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Environmental Emergencies. Condell Medical Center EMS System CE August 2009 Site Code #107200E-1209. Prepared by: Captain Tony Carraro Greater Round Lake F.P.D. Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P. Objectives.

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environmental emergencies

Environmental Emergencies

Condell Medical Center

EMS System CE

August 2009

Site Code #107200E-1209

Prepared by: Captain Tony Carraro

Greater Round Lake F.P.D.

Reviewed/revised by: Sharon Hopkins, RN, BSN, EMT-P


Upon successful completion of the this module, the EMS provider will be able to:

  • Identify the various ways that the body loses and gains heat.
  • Identify the differences of cold emergencies (frostbite, mild hypothermia, severe hypothermia).
  • Identify the signs and symptoms of cold emergencies
  • Identify the management for cold emergencies.
  • Identify the differences between the heat emergencies heat cramps, heat exhaustion and heat stroke.
objectives cont d
Objectives cont’d
  • Identify the signs and symptoms of heat emergencies.
  • Identify the management of heat emergencies.
  • Define drowning.
  • Identify the complications of drowning in fresh water versus salt water.
  • Identify management of drowning cases.
  • Identify complications related to diving.
  • Identify the differences between allergic reactions without airway involvement, with airway involvement, and anaphylaxis.
objectives cont d1
Objectives cont’d
  • Identify signs and symptoms of allergic reactions.
  • Identify the emergency medical care of bites and stings.
  • Identify management of allergic reactions.
  • Participate in case scenario presentations.
  • Return demonstrate use of an EpiPen®.
  • Demonstrate drawing up and administration of Epinephrine 1:1000 IM and SQ.
  • Describe when to use CPAP and how to monitor effectiveness.
loss and gain of body heat
Loss and Gain of Body Heat
  • Conduction: Heat flows from warmer material (body) to cooler one (environment).
  • Convection: Currents of air or water pass over the body, carrying away heat.
  • Radiation: Sending out energy, such as heat, in waves into space.
loss and gain of body heat cont
Loss and Gain of Body Heat cont’
  • Evaporation: The change from a liquid to a gas.
    • When the body perspires or gets wet, evaporation of the perspiration or liquid has a cooling effect on the body
  • Respiration: Breathing during respiration; body heat is lost as warm air is exhaled from the body
water chill
Water Chill

Water chill: conducts heat away 25 times faster than still air

wind chill
Wind Chill
  • Wind Chill: Chilling caused by convection of heat from the body in the presence of air currents.
  • The more wind, the greater the heat loss. At 10 degrees and a 20 mph wind the amount of heat lost is the same as if it was minus 25 degrees.
  • Cooling that effects the entire body
  • Causes a state of low body temperature, specifically low core temperature
  • A core temperature dropping below 950F (35.50C) is considered hypothermic
  • FYI – 98.60F = 370C
conversion formula for temperature
0F to 0C

0C = 5/9 (0F – 32)

Ex: 98.20F = ?0C

- 5/9 (98.2 – 32)

- 5/9 (66.2)

- 5 x 66.2 / 9

- 331/9

- 36.80C

0C to 0F

0F = 9/50C +32

Ex: 28.40C = ?0F

9/5(28.4) + 32

9/5 x 28.4 + 32

9x28.4/5 + 32

255.6/5 + 32

51.12 + 32


Conversion Formula For Temperature
degrees of hypothermia
Degrees of Hypothermia
  • Mild: A core temperature greater than 900F (320C) with signs and symptoms of hypothermia.
  • Severe: A core temperature of less than 90 0F (320C) with signs and symptoms of hypothermia.
predisposing factors
Predisposing Factors
  • Age – Very Young
    • Larger skin surface area/less fat compared to adults
    • Little or no shivering
      • Shivering mechanism immature so can’t generate heat via shivering
    • Too immature in skills to independently put on or take off clothing
predisposing factors1
Predisposing Factors
  • Age – Very Old
    • Failing body systems
    • Chronic illness
    • Lack of exercise
    • Certain medications
localized cold injuries
Localized Cold Injuries
  • Superficial Frostbite (frost nip)
    • Some freezing of the epidermal tissue
    • Redness followed by blanching
    • Diminished sensation
    • Skins remains soft
    • As area is re-warmed it begins to tingle
signs symptoms of deep late local cold injury
Signs & Symptoms ofDeep (Late) Local Cold Injury

