dot national standard emt-intermediate/85 refresher

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training

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DOT National Standard

EMT-Intermediate/85 RefresherDOT National Standard

EMT-Intermediate/85 Refresher

Welcome!


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are needed to see this picture.MEDICAL EMERGENCIES

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

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


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are needed to see this picture.MEDICAL EMERGENCIES

FROSTBITEFROSTBITE • Perspective• Pathophysiology• Epidemiology• PE & Diagnostic

Findings• S/S• Differential

considerations• Tx

• Perspective• Pathophysiology• Epidemiology• PE & Diagnostic

Findings• S/S• Differential

considerations• Tx


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perspective

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

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


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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

• 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


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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%)

• 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%)


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epidemiology• US

– Most cases of frostbite are mild (frostnip)– 12% of cases more severe

• US– Most cases of frostbite are mild (frostnip)– 12% of cases more severe


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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

• 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


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pathophysiology• Immediately after freezing & thawing,

an acid cascade forms & erythrostasis, which results in venule & arterial thrombosis– And subsequent ischemia, necrosis, dry

gangrene

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

gangrene


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are needed to see this picture.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

• First degree (frostnip)– Partial skin freezing– Erythema– Mild edema– Lack of blisters

• Pt complains of stinging & burning, followed by throbbing


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• 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

• 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


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• 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

• 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


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• 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

• 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


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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

• 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


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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

• 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


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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

• 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


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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

• 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


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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

• 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


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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

• 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


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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

• 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


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are needed to see this picture.Differential diagnosis• Peripheral vascular disease

• Cellulitis

• Dermatitis

• Trauma to an extremity

• Compartment syndrome (mimic or co-exist)

• Peripheral vascular disease

• Cellulitis

• Dermatitis

• Trauma to an extremity

• Compartment syndrome (mimic or co-exist)


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

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


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are needed to see this picture.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.

• 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.

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