DOT National Standard EMT-Intermediate/85 Refresher

1. Welcome! DOT National Standard EMT-Intermediate/85 Refresher

2. MEDICAL EMERGENCIES • Allergic reaction • Possible overdose • Near-drowning • ALOC • Diabetes • Seizures • Heat & cold emergencies • Behavioral emergencies • Suspected communicable disease

3. FROSTBITE Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx MEDICAL EMERGENCIES

4. perspective • Frostbite: • 1st degree • 2nd degree • 3rd degree • 4th degree

5. perspective • Groups at high risk for frostbite include military personnel, outdoor workers, the elderly, the homeless, people who abuse drugs including alcohol & those with psychiatric disorders

6. perspective • The areas most commonly affected by frostbite are • head (31% to 39.1% of cases) • hands (20% to 27.9%) • feet (15% to 24.9%)

7. epidemiology • US • Most cases of frostbite are mild (frostnip) • 12% of cases more severe

8. pathophysiology • Several mechanisms have been proposed to explain the pathophysiology of freezing injuries • Freezing alone is usu. not sufficient to cause tissue death • Depth of tissue freezing depends on • Temperature, duration of exposure, velocity of freezing

9. pathophysiology • Immediately after freezing & thawing, an acid cascade forms & erythrostasis, which results in venule & arterial thrombosis • And subsequent ischemia, necrosis, dry gangrene

10. s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives • First degree (frostnip) • Partial skin freezing • Erythema • Mild edema • Lack of blisters • Pt complains of stinging & burning, followed by throbbing

11. s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives • Second degree injury • Full thickness skin freezing • Formation of substantial edema over 3-4 hours • Erythema • Formation of clear blisters filled with fluid • Pt c/o numbness followed later by aching and throbbing

12. s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives • Third degree injury • Damage that extends into subdural • Hemorrhage blisters form & are associated with skin necrosis & a gray-blue discoloration of the skin • Pt c/o: it feels like a “block of wood” which is followed later by burning, throbbing, & shooting pains

13. s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives • Fourth degree injury • Characterized by extension into subcutaneous tissue, muscle, bone, & tendon • Not much edema • Skin is mottled, w/ nonblanching cyanosis, & eventually forms a deep, dry, black, mummified eschar • Pt c/o deep, aching joint pain

14. Treatment • Scene Size Up • ABCs & spinal immobilization • Assessment: VS, trauma, circulation/sensation/function/skin of all extremities, nose, ears, duration, ambient temperature, PMH & meds • If appropriate, GO TO PROTOCOL: Altered Mental Status/ALOC or Hypothermia

15. Treatment • Protect: Prevent further heat loss & injury. Remove tight or wet clothing & jewelry • Transport: Backup indicated if field re-warming is to be attempted • IV: Saline lock if field re-warming to be attempted or analgesia required per PROCEDURE: IV Access & IV Fluid Administration

16. Treatment • PARKMEDIC BASE HOSPITAL/COMMUNICATION FAILURE ORDERS • Rewarm: rarely performed in the field. Consider only if ALL of the following • Evacuation is not possible in <6-12 hours • Pt is not hypothermic • There is sufficient supply of warm water • There is no risk of re-freezing

17. Treatment • Use 100.4-107.6 F water only. Use thermometer • Provide analgesia is ALS available • Immerse until skin is soft, pink, pliable & painful (Do NOT rub) • After re-warming place gauze between toes & fingers, and dress • Protect from further injury and refreezing if possible • Pt should not walk on thawed feet

18. Treatment • Morphine • Adult: if severe pain, SBP >100, & normal mental status • IM: 5mg (0.5ml) q 15 min PRN pain (max 20mg) • IV: 4-10mg (0.4-1ml) SIVP q 15 min PRN pain (max 20mg) • Pediatric Base Hospital Order ONLY, NOT in communication failure • IM: 0.2mg/kg (0.02ml/kg). Repeat in 15min x1 prn pain • IV: 0.1mg/kg (0.01ml/kg). Repeat in 15 min x1 prn pain

19. Treatment • Ondansetron • Adult: IV 4mg SIVP over 2-5 min, repeat in 15 min x 2 prn nausea • IM: If no IV, give 8mg IM, repeat in 15min x1 prn nausea • 3mos-14yrs: IV/IO: 0.1mg/kg (max 4mg) SIVP over 2-5min, repeat in 15min x 2 • IM: If no IV, give 0.2mg/kg (max 8mg) IM, repeat in 15min x 1 prn nausea • 0-3mos: IV/IO: Base Hospital Order ONLY. 0.1mg/kg SIVP • IM: contraindicated for pts <3 months of age

20. Treatment • Acetaminophen • >10-adult: 1,000mg PO q 4-6 hrs, not to exceed 4,000mg in 24 hr • 0-10yrs: 20mg/kg PO q 4-6 hrs, not to exceed 4,000mg in 24 hr • Ibuprofen • >10-Adult: 600mg PO q 6 hrs • 6mos-10yrs: 5mg/kg PO (liquid or tablet) q 6 hours, max dose 200mg

21. Differential diagnosis • Peripheral vascular disease • Cellulitis • Dermatitis • Trauma to an extremity • Compartment syndrome (mimic or co-exist)

22. Perspective • Pathophysiology • Epidemiology • PE & Diagnostic Findings • S/S • Differential considerations • Tx

23. Questions? • References • Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. • Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. • Wolfson, Allan B. ed. , Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.