Severe frostbite

White, waxy skin

Firm or frozen on surface

Swelling and blisters may occur

Skin blotchy, mottled, or grayish yellow or blue

partial thickness 2 nd degree burn
Partial Thickness (2nd Degree) Burn
  • It can be difficult to tell the difference between injuries from heat versus cold exposure
localized cold injury
Localized Cold Injury
  • Clear boundaryseparates injured/ uninjured areas
emergency care of superficial early local cold injury
Emergency Care ofSuperficial (Early) LocalCold Injury

Remove patient from environment

Re-warm patient

Protect area from further injury

Splint and cover extremity

Do not rub or massage

Do not re-expose to cold

trench foot
Trench Foot
  • Trench Foot - immersion foot
    • Similar to frostbite, but occurs in temperatures above freezing
    • Pain may be present
    • Blisters form on spontaneous re-warming
  • Treatment
    • Early recognition
    • Warm, dry, aerate, & elevate feet
  • Prevention more effective
    • Avoid prolonged exposure standing in water and remove wet socks/shoes
trench foot1
Trench Foot
  • Trench foot could also develop following prolonged exposure to urine soaked clothing in contact with feet
    • Consider a patient who lies undiscovered for several days in their home
signs and symptoms
Signs and Symptoms

Mild Hypothermia

Severe Hypothermia

No Shivering

Dysrhythmias, asystole

Loss of voluntary muscle control


Undetectable pulse and respirations

  • Lethargy
  • Shivering
  • Lack of coordination
  • Pale, cold, dry skin
  • Early rise in blood pressure, heart and respiratory rate
treatment for hypothermia
Treatment for Hypothermia
  • Remove wet garments
  • Prevent further heat loss
  • Protect from further wind chill exposure
  • Use passive external warming methods
    • Blankets
  • Maintain patient in horizontal position.
treatment for hypothermia cont
Treatment for Hypothermia cont’
  • Avoid rough handling, which can trigger dysrhythmias
  • Monitor temperature
  • Monitor the cardiac rhythm
passive vs active re warming
Passive vs. Active Re-warming


Allows body to re-warm itself

Remove wet clothing

Cover with blanket(s)


Application of external heat sources to patient

region x sop hypothermia cold emergencies
Region X SOP – Hypothermia/Cold Emergencies


Routine Medical Care

Move pt to warm environment as soon as possible and prevent re-exposure

Rapidly re-warm frozen areas with tepid (warm) water (if feasible)

Hot packs wrapped in a towel may be used


Protect with light, dry, sterile dressing

Do not let affected skin surfaces rub together

hypothermia sop cont d
Hypothermia SOP cont’d


Routine Medical Care

Avoid rough handling and excess activity

Apply heat packs to axilla, groin, neck and thorax

Assess pulse

Pulse present Pulse Absent

Transport (see next page)

hypothermia sop cont d1
Hypothermia SOP cont’d


Follow appropriate

cardiac protocol but

extend times between

meds – repeat defib

as core temp rises



Follow appropriate cardiac

protocol, but limit shocks to 1 and withhold IV medications


Pulse absent

Can extremities be flexed?

region x sop hypothermia cold emergencies1
Region X SOP – Hypothermia/Cold Emergencies

Pediatric Considerations

Assess for severe cardiorespiratory compromise:

Shivering, decreased LOC, cyanosis despite oxygen administration, increased/decreased respiratory rate, dysrhythmias, dilated sluggish pupils, decreased reflexes, or weak/thready pulses

heat emergencies
Heat Emergencies
  • Hyperthermia: a state of unusually high body temperature, specifically the core temperature
  • A fever (pyrexia) is the elevation of the body temperature above normal for that person
  • A person’s normal temperature may be one or two degrees above or below 98.6 degrees

FYI: 98.60F = 370C

types of heat emergencies
Types of Heat Emergencies
  • Heat cramps
    • Muscle cramps from over exertion and dehydration
  • Heat exhaustion
    • Mild heat illness; acute reaction to heat exposure
  • Heat stroke
    • True environmental emergency occurring when the body’s hypothalamic temperature regulation is lost
predisposing factors to consider
Predisposing Factors to Consider

Preexisting Illness

Heart disease








predisposing factors2
Predisposing Factors

Young age – Newborns/Infants

  • Poor thermoregulation system (under developed)
  • Can’t remove own clothing (skills immature)

