first responder workshop 2010 jim holliman, m.d., f.a.c.e.p. program manager, afghanistan healthcare...

First Responder First Responder Workshop 2010 Workshop 2010

Jim Holliman, M.D., F.A.C.E.P.Jim Holliman, M.D., F.A.C.E.P.Program Manager, Afghanistan Healthcare Program Manager, Afghanistan Healthcare SectorSector Reconstruction ProjectReconstruction ProjectCenter for Disaster and Humanitarian Center for Disaster and Humanitarian AssistanceAssistance MedicineMedicineUniformed Services University of the Health Uniformed Services University of the Health SciencesSciencesBethesda, Maryland, U.S.A.Bethesda, Maryland, U.S.A.

Goals of This WorkshopGoals of This Workshop

Using a case - based format for 20 Using a case - based format for 20 of the common types of cases of the common types of cases seen by first responders :seen by first responders :Present critical actions that should Present critical actions that should be done for each casebe done for each case

Review pitfalls to avoid on each Review pitfalls to avoid on each casecase

Have a two - way discussion of Have a two - way discussion of other aspects of each caseother aspects of each case

Cases to be Presented in Cases to be Presented in this Workshopthis Workshop

Cardiac arrestCardiac arrestBurnsBurnsElectrocutionElectrocutionChest painChest painStrokeStrokeDyspneaDyspneaInsecticide Insecticide poisoningpoisoning

Medication overdoseMedication overdoseMultiple traumaMultiple traumaPediatric traumaPediatric trauma

Precipitous childbirthPrecipitous childbirthHeat illnessHeat illnessAcute psychosisAcute psychosisObvious fatalityObvious fatalitySnakebiteSnakebiteComaComaShockShockNear-drowningNear-drowningAllergic reactionAllergic reactionSeizureSeizure

Case 1Case 1Cardiac ArrestCardiac Arrest

65 year old male65 year old maleFamily called because he had Family called because he had chest painchest pain

Lying in bed in homeLying in bed in homeApneic, cyanotic, no pulseApneic, cyanotic, no pulseHas history of "heart problems" Has history of "heart problems" and "colon cancer 12 years ago" and "colon cancer 12 years ago" according to the familyaccording to the family

Cardiac ArrestCardiac ArrestCritical ActionsCritical Actions

Verify presence of cardiac arrestVerify presence of cardiac arrestQuickly start CPRQuickly start CPRFind out quickly if the patient has a Find out quickly if the patient has a "Do not attempt resuscitation status" "Do not attempt resuscitation status" certified by their doctorcertified by their doctor

Move quickly to ambulanceMove quickly to ambulanceContact advanced medical help Contact advanced medical help (doctor or ambulance with defibrillator (doctor or ambulance with defibrillator if available)if available)

Rapid transport to closest hospital Rapid transport to closest hospital

Cardiac ArrestCardiac ArrestPitfalls to AvoidPitfalls to Avoid

Not checking the resuscitation status Not checking the resuscitation status of the patientof the patient

Taking a detailed history before Taking a detailed history before starting resuscitation effortsstarting resuscitation efforts

Not considering hypothermiaNot considering hypothermiaNot checking for signs of injuryNot checking for signs of injuryNot notifying the receiving medical Not notifying the receiving medical facility as early as possiblefacility as early as possible

Expecting a high success rateExpecting a high success rate

Case 2 Case 2 BurnsBurns

28 year old male28 year old maleWas cleaning motor with gasoline Was cleaning motor with gasoline when it explodedwhen it exploded

The table and curtain in the room also The table and curtain in the room also caught fire ; the room is smokycaught fire ; the room is smoky

Second and third degree burns of face, Second and third degree burns of face, neck, chest, and armsneck, chest, and arms

Awake and alert but coughing Awake and alert but coughing frequentlyfrequently

Pulse 120, resps. 20, BP 136 / 88Pulse 120, resps. 20, BP 136 / 88

Burns Burns Critical ActionsCritical Actions

Protect yourself if the fire is still burningProtect yourself if the fire is still burningRemove patient from smoky environment Remove patient from smoky environment quicklyquickly

