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!
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+ Physiological Effects
of Firefighting
Watford, Herbert - Firefighter Resuscitation - EM Today 2014 20
+Physiological Effects of Firefighting
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+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
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+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
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+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
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+Other Stress of Fire/EMS Response
Alarm Response
“Noxious Arousal” from pager
T-wave inversion seen even in healthy
subjects
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+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.
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+Question
Is a reduced SEVR and increased RPP
related to sudden cardiac events during
firefighting?
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+Answer
We don’t know…
More research into the effects of
firefighting is needed!
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+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)
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+Hematological and Blood Chemistry
Changes
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Smith et al. 2013 - Clotting and fibrinolytic changes after firefighting activities
*Decreased Platelet closure time == Quicker Clotting
+Fibrinolytic changes
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Smith et al. 2013 - Clotting and fibrinolytic changes after firefighting activities
+Coagulatory changes
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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
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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.
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+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.
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+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
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+ Chemical Exposures
during Firefighting
Watford, Herbert - Firefighter Resuscitation - EM Today 2014 37
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”…
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+Toxic Twins
Hydrogen Cyanide Carbon Monoxide
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+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
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+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
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+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
Used with permission from Capt. Steve Jones – Burlington Fire
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”)
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+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
Used with permission from Capt. Steve Jones – Burlington Fire
Dept
+Food for thought…
Air monitoring of
these firefighters at
this moment found
HCN levels to be:
38 ppm
46
Used with permission from Capt. Steve Jones – Burlington Fire
Dept
+Treatment
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+Suggested Literature Review
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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
Watford, Herbert - Firefighter Resuscitation - EM Today 2014 49
+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.
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+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?
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+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!
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+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
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+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?
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+Your Plan?
What is your plan for:
EMS response to structure fires?
Rehab?
RIT?
Downed firefighters?
Cyanide exposure?
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+FD-CPR References
Us: Christopher.Watford@lelandfirerescue.com
Mike.Herbert@lelandfirerescue.com
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!)
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+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.
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+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.
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+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.
Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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+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.
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