Older age – Elderly

  • Poor thermoregulation system
    • Don’t sense the heat level
  • Interference with prescribed medication
  • Limited ability to escape heat
    • Often wear multiple layers of clothing
  • Lack of air conditioned environment
symptoms of heat exposure
Symptoms of Heat Exposure
  • Diaphoresis (sweating as a compensation to cool down)
  • Increased skin temperature
  • Flushing
  • As heat symptoms progress additional signs and symptoms may develop
    • Altered mental status
    • Altered level of consciousness
    • Altered vital signs
signs and symptoms heat cramps
Signs and Symptoms Heat Cramps


Normal body temperature

Normal vital signs

Sweating, pale

Skeletal muscle cramps

c/o weakness, dizziness, faintness

signs symptoms heat exhaustion
Signs & Symptoms Heat Exhaustion

Anxiety to possible loss of consciousness

Body temperature slightly elevated (>1000F)

Normal B/P

Pulse weak

Respirations rapid, shallow

Skin normal to cool; clammy; heavy sweating

Occasional muscle cramps

CNS symptoms: Headache, paresthesia, diarrhea

signs symptoms of heat stroke
Signs & Symptoms of Heat Stroke

Confusion, disorientation, loss of consciousness

Hot skin, can be dry or moist, with high temp

Low blood pressure

Rapid, weak pulse that later slows

Deep respirations that eventually slow and become shallow

Possible seizures

it s all relative
It’s All Relative!!!
  • Polar bears are collapsing from heat exhaustion as the normal temperature in polar regions has risen from 20 degrees below zero to 15 degrees below zero
emergency care of heat exposure patient with normal to cool skin
Emergency Care of Heat Exposure Patient with Normal to Cool Skin

Remove from hot environment.

Administer high-concentration oxygen.

Loosen or remove clothing.

Cool by fanning.

Patient supine, legs elevated.

Avoid drinking plain water to rehydrate.

emergency care of heat exposure patient with hot skin
Emergency Care of Heat Exposure Patient with Hot Skin

Remove patient from hot environment.

Remove clothing.

Administer high-concentration oxygen.

Apply cool packs to neck, groin, armpits.

Keep skin wet (aids in evaporation).

Fan aggressively (aids in convection).

Transport immediately.

region x sop heat emergencies adult pediatric
Region X SOP- Heat Emergencies, Adult & Pediatric

Heat Cramps

Move patient to a cooler environment

Do not massage cramped muscles


region x sop heat emergencies adult peds
Region X SOP- Heat Emergencies, Adult (Peds)

Heat Exhaustion

Adults - IV fluid challenge in 200 ml increments

(Peds: IV fluid challenge 20 ml/kg; may repeat to max 60 ml/kg)

Gradual cooling procedure

Move patient to cool environment

Remove as much clothing as possible to facilitate cooling

Place in supine position with feet elevated

region x sop heat emergencies adult
Region X SOP- Heat Emergencies, Adult

Heat Stroke

IV fluid challenge in 200 ml increments

Rapid cooling procedure

Follow gradual procedure along with:

Douse towels or sheets with cool water, place on patient, and fan body

Cold packs to lateral chest wall, groin, axilla, carotid arteries, temples, and behind knees

If actively seizing, follow seizure protocol


region x sop heat emergencies pediatrics
Region X SOP- Heat Emergencies, Pediatrics

Heat Stroke – Peds

IV fluid challenge 20 ml/kg; may repeat to max 60 ml/kg

Rapid cooling procedure

Douse towels/sheets with cool water & place on patient, fan body; cold packs to lateral chest, groin , axilla, carotid arteries, temples, behind knees

Stop cooling if shivering begins

Consider Valium 0.2mg/kg IVP/IO over 2 min every 15 min til shivering stops (or 0.5 mg/kg rectal)