Airway / breathing / circulation ("ABC") Airway / breathing / circulation ("ABC") assessmentassessment

Get all burned clothes off the patientGet all burned clothes off the patientCover with clean dry sheetsCover with clean dry sheetsStart oxygen if any potential airway problem Start oxygen if any potential airway problem or smoke inhalationor smoke inhalation

Copious irrigation with water if a chemical Copious irrigation with water if a chemical burnburn

Rapid transport to appropriate hospitalRapid transport to appropriate hospital

BurnsBurnsPitfalls to AvoidPitfalls to Avoid

Not removing all potentially smoldering Not removing all potentially smoldering clothes & stopping the burning processclothes & stopping the burning process

Continued soaking of a large burn area Continued soaking of a large burn area thus making the patient hypothermicthus making the patient hypothermic

Mis-estimating the extent of the burn Mis-estimating the extent of the burn Not recognizing the potential for airway Not recognizing the potential for airway compromisecompromise

Not recognizing other associated Not recognizing other associated traumatic injuriestraumatic injuries

Case 3Case 3ElectrocutionElectrocution

24 year old male24 year old maleWas working on a roof 4 meters high when he Was working on a roof 4 meters high when he touched an overhead electric power line, was touched an overhead electric power line, was shocked, and fell off the roofshocked, and fell off the roof

Was initially unconscious, now is awake but Was initially unconscious, now is awake but confusedconfused

Has entrance burns on one hand and his Has entrance burns on one hand and his sandals are smolderingsandals are smoldering

Complains of limb and back painComplains of limb and back painPulse 96, resps. 20, BP 94 / 64Pulse 96, resps. 20, BP 94 / 64

ElectrocutionElectrocutionCritical ActionsCritical Actions

Turn off the electric power or push the Turn off the electric power or push the patient off the electric source with an patient off the electric source with an object that does not conduct electricityobject that does not conduct electricity

ABC assessmentABC assessmentDetermine if high voltage (> 1000 volts)Determine if high voltage (> 1000 volts)Assess for other associated injuriesAssess for other associated injuriesRapid transport to hospital (may require Rapid transport to hospital (may require very large amounts of intravenous fluid)very large amounts of intravenous fluid)

Fairly good chance of success even if Fairly good chance of success even if prolonged CPR requiredprolonged CPR required

ElectrocutionElectrocutionPitfalls to AvoidPitfalls to Avoid

Not checking for associated trauma Not checking for associated trauma such as spinal injury, joint such as spinal injury, joint dislocations, etc., and not dislocations, etc., and not performing appropriate spinal performing appropriate spinal immobilization or splintingimmobilization or splinting

Not appreciating that there may be Not appreciating that there may be large amounts of muscle damage large amounts of muscle damage beneath unburned skinbeneath unburned skin

Not checking for exit woundsNot checking for exit wounds

Case 4Case 4Chest PainChest Pain

48 year old female48 year old femaleComplains of anterior chest pain with Complains of anterior chest pain with radiation to the neck for 2 hoursradiation to the neck for 2 hours

No previous history of heart diseaseNo previous history of heart diseaseAwake and alert, diaphoreticAwake and alert, diaphoreticAlso complains of shortness of breathAlso complains of shortness of breathNo allergiesNo allergiesHusband is reluctant for her to go to Husband is reluctant for her to go to hospitalhospital


Chest PainChest PainCritical ActionsCritical Actions

Assume a life - threatening cause is present Assume a life - threatening cause is present until definitively proven otherwiseuntil definitively proven otherwise

ABC assessmentABC assessmentStart oxygen if availableStart oxygen if availableGive an aspirin (80 to 500 milligrams) if not Give an aspirin (80 to 500 milligrams) if not allergic to aspirin or nonsteroidals, and allergic to aspirin or nonsteroidals, and cardiac ischemia is suspectedcardiac ischemia is suspected

Rapid transport to a hospital with cardiology Rapid transport to a hospital with cardiology capabilitiescapabilities

Chest PainChest PainPitfalls to AvoidPitfalls to Avoid

Not suspecting cardiac ischemia in younger Not suspecting cardiac ischemia in younger or female patientsor female patients

