Environmental Emergencies

Sharon Brown, RN

Heat Related EmergenciesHeat related physiology

Information about body temperature is collected by thermoreceptors and sent to hypothalamus

Sweating is primary response to heat ~ loss of NA, K, fluids can lead to dehydration

Heat EdemaOccurs during long periods of standing or

sitting“Theme Park Rash”Tx is rest, elevation

Heat CrampsLeg, shoulder, thigh, and abdominal crampsForm of hyponatremia r/t loss of sodium and

excess water intakeTX includes rest, cooling measures.D/C teaching includes encourage adding

electrolye drinks while outdoors

Heat ExhaustionProlonged heat exposure without adequate

fluid replacementTemp can be greater than 104S/S ~ pale, ashen, profuse sweating,

weakness, hypotensive, tachycardic, severe thirst

Tx – cooling measures, IVF replacement

Heat StrokeEmergent and life threatening. Mortality rate

is 50%S/S – skin is hot and dry. Temp is greater than

106, ALOCCooling measures – wet cloths, fans, ice packs

at arm pits, neck and groin. Prevent shivering with Demerol or ativan

Monitor for Rhabdomyolysis (dark urine, muscle cramps)

Aggressive cooling is continued until around 102 degrees

Cold Related EmergenciesBody attempts to conserve heat by

vasoconstriction and produce heat by shivering

DM patients cannot feel extreme changes and may not be aware of potential harm

ChilblainsChilblains is caused by intermittent, prolonged

exposureto damp, nonfreezing environments that are

abovefreezing resulting in painful inflamed lesions

over theexposed sites (usually hands, ears, lower legs

and feet),with no permanent impairment.

Frostnip is a very mild form of frostbite

FrostbiteTrue tissue freezing with

formation of ice crystals in tissue

Most common areas include fingers, toes, ears, nose

Most severe injury results from tissues that freeze, thaw, and then refreeze again

Frostbite degrees of severity1st degree

Pale skin, may be cyanotic, edema, decreased sensation

Superficial 2nd degreeCyanotic, edema, blisters, decreased sensation

Deep 2nd degreePale & cyanotic, edema, anesthesia at site, non-

pliable skin3rd degree

Pale, cyanotic, necrotic, gangrene

FrostbiteTX includes

Rapidly re-warm affected area in 100-108 temp water for 15-30 minutes

Endpoint of rewarming is softening of skin and return of sensation

Elevate affected part

HypothermiaPhysiologic changes with hypothermia

79 degrees – obtunded, no DTR’s, no pain response

77 degrees – apnea, pulmonary edema68 degrees – asystole

Treatment for ALL patientsRemove all wet garmentsProvide warm blanketsLimit movement

Mild Hypothermia93.2-96.8Slurred speech, shivering, pale skin

(vasoconstriction)Passive rewarming (0.5-2F/hour)

Moderate Hypothermia86-93.2ALOC, decreased RR, shivering stops at 89Need to re-warm core as well as extremities

because of re-warming shock! (cold blood from periphery reaches core and causes hypotension and dysrythmias)

Severe HypothermiaLess than 86 degreesPupils are fixed and dilatedBradycardia, comaIf VF occurs, attempt defib x 1. If no

response, need to focus on rewarming patient first.

Requires passive external, active external, and active internal rewarming

Submersion Incidents4,000 deaths/year40% are less than 4 years oldDie from hypoxia…not from too much fluid in

lungsCold water has better prognosis than warm

water, but cold water has higher risk for dysrhythmias

TX – ABC’s, must consider secondary trauma, monitor for pulmonary complications

Submersion Death generally occurs from hypoxia

followed by respiratory failure and ischemic neurologic injury

• Most drowning are considered wet drowning in which the alveoli develop impaired gas exchange after the lungs are flooded; aspiration of as little as 5 cc/kg can result in wet drowning

• About 10-20% of victims suffer dry drowning, in which glottic closure and laryngospasm occur before aspiration of liquid, followed by asphyxia

SnakebitesOnly 10-15 deaths/year, but several thousand

bitesMost are pit vipers

Snake bites, cont.S/S ~ metallic taste, muscle quivering,

tingling around mouth, burning at wound site, diaphoresis, seizures

Need to know time, location and description of snake

Pit viper ~ puncture from fangs, semi circle teeth marks

Coral snake ~ scratch marks, teeth marksTreatment

Decrease movement, immobilze extremity, don’t elevate

Need anti venin. (administer within 4 hours of bite) May need to transfer out.

Dog BitesMost common animal bite seen in EDCopious wound irrigationMost wounds are left open to heal from inside

out d/t high risk of infectionPatient is usually prescribed antibiotics

Spider bitesBlack Widow

Lives in dark areasFound in all states except AlaskaOnly female is poisonous with red hourglass on

bellyInitial bite is felt as pinprick

20 minutes~dull ache, abd. pain, cramping, parasthesias

1 hour ~ severe pain, increases within 12-48 hours Can progress with hypotension, shock, and resp.

failureTX – ice to bite site, Ca gluconate, antivenin

Black Widow

Spider BitesBrown Recluse

Small brown or tan spider with a band (violin shaped)

Bite is initially painless or mild, localized 2-4 hours – pain, redness and blistering 2-4 days – painful purpura 7-14 days – necrotizing, ulcerated wound

s/s – fever, chills, N/V, joint painTX- cool compress, debridement, HBO, Dapsone

(used for leprosy)

Brown Recluse

Lyme DiseaseBulls’ Eye lesion following Tick Bite (can be

delay of 3-30 days)Tick must be attached for 24 hours to

transmit diseaseNon-specific flu s/s and can develop into

systemic illness with neuro changes (memory loss, meningitis, poor motor coordination)

Tx – amoxicillin, doxycycline

Lyme Disease