If actively seizing, follow seizure protocol

definition drowning
Definition Drowning
  • Submersion or immersion in a liquid
    • prevents the person from breathing air
    • patient has a primary respiratory impairment
  • 4,500 people die of drowning every year in the U.S.
    • 3rd leading cause of accidental death in the USA
  • 40 % of deaths are children under 5 years old
  • Deaths again peak in teenagers
  • Third peak is in elderly who drown in bath tubs
near drowning
  • This term is not used anymore due to the confusion regarding the terms “drowning” and “near-drowning”
  • All incidents are referred to as “drowning”
pathophysiology of drowning
Pathophysiology of Drowning
  • Following submersion, if conscious, victim will experience up to three minutes of apnea (involuntary reflex)
  • Blood is shunted to heart and brain due to mammalian dive reflex
  • While apneic the PaCO2 in blood rises and the PaO2 falls.
mammalian dive reflex
Mammalian Dive Reflex
  • A complex cardiovascular reflex
    • Stimulated by submersion of face and nose
  • Breathing inhibited
  • Bradycardia develops
  • Protective function of vasoconstriction
    • Almost all areas sacrificed with decreased blood flow
  • Cerebral & cardiac blood flow is maintained
    • Heart and brain receive blood flow
pathophysiology of drowning cont d
Pathophysiology of Drowningcont’d
  • The stimulus from hypoxia (low oxygen) overrides the sedative effects of hypercarbia (excess carbon dioxide)
  • Central nervous system (CNS) stimulated
  • Until unconscious, the victim will panic
    • Patient makes violent inspiratory and swallowing efforts
pathophysiology of drowning cont d1
Pathophysiology of Drowningcont’d
  • Copious amounts of water enter into mouth, pharynx and stomach
    • laryngospasm and bronchospasm result in deeper coma
  • Reflex swallowing continues
    • gastric distention, vomiting and aspiration
  • If untreated:
    • hypoxia, hypotension, bradycardia and then death develops
dry versus wet drowning
Dry Versus Wet Drowning
  • Dry drowning
    • Significant amount of water does not enter the lungs due to laryngospasm
  • Wet drowning
    • Laryngospasm does not occur and a significant quantity of water enters the lungs.
predisposing factors drowning
Predisposing Factors & Drowning
  • Use of alcohol
  • Lack of ability to swim
  • Swimming in unprotected, non-monitored areas
  • Not following posted warnings
factors affecting survival
Factors Affecting Survival
  • Cleanliness of the water
  • Length of time submerged
  • Age and health of victim
  • Temperature of water (cold water = under 68 degrees.)
  • Children have a longer survival time and greater probability of successful resuscitation
fresh water vs salt water
Fresh Water vs Salt Water
  • Fresh Water
    • Water diffuses across the alveoli into bloodstream
      • Blood is diluted
      • O2 carrying capacity decreased
      • Bleeding lung inflammation develops
      • Surfactant is destroyed
        • Substance that keeps alveoli open
      • Alveoli collapses
    • Ventricular fibrillation often occurs
fresh water vs salt water1
Fresh Water VS Salt Water
  • Salt Water
    • Salt water is 3 to 4 times more hypertonic than plasma
    • Water drawn from the bloodstream into alveoli
    • Pulmonary edema develops
    • Blood volume decreases causing shock

Primary concerns:

Everyone’s safety

Assume cervical spine injury and treat for spine injury

If cervical injury cannot be ruled out:

Attempt resuscitation of submerged cardiac arrest patient unless medical direction rules it out.

  • Protect the patient from heat loss
  • Avoid laying the patient on a cold surface
    • Would continue to lose body heat via conduction
  • Remove wet clothing and cover the body with dry warm linen
    • Want to prevent evaporation of body heat
  • Assess airway, breathing and circulation, need for CPR and defibrillation

If patient responsive and spine injury

not ruled out

- Immobilize head manually

- Use backboard to remove from water

region x sop near drowning
Region X SOP – Near Drowning

Routine Trauma Care

C-spine precautions

Oxygen 100%

Consider CPAP if patient condition indicates


Awake, alert, normal



sop near drowning cont d
SOP Near Drowning cont’d


Abnormal respirations; altered mental status

Evaluate for gag reflex

Negative Positive

Intubate & assist Assist ventilations via

ventilations via BVM BVM

Asses for hypothermia

Normothermic Hypothermic

Treat dysrhythmias per Refer to hypothermia

protocol protocol

region x sop near drowning1
Region X SOP – Near Drowning

Pediatric Consideration

Aggressive airway management

Be aware of potential for C-spine injury and hypothermia

Studies indicate potential for survival after prolonged submersion especially in cooler water