Not considering cardiac ischemia in elderly Not considering cardiac ischemia in elderly patients with vague symptoms (remember patients with vague symptoms (remember many elderly patients with acute myocardial many elderly patients with acute myocardial infarction will NOT have chest pain)infarction will NOT have chest pain)

Taking the patient to a medical facility that Taking the patient to a medical facility that does not have advanced cardiac caredoes not have advanced cardiac care

Not starting oxygen or giving aspirinNot starting oxygen or giving aspirin

Case 5 Case 5 StrokeStroke

60 year old male60 year old maleSuddenly developed weaknes of the Suddenly developed weaknes of the left side and "garbled speech" left side and "garbled speech" according to the family 30 minutes according to the family 30 minutes agoago

The family does not know what The family does not know what medicines he takesmedicines he takes

He is sleepy but arousable, and his He is sleepy but arousable, and his speech is difficult to understandspeech is difficult to understand


StrokeStrokeCritical ActionsCritical Actions

ABC assessment, may need airway ABC assessment, may need airway management if level of consciousness is management if level of consciousness is depresseddepressed

Check fingerstick blood sugarCheck fingerstick blood sugarCheck pulse oximetry if availableCheck pulse oximetry if availableStart oxygen if availableStart oxygen if availableDetermine time of onset of symptomsDetermine time of onset of symptomsRapid transport to a hospital with a Rapid transport to a hospital with a computed tomography scannercomputed tomography scanner

Repeat the neurological exam at frequent Repeat the neurological exam at frequent intervalsintervals

StrokeStrokePitfalls to AvoidPitfalls to Avoid

Not checking for hypoxia or hypoglycemia Not checking for hypoxia or hypoglycemia earlyearly

Not protecting the patient's airway if they Not protecting the patient's airway if they have a depressed level of consciousnesshave a depressed level of consciousness

Not checking for associated injury (the Not checking for associated injury (the patient may fall down from sudden patient may fall down from sudden weakness)weakness)

Overtreating elevated blood pressureOvertreating elevated blood pressureNot repeating the neurologic exam to see if Not repeating the neurologic exam to see if there is worsening or improvement of the there is worsening or improvement of the patient's symptoms and signspatient's symptoms and signs

Case 6 Case 6 DyspneaDyspnea

44 year old male44 year old maleLong history of smoking cigarettesLong history of smoking cigarettesAlso history of asthma and pneumoniaAlso history of asthma and pneumoniaNo allergiesNo allergiesUses salbutamol inhaler as neededUses salbutamol inhaler as neededComplains of progressive shortness of Complains of progressive shortness of breath and frequent cough for the past breath and frequent cough for the past several days ; no chest painseveral days ; no chest pain

Pulse is 112, resp. rate 32, BP 155 / 100Pulse is 112, resp. rate 32, BP 155 / 100

DyspneaDyspneaCritical ActionsCritical Actions

ABC assessment ; check and record pulse ABC assessment ; check and record pulse oximetry if availableoximetry if available

Start oxygenStart oxygenIf the patient is wheezing, have him use his If the patient is wheezing, have him use his metered dose inhaler meds if available (this metered dose inhaler meds if available (this is safe even if the dyspnea has a cardiac is safe even if the dyspnea has a cardiac cause)cause)

If not hypotensive, don't force the patient If not hypotensive, don't force the patient to lie flatto lie flat

Rapid transport to an appropriate medical Rapid transport to an appropriate medical facilityfacility

DyspneaDyspneaPitfalls to AvoidPitfalls to Avoid

Not starting oxygen for fear of Not starting oxygen for fear of "suppressing respiratory drive""suppressing respiratory drive"

Not considering a cardiac cause Not considering a cardiac cause Dismissing hyperventilation as just Dismissing hyperventilation as just due to anxietydue to anxiety

Not providing aggressive airway Not providing aggressive airway management for patients with a management for patients with a depressed mental statusdepressed mental status

Case 7Case 7Insecticide (Organophosphate) Insecticide (Organophosphate) PoisoningPoisoning

30 year old female30 year old femaleIngested liquid insecticide in a Ingested liquid insecticide in a suicide attemptsuicide attempt

Actively vomiting, diaphoretic, Actively vomiting, diaphoretic, drooling, complaining of shortness drooling, complaining of shortness of breathof breath

Vomitus all over the patient's Vomitus all over the patient's clothesclothes

Pulse 90, resp. rate 36, BP 100 / 60Pulse 90, resp. rate 36, BP 100 / 60

Insecticide PoisoningInsecticide PoisoningCritical ActionsCritical Actions

Protect yourself ; remember the patient's clothes Protect yourself ; remember the patient's clothes may be contaminated and all the patient's body may be contaminated and all the patient's body fluids (sputum, emesis, etc.) may contain the fluids (sputum, emesis, etc.) may contain the insecticide ; use universal precautionsinsecticide ; use universal precautionsMake sure the ambulance is well ventilated (to Make sure the ambulance is well ventilated (to prevent your exposure to "off-gassing")prevent your exposure to "off-gassing")

ABC assessment ; start oxygenABC assessment ; start oxygenRemove all the patient's clothes and footwear Remove all the patient's clothes and footwear and bag these in plastic ; decontaminate the skin and bag these in plastic ; decontaminate the skin by irrigation with water if the skin was exposed by irrigation with water if the skin was exposed to powder or liquidto powder or liquid

Rapid transport to appropriate medical facilityRapid transport to appropriate medical facility

Insecticide PoisoningInsecticide PoisoningPitfalls to AvoidPitfalls to Avoid

Getting yourself poisoned by skin exposure Getting yourself poisoned by skin exposure to contaminated clothes or vomitus or to contaminated clothes or vomitus or breathing off-gassed vaporsbreathing off-gassed vapors

Failing to decontaminate the patient prior Failing to decontaminate the patient prior to entering the ambulanceto entering the ambulance

Not assessing for other exposures or Not assessing for other exposures or ingestantsingestants

Not providing supportive care (oxygen, Not providing supportive care (oxygen, suction of airway secretions, etc.)suction of airway secretions, etc.)

Not properly disposing of contaminated Not properly disposing of contaminated clothes or footwearclothes or footwear

Case 8Case 8Medication OverdoseMedication Overdose

18 year old female18 year old femaleHistory of depression and prior History of depression and prior suicide attemptssuicide attempts

Taking several antidepressant Taking several antidepressant meds but family does not know meds but family does not know the namesthe names

Took "a large number" of multiple Took "a large number" of multiple pills about one hour agopills about one hour ago

Now drowsy but arousableNow drowsy but arousablePulse 120, resp. rate 14, BP 104 / Pulse 120, resp. rate 14, BP 104 / 5555

Medication OverdoseMedication OverdoseCritical ActionsCritical Actions

ABC assessmentABC assessmentTry to identify what meds and how many Try to identify what meds and how many the patient took and the time of ingestion the patient took and the time of ingestion ; collect all pill bottles in the home and ; collect all pill bottles in the home and bring these to the hospitalbring these to the hospital

Monitor the patient closely ; sudden Monitor the patient closely ; sudden deterioration may occurdeterioration may occur

Try to determine if the ingestion was Try to determine if the ingestion was accidental or suicidalaccidental or suicidal

Medication OverdoseMedication OverdosePitfalls to AvoidPitfalls to Avoid

Trying to make the patient vomit (just Trying to make the patient vomit (just predisposes to aspiration)predisposes to aspiration)

Not identifying all co-ingestantsNot identifying all co-ingestantsNot preventing the patient from accessing Not preventing the patient from accessing other items to use in another suicide other items to use in another suicide attempt ; not closely monitoring the attempt ; not closely monitoring the patient at all timespatient at all times

Not evaluating the airway or providing Not evaluating the airway or providing oxygen if the patient has a depressed oxygen if the patient has a depressed mental statusmental status

Case 9 Case 9 Multiple TraumaMultiple Trauma

30 year old male truck driver30 year old male truck driverTruck ran off road at high speed and Truck ran off road at high speed and rolled overrolled over

Patient was thrown 5 meters from the Patient was thrown 5 meters from the vehiclevehicle

Unconscious, several scalp lacerations Unconscious, several scalp lacerations actively bleeding, abrasions over chest actively bleeding, abrasions over chest and abdomen, deformity of left thigh and and abdomen, deformity of left thigh and ankleankle


Multiple TraumaMultiple TraumaCritical ActionsCritical Actions

If motor vehicle crash, assess scene for If motor vehicle crash, assess scene for rescuer safety (is there need for water or rescuer safety (is there need for water or foam to cover spilled gasoline or hot foam to cover spilled gasoline or hot engine, etc.)engine, etc.)