dive injuries descent
Dive Injuries (Descent)
  • Barotrauma: Injuries caused by changes in pressure
  • The “squeeze”
    • Injury to the inner ear
  • Signs and symptoms
    • Middle ear PAIN
    • Ringing in the ears
    • Dizziness
    • Hearing loss
    • In severe cases rupture of the eardrum
dive injuries at the bottom
Dive Injuries At the Bottom
  • Nitrogen narcosis (raptures of the deep)
    • Breathing compressed air under pressure
    • Nitrogen becomes toxic to cerebral function
    • Diver appears intoxicated and may take unnecessary risks
    • Panic will worsen the situation
    • Disorientation, confusion
  • Problems disappear on surfacing
dive injuries during ascent
Dive Injuries During Ascent
  • Decompression sickness (the bends)
    • Dives below 33 feet require staged ascent to prevent the bends
    • Rapid reduction of air pressure while ascending after exposure to compressed air
      • Dissolved nitrogen does not leave blood
    • Nitrogen bubbles form, especially in the abdomen and joints, obstructing blood vessels causing severe pain
ascent injuries cont d
Ascent Injuries cont’d
  • Pulmonary overpressure
    • Can occur with deep or shallow dive (as little as 3 feet)
    • Occurs if the breath is held during the ascent
      • Compressed air in the lungs now expands
      • Alveoli rupture if air is not exhaled
      • An air embolism may enter the circulatory system from the damaged lung
      • Pneumothorax will occur if the alveoli ruptures into the pleural cavity
assessment of dive emergencies
Assessment of Dive Emergencies
  • Time signs and symptoms began
  • Type of breathing apparatus and suit worn
  • Depth, number of dives, duration of dives
  • Rate of ascent
  • Experience of diver
  • Aircraft travel following a dive
  • Medication and alcohol use
  • Medical history and previous events
  • ABC’s
  • CPR (if required) and high flow O2
  • Secure airway (if required)
  • Keep patient supine
  • Protect from excessive heat or cold
  • Evaluate and transport
allergic reactions
Allergic Reactions
  • Allergic Reaction
    • An exaggerated response by the immune system to a foreign substance
  • Anaphylaxis
    • A biochemical chain of events following exposure to a particular substance that leads to shock and possible death
    • Life threatening emergency that requires prompt recognition and specific treatment
what is the difference
What is the Difference???
  • Anaphylaxis is life-threatening
    • Blood pressure is low
    • Patient is in shock
    • Patient will die from respiratory compromise and shock
  • Allergic reaction
    • Annoying, bothersome with systemic reaction but patient not in shock


agents that may cause anaphylaxis
Agents that May Cause Anaphylaxis
  • Antibiotics and other drugs
  • Foreign proteins (horse serum, Streptokinase)
  • Foods (nuts, eggs, shrimp)
  • Allergen extracts (allergy shots)
  • Hymenoptera stings (bees, wasps)
  • Hormones (insulin)
  • Blood products
  • Aspirin and Non-steroidal anti-inflammatory (NSAIDs)
  • Preservatives
  • X-ray contrast media (ie: iodine)
pathophysiology of anaphylaxis
Pathophysiology of Anaphylaxis

Antigen exposure

Release of chemicals including histamine

Constriction of

extravascular smooth


  • Capillary




Abdominal cramps,

diarrhea, vomiting


laryngeal edema

3rd spacing



  • Peripheral



pathophysiology cont d
Pathophysiology cont’d

3rd spacing (fluid leaking

from intravascular space

Relative hypovolemia


Decreased cardiac output

Decreased tissue perfusion

Impaired cellular function

Cellular death

systemic reactions
Systemic Reactions






body systems affected
Body Systems Affected
  • Immune system
    • Principle system affected
  • Cardiovascular system
  • Respiratory system
  • Nervous system
  • Gastrointestinal system