ABC assessment ; start oxygenABC assessment ; start oxygenControl external bleeding with direct Control external bleeding with direct pressurepressure

Immobilize spine and apply limb splintsImmobilize spine and apply limb splintsLimit on-scene time as much as possibleLimit on-scene time as much as possibleMake sure someone checks the scene for Make sure someone checks the scene for other "hidden" victimsother "hidden" victims

Rapid transport to trauma centerRapid transport to trauma center

Multiple TraumaMultiple TraumaPitfalls to AvoidPitfalls to Avoid

Not prioritizing the "ABC's"Not prioritizing the "ABC's"Being inefficient and taking too much time Being inefficient and taking too much time at the scene ; performing actions at the at the scene ; performing actions at the scene that could wait until the patient is in scene that could wait until the patient is in the ambulancethe ambulance

Not having someone search the scene for Not having someone search the scene for other victimsother victims

Not notifying the receiving medical facility Not notifying the receiving medical facility earlyearly

Not taking measures to prevent Not taking measures to prevent hypothermiahypothermia

Not frequently reassessing the patientNot frequently reassessing the patient

Case 10Case 10Pediatric TraumaPediatric Trauma

5 year old male5 year old maleWalking across road and hit by car at high Walking across road and hit by car at high speedspeed

Thrown 6 meters by the impactThrown 6 meters by the impactReported initial loss of consciousnessReported initial loss of consciousnessNow sceamingNow sceamingBleeding lacerations of scalp, right arm, Bleeding lacerations of scalp, right arm, and left flank, deformity left thighand left flank, deformity left thigh


Pediatric TraumaPediatric TraumaCritical ActionsCritical Actions

Scene safety and ABC assessment ; Scene safety and ABC assessment ; oxygenoxygen

Stop external bleeding with direct Stop external bleeding with direct pressure dressingspressure dressings

Try to notify the parents if they are not at Try to notify the parents if they are not at the scene and find out the patient's the scene and find out the patient's medical history, allergies, and current medical history, allergies, and current medsmedsLimit on-scene time as much as possible Limit on-scene time as much as possible howeverhowever

Reassure and try to verbally calm the childReassure and try to verbally calm the childRapid transport to (pediatric) trauma Rapid transport to (pediatric) trauma centercenter

Pediatric TraumaPediatric TraumaPitfalls to AvoidPitfalls to Avoid

Not prioritizing the "ABC's"Not prioritizing the "ABC's"Focusing on one obvious injury and not Focusing on one obvious injury and not performing a complete assessmentperforming a complete assessment

Not taking measures to prevent Not taking measures to prevent hypothermiahypothermia

Not providing reassurance to the childNot providing reassurance to the childUsing terminology the child does not Using terminology the child does not understandunderstand

Taking the child to a facility not capable of Taking the child to a facility not capable of pediatric carepediatric care

Case 11Case 11Precipitous ChildbirthPrecipitous Childbirth

30 year old female30 year old female5 prior pregnancies with vaginal 5 prior pregnancies with vaginal deliveriesdeliveries

Started having strong contractions 2 Started having strong contractions 2 hours ago, now every 2 minuteshours ago, now every 2 minutes

"Water broke" one hour ago"Water broke" one hour agoPulse 110, resp. rate 24, BP 110 / 60Pulse 110, resp. rate 24, BP 110 / 60Now says she feels as if she must use the Now says she feels as if she must use the toilettoilet

Precipitous ChildbirthPrecipitous ChildbirthCritical ActionsCritical Actions

ABC assessmentABC assessmentStart oxygen if possible fetal distress Start oxygen if possible fetal distress (prolapsed cord, breech crowning, etc.)(prolapsed cord, breech crowning, etc.)

Position mother so if baby is suddenly Position mother so if baby is suddenly delivered, the baby will not fall or be delivered, the baby will not fall or be injuredinjured

Don't insert anything in the vagina (could Don't insert anything in the vagina (could stir up bleeding)stir up bleeding)

Expose the perineum if any possibility of Expose the perineum if any possibility of crowningcrowning

Rapid transport to obstetric facilityRapid transport to obstetric facility

Precipitous ChildbirthPrecipitous ChildbirthPitfalls to AvoidPitfalls to Avoid

Not safely positioning the motherNot safely positioning the motherNot recognizing urge to void or Not recognizing urge to void or defecate as a sign of imminent deliverydefecate as a sign of imminent delivery

Not starting oxygen if any possibility of Not starting oxygen if any possibility of fetal distressfetal distress

Not providing reassurance to the Not providing reassurance to the mother and familymother and family

Not notifying the receiving facility earlyNot notifying the receiving facility early

Case 12Case 12Heat IllnessHeat Illness

68 year old male68 year old maleFound unconscious in very hot poorly Found unconscious in very hot poorly ventilated upstairs room in an apartment ventilated upstairs room in an apartment bulidingbuliding

Outside air temperature > 40 degrees Outside air temperature > 40 degrees Centigrade for the past 5 daysCentigrade for the past 5 days

Responds only to painful stimuliResponds only to painful stimuliSkin dry and very warmSkin dry and very warmPulse 112, Resps. 22, BP 90 / 60Pulse 112, Resps. 22, BP 90 / 60

Heat IllnessHeat IllnessCritical ActionsCritical Actions

RecognitionRecognitionABC assessmentABC assessmentMeasure temperature if thermometer Measure temperature if thermometer availableavailable

Check fingerstick blood sugar if abnormal Check fingerstick blood sugar if abnormal mental statusmental status

Start cooling measures earlyStart cooling measures earlyScalp, axillary, and groin ice packsScalp, axillary, and groin ice packsWater mist and fanWater mist and fanTry to avoid causing shiveringTry to avoid causing shivering

Rapid transport to medical facilityRapid transport to medical facility

Heat IllnessHeat IllnessPitfalls to AvoidPitfalls to Avoid

Attributing altered mental status from Attributing altered mental status from hyperthermia to something else such as hyperthermia to something else such as alcohol intoxicationalcohol intoxication

Not starting cooling measures as part of Not starting cooling measures as part of initial resuscitationinitial resuscitation

Excessive fluid treatment for classic Excessive fluid treatment for classic heatstrokeheatstroke

Not anticipating multiorgan dysfunctionNot anticipating multiorgan dysfunctionCausing excess shivering from cooling Causing excess shivering from cooling measures (shivering may make the measures (shivering may make the patient's temperature go even higher)patient's temperature go even higher)

Case 13Case 13Acute PsychosisAcute Psychosis

32 year old male32 year old maleFound running in circles in the streetFound running in circles in the streetYelling loudly "the spiders are after me ! "Yelling loudly "the spiders are after me ! "Previous history of "psychiatric problems"Previous history of "psychiatric problems"No allergies according to familyNo allergies according to familyStopped taking his haloperidol recentlyStopped taking his haloperidol recentlyPulse 120, Resps. 24, BP 160 / 100Pulse 120, Resps. 24, BP 160 / 100

Acute PsychosisAcute PsychosisCritical ActionsCritical Actions

Protect yourself from injury if the patient is Protect yourself from injury if the patient is potentially combativepotentially combative

ABC assessmentABC assessmentMay require physical restraints for both May require physical restraints for both patient safety and rescuer safetypatient safety and rescuer safety

Check for hypoxia and hypoglycemiaCheck for hypoxia and hypoglycemiaDetermine if alcohol or illicit drug ingestion Determine if alcohol or illicit drug ingestion may be contributingmay be contributing