(Note: this list is not all inclusive)

effects on body systems
Effects on Body Systems
  • Skin
    • Flushing
    • Itching
    • Hives
    • Swelling
    • Cyanosis
  • Cardiovascular system
    • Vasodilation
    • Increased heart rate
    • Decreased blood pressure
effects cont d
Effects cont’d
  • Respiratory system
    • Respiratory difficulty
    • Sneezing, coughing
    • Wheezing, stridor
    • Laryngeal edema
    • Laryngospasm
    • Bronchospasm
effects cont d1
Effects cont’d
  • Gastrointestinal system
    • Nausea and vomiting
    • Abdominal cramping
    • Diarrhea
  • Nervous system
    • Dizziness
    • Headache
    • Convulsions
    • Tearing
allergic response helpful or killer
Allergic Response – Helpful or Killer?
  • Cascade of events after exposure to an antigen
    • To remove antigen from the body & prevent further ones from entering
  • Bronchospasm – prevents entrance into the respiratory system
  • Coughing – removes antigen from the respiratory system
  • 3rd spacing (leaky capillaries) – shifts antigen from vascular space into interstitial space for removal via the lymph system
  • Vomiting & diarrhea – removes antigen from GI system
severe allergic response
Severe Allergic Response
  • Bronchospasm
    • Respiratory compromise
  • 3rd spacing
    • Cardiovascular collapse
    • Decreased cardiac output from vasodilation
    • Fluid shift
    • Relative hypovolemia
bites and stings
Bites and Stings
  • Often patient unaware of offending agent
  • May have delayed response in calling/seeking medical care
  • Obtain a detailed history
    • Was patient in any activity putting them at risk for exposure
  • Treat the signs and symptoms
generalized signs symptoms bites and stings
Generalized Signs & Symptoms Bites and Stings

Dizziness and chills


Nausea and vomiting

Respiratory distress

Bite marks or stinger

Localized pain or itching

Numbness body part

Burning sensation followed by pain

Redness and swelling


Muscle cramps, chest tightening and joint pain

treatment of bites and stings
Treatment of Bites and Stings

Treat for shock

Contact medical control

Immobilize affected limb slightly below heart level

Prevent exertion of patient

Wash area gently – use sterile normal saline

Remove jewelry distal to affected area

Observe for allergic reaction

Apply ice indirectly to the wound

removing stingers
Removing Stingers
  • The faster the stinger is removed, the less venom enters and the smaller the reaction
  • Lesson – get the stinger out anyway possible as soon as possible
tick lyme disease
Tick (Lyme Disease)
  • Tweezers are used to remove the deer tick
  • Grasp the tick as close to the skin and pull upward
region x sop adult allergic reaction
Region X SOP Adult Allergic Reaction

Hives, itching, and rash

GI distress

Patient alert

Skin warm and dry

Systolic B/P > 100 mmHg

Routine medical care

Benadryl 25 mg IVP slowly over 2 minutes or IM


region x sop pediatric allergic reaction
Region X SOP Pediatric Allergic Reaction

Hives, itching, and rash

GI distress

Patient alert

Skin warm and dry

Apply ice/cold pack to site

Benadryl 1 mg/kg IVP slowly over 2 minutes or IM

Maximum 25 mg


region x sop adult allergic reaction with airway involvement
Region X SOP Adult Allergic Reaction with Airway Involvement

Patient alert

Skin warm and dry

Systolic B/P > 100 mmHg

Epinephrine 1:1000 0.3 mg SQ

Benadryl 50 mg IVP slowly over 2 minutes or IM

If wheezing, Albuterol 2.5 mg/3ml; may repeat


region x sop pediatric allergic reaction with airway involvement
Region X SOP Pediatric Allergic Reaction with Airway Involvement

Patient alert; skin warm & dry

Epinephrine 1:1000 SQ 0.01 mg/kg Maximum 0.3 ml per single dose; May repeat every 15 minutes

Benadryl 1 mg/kg IVP slowly over 2 minutes Maximum 50 mg

Albuterol 2.5 mg/3ml; may repeat


region x sop adult anaphylaxis
Region X SOP - Adult Anaphylaxis

Unstable; altered mental status; B/P <100 mmHg

Maintain and support airway; intubate as indicated

IV wide open

Epinephrine 1:1000 0.5 mg IM

Benadryl 50 mg IVP slowly over 2 minutes or IM

If wheezing, Albuterol 2.5 mg/3ml; may repeat


If worsening condition, contact Medical Control

region x sop pediatric anaphylaxis
Region X SOP - Pediatric Anaphylaxis

Unstable, altered mental status

Epinephrine 1:1000 IM 0.01 mg/kg Maximum 0.3 ml per single dose; may repeat every 15 minutes