Make sure the patient is not hyperthermic Make sure the patient is not hyperthermic (this can accompany amphetamine or (this can accompany amphetamine or cocaine use)cocaine use)

Acute PsychosisAcute PsychosisPitfalls to AvoidPitfalls to Avoid

Not assessing for "reversible" or medical Not assessing for "reversible" or medical causes of the psychosiscauses of the psychosis

Not restraining the patient safelyNot restraining the patient safelySafest approach to the combative patient is Safest approach to the combative patient is to wait until 4 or 5 first responders are to wait until 4 or 5 first responders are available before closely approaching the available before closely approaching the patientpatient

Trying to verbally reason with the patientTrying to verbally reason with the patientNot searching the restrained patient for Not searching the restrained patient for weaponsweapons

Case 14Case 14Obvious FatalityObvious Fatality

85 year old male85 year old maleLast seen by family over 12 hours Last seen by family over 12 hours agoago

Found by family unresponsive in Found by family unresponsive in bedbed

History of metastatic cancer and History of metastatic cancer and advanced cardiac diseaseadvanced cardiac disease

No pulse or resps.No pulse or resps.Dependent lividity notedDependent lividity noted

Obvious FatalityObvious FatalityCritical ActionsCritical Actions

Don't start any resuscitation if death criteria Don't start any resuscitation if death criteria clearly present (dependent lividity, rigor clearly present (dependent lividity, rigor mortis, initial decomposition, major mortis, initial decomposition, major dismemberment or open head injury dismemberment or open head injury incompatible with life, etc.)incompatible with life, etc.)

Notify appropriate local authoritiesNotify appropriate local authoritiesCounsel the familyCounsel the familyCover the body from public view and treat the Cover the body from public view and treat the body with cultural respectbody with cultural respect

Don't leave the family until responsibilty for Don't leave the family until responsibilty for the body has been transferred to local the body has been transferred to local authorities or a funeral directorauthorities or a funeral director

Obvious FatalityObvious FatalityPitfalls to AvoidPitfalls to Avoid

Overlooking resuscitatable hypothermiaOverlooking resuscitatable hypothermiaMoving the body or altering the scene if Moving the body or altering the scene if any possibility of homicideany possibility of homicide

Leaving the family before arrangements Leaving the family before arrangements for management of the body are verifiedfor management of the body are verified

Not notifying the local authorities or the Not notifying the local authorities or the patient's regular doctorpatient's regular doctor

Continuing resuscitation attempts when Continuing resuscitation attempts when started by others but when clearly started by others but when clearly inappropriateinappropriate

Case 15Case 15SnakebiteSnakebite

18 year old male18 year old maleWas walking through tall grass Was walking through tall grass when bitten by a large black snake when bitten by a large black snake on the right leg about one half on the right leg about one half hour agohour ago

Did not see what kind of snake it Did not see what kind of snake it waswas

Now complaining of nausea and Now complaining of nausea and vomiting and feeling weakvomiting and feeling weak


SnakebiteSnakebiteCritical ActionsCritical Actions

Move patient a safe distance from Move patient a safe distance from the snake if it is still in the vicinitythe snake if it is still in the vicinity

ABC assessmentABC assessmentTry to identify the snake type but Try to identify the snake type but don't take any risk to do sodon't take any risk to do so

Apply "lymphatic" tourniquet Apply "lymphatic" tourniquet above the bite site (snug but not above the bite site (snug but not too tight)too tight)

Rapid transport to a medical Rapid transport to a medical facility that has antiveninfacility that has antivenin

SnakebiteSnakebitePitfalls to AvoidPitfalls to Avoid

Trying to capture the snake and Trying to capture the snake and bring it also to the hospitalbring it also to the hospital

Excessive ice treatment of the Excessive ice treatment of the bite sitebite siteCan cause tissue damage like Can cause tissue damage like frostbitefrostbite

Incising the bite site to try to Incising the bite site to try to release venomrelease venom

Not recognizing signs of systemic Not recognizing signs of systemic envenomationenvenomation

Case 16Case 16ComaComa

35 year old male35 year old maleFound by coworkers lying on the floor in Found by coworkers lying on the floor in a garage, last seen by them two hours a garage, last seen by them two hours agoago