Benadryl 1 mg/kg IVP slowly over 2 minutes; maximum 50 mg

IV fluid challenge 20 ml/kg; repeat as indicated; maximum 60 ml/kg

Albuterol 2.5 mg/3ml; may repeat

If no response and continued deterioration, contact Medical Control to consider Epinephrine 1:10,000 IV/IO 0.01 mg/kg; repeated every 5 min as indicated

  • An auto injection device prescribed for patients susceptible to anaphylaxis
  • Patient can initiate immediate care while waiting for EMS response
  • 2 doses
    • EpiPen ® - Adult dose 0.3 mg
    • EpiPen® Jr - Pediatric dose 0.15 mg
  • Stored at room temperature
  • Trainer pen received with device
using the epipen
Using the EpiPen
  • Remove the yellow or green cap from the carrying case
  • Slide the pen out and remove the gray safety cap
  • With a firm grip, jab the black tip into the outer thigh (designed to work through clothing)
  • Listen for the click and hold for 10 seconds
  • Needle stays exposed after use
  • Red plunger visible in window when med is administered
  • Dose wears off in approximately 15 – 20 minutes
  • EpiPen®
  • EpiPen® Jr



Jab into



  • Antihistamine
    • Blocks histamine release in allergic reactions
  • Max effects in 1-3 hours with a duration of 6-12 hours
  • Side effects include drowsiness and drying of bronchial secretions
  • Elderly are particularly sensitive to Benadryl
    • Watch for hypotension
administering epinephrine sq or im
Administering Epinephrine SQ or IM
  • Check the medication 3 times prior to admin
  • If from a vial, cleanse off the rubber stopper
  • If from an ampule, break open
  • Draw up specified amount of medication
  • Clear syringe of all bubbles
  • Draw up 0.1 ml of air in the prepared syringe
  • IM – pull skin taut and inject at 900 angle
  • SQ – pinch up skin and inject at 450 angle
  • Aspirate and if no blood return, inject
  • Remove needle and massage site
  • Sympathomimetic mimicking the sympathetic nervous system (flight or fight) response
  • Most useful for 2 desired responses
    • Vasoconstriction
    • Bronchodilation
  • Use with caution in the elderly & presence of heart disease
    • Increases heart rate and strength of contractions which may not be well tolerated by these populations
is there airway involvement
Is There Airway Involvement?
  • In some patients airway involvement is clear
    • Wheezing
    • Swelling of tongue
  • In some cases the airway involvement is unclear
    • Throat feels scratchy but breath sounds are clear
  • If doubtful of airway involvement, contact Medical Control for guidance regarding use of Epinephrine 1:1000
  • Sympathomimetic (mimicking the sympathetic nervous system)
  • Bronchodilator
  • Onset 5-15 minutes
  • Watch for tachycardia – usually dose related
  • To be effective, the patient must be coached while inhaling the medication
    • Slow down the breathing
    • Begin to take deeper breathes
    • Hold the breath in to enhance medication absorption
  • Useful to expand the alveoli space to allow more surface space for oxygen exchange
  • To be used simultaneously with drug therapy
  • Watch for vasodilation and drop in blood pressure
    • Occurs with all therapies used for pulmonary edema (Nitroglycerin, Lasix, Morphine)
  • If indicated in pulmonary edema, use it
  • Call for Medical Control orders in symptomatic COPD (wheezing)
  • Patient will need coaching to get use to the tight fitting mask
  • Patient will need encouragement at least the first few minutes to tolerate the mask
    • CPAP is effective within a few minutes and the symptoms dramatically begin to improve quickly
  • CPAP will use up portable O2 cylinders quickly
    • Be prepared to switch portable tanks when not using the fixed unit in the ambulance
whisperflow cpap device
Whisperflow CPAP Device

Mask, head straps,

CPAP valve

Generator and

1 way filter

case scenario 1
Case Scenario #1
  • It is a cold January morning and 911 is called for a “woman down”.
  • Wind chill 20 degrees below zero
  • Patient is 89 y/o female who apparently slipped on the ice while retrieving mail
  • Unconscious and unresponsive
  • Extremities cold to the touch; skin pale
  • VS: B/P unobtainable; P – 50 & weak; R – 8
  • How do you handle this call?
case scenario 1 discussion
Case Scenario #1 - Discussion
  • Scene is not safe; EMS in danger due to the elements
  • Use C-spine immobilization
  • Move patient into ambulance
  • Assist ventilations with BVM
  • Remove wet clothing, cover with blanket, turn up rig heat
  • Transport for re-warming from the body’s core outward
case scenario 2
Case Scenario #2
  • Your patient is a 28 y/o female running in a race.
  • The temp is 960F and the humidity is 70%
  • The patient complains of leg cramps and abdominal pain.
  • Assessment: diaphoretic, skin cool & pale
  • VS: B/P 100/66; P – 128 weak; R – 26 regular
  • What do you think and what is your action plan?
case scenario 2 discussion
Case Scenario #2 Discussion
  • Patient most likely has heat cramps
    • Excessive loss of salt and water from sweating
  • Move to a cool environment
  • Acceptable practices:
    • Placing cool towels on patient
    • Fanning the patient to increase air currents
    • Allowing the patient to drink an electrolyte drink (ie: sports drink)
      • Drinking water without salt worsens the cramps
  • Transport
case scenario 3
Case Scenario #3
  • You are on the scene of a 16 y/o male who fell into the water while canoeing. He was found 45 minutes later lying face down. The water temperature is approximately 500F. He is pulseless and apneic. Friends have started CPR.
  • What do you think and what interventions are appropriate?
case scenario 3 discussion
Case Scenario #3 Discussion
  • Cold water drowning
  • Continue CPR
    • Resuscitation may be possible after extended periods of time in cold water
  • After placing the patient on a monitor, follow the appropriate protocol
  • Follow c-spine precautions restricting motion of the spine
case scenario 4
Case Scenario #4
  • A 28 y/o male was diving with friends. He was found floating face up in the water.
  • Patient complains of tightness in his chest and weakness in his right arm and leg
  • VS: B/P 110-78; P – 82 regular and strong; R – 22 and labored
  • What do you think and what interventions are appropriate?
case scenario 4 discussion
Case Scenario #4 Discussion
  • This patient most likely is suffering from an air embolism
  • Arterial air embolism occurs when a diver holds their breath while ascending
    • Air in the alveoli expand and tear the alveolar walls
    • Air enters the pulmonary circulation
    • Air is returned to the heart and pumped into the systemic circulation where emboli obstruct blood flow
case scenario 4 discussion cont d
Case Scenario #4 Discussion cont’d
  • Administer O2 via non-rebreather mask
  • Transport supine
    • Do not place the patient in any form of a sitting position – air rises
    • Need to prevent air from traveling to the brain
  • IV as precaution
    • Fluid rate at keep open
case scenario 5
Case Scenario #5
  • You are dispatched to a parking lot at 1530 and find a 2 y/o male unresponsive in the father’s arms
  • The child was left sleeping in the car with the windows rolled up
  • Temperature is 850F with 88% humidity
  • Patient is unresponsive; skin hot, dry, and red
  • Lips are a bluish gray color
  • Extremities mottled with a cap refill > 2 sec
  • VS: P - > 200; R – 70 and shallow
  • What do you think, what is your action?
case scenario 5 discussion
Case Scenario #5 Discussion
  • Heat stroke
    • Hot, dry, red skin; unresponsive with history of being in a closed car
  • This is a life threatening condition
  • Resp rate of 70 indicates respiratory failure
    • Inadequate tidal volume at this rate
    • Patient will tire before long
  • Cardiac rate >200 too fast for an adequate cardiac output
  • Extreme body temp increases the metabolic demand in the body on all organ systems
case scenario 5 cont d
Case Scenario #5 cont’d
  • Begin to assist ventilations with supplemental O2
  • Strip off clothing, turn up the air conditioner, place wet towels and cold packs on the patient
  • IV access
    • Consider IO
    • Fluid challenge 20 ml/kg
  • If peds patient begins to shiver, administer Valium
    • 0.2 mg/kg IVP/IO over 2 minutes every 15 minutes or until shivering stops
  • Bledsoe, B. Porter, R., Cherry, R. Paramedic Care Principles and Practices. Volume 3
  • Dalton, A., Walker, R. Mosby’s Paramedic Refresher and Review. Elsevier Mosby. 2006.
  • Limmer, D., O’Keefe, M. Brady Emergency Care 10th Edition
  • Nagel, K., Coker, N. EMT-Basic Review – A Case Based Approach. Elsevier Mosby. 2005.
  • Region X SOP’s. March 2007, Amended January 1, 2008
  • www.epipen.com