No histroy of alcohol or illicit drug useNo histroy of alcohol or illicit drug useUnconscious, responds to pain only by Unconscious, responds to pain only by limb withdrawllimb withdrawl

Pulse 60, resps. 12 and snoring, BP Pulse 60, resps. 12 and snoring, BP 166 / 100166 / 100

Coma Coma Critical ActionsCritical Actions

ABC assessmentABC assessmentMay benefit from nasal airwayMay benefit from nasal airwayStart oxygen routinelyStart oxygen routinely

Neck and spine immobilization if Neck and spine immobilization if any possibility of traumaany possibility of trauma

Check for hypoxia and Check for hypoxia and hypoglycemiahypoglycemiaConsider also carbon monoxide Consider also carbon monoxide intoxication, and hypothermia or intoxication, and hypothermia or hyperthermiahyperthermia


ComaComaPitfalls to AvoidPitfalls to Avoid

Failure to consider possibility of spine Failure to consider possibility of spine injury and provide spine immobilizationinjury and provide spine immobilization

Failure to check for hypoxia or Failure to check for hypoxia or hypoglycemiahypoglycemia

Attributing coma just to alcohol Attributing coma just to alcohol intoxicationintoxication

Taking the patient to a medical facility Taking the patient to a medical facility without a computed tomography (CT) without a computed tomography (CT) scannerscanner

Case 17Case 17ShockShock

20 year old female20 year old femaleCalled ambulance because of Called ambulance because of severe lower abdominal painsevere lower abdominal pain

Last menstrual period 7 weeks Last menstrual period 7 weeks agoago

No prior abdominal problemsNo prior abdominal problemsNo current meds or allergiesNo current meds or allergiesPulse 92, resps. 22, BP 60 / 30Pulse 92, resps. 22, BP 60 / 30Skin pale and diaphoreticSkin pale and diaphoretic

ShockShockCritical ActionsCritical Actions

ABC assessmentABC assessmentStart oxygen routinelyStart oxygen routinelyStop any external blood loss with Stop any external blood loss with pressure dressingspressure dressings

Elevate legsElevate legsRapid transport to medical facilityRapid transport to medical facility

ShockShockPitfalls to AvoidPitfalls to Avoid

Not diagnosing shock just because Not diagnosing shock just because the patient has a near normal the patient has a near normal blood pressure or pulseblood pressure or pulse

Not starting oxygenNot starting oxygenNot rechecking the patient's vital Not rechecking the patient's vital signs frequentlysigns frequently

Not notifying the receiving facility Not notifying the receiving facility earlyearly

Case 18Case 18Near-drowningNear-drowning

12 year old male12 year old maleFell off bridge into lakeFell off bridge into lakeWas submerged 5 to 10 minutesWas submerged 5 to 10 minutesWas unconscious when pulled Was unconscious when pulled from the waterfrom the water

Now drowsy but arousable, Now drowsy but arousable, coughing frequentlycoughing frequently


Near-drowningNear-drowningCritical ActionsCritical Actions

ABC assessmentABC assessmentMay need to suction upper airwayMay need to suction upper airwayEven prolonged CPR may be Even prolonged CPR may be successful (particularly in cold water successful (particularly in cold water near-drownings)near-drownings)

Start oxygen if patient still Start oxygen if patient still symptomaticsymptomatic

Don't induce vomitingDon't induce vomitingAssess for associated traumaAssess for associated traumaCheck for hypoxia and hypoglycemia if Check for hypoxia and hypoglycemia if altered mental statusaltered mental status


Near-drowningNear-drowningPitfalls to AvoidPitfalls to Avoid

Doing CPR with the patient's head higher Doing CPR with the patient's head higher than the chest (after rescue from the water, than the chest (after rescue from the water, position patient parallel to shore line so position patient parallel to shore line so head and heart are at same level)head and heart are at same level)

Not checking for associated trauma (such as Not checking for associated trauma (such as neck injury from diving)neck injury from diving)

Performing the Heimlich maneuver routinely Performing the Heimlich maneuver routinely (it just predisposes to vomiting and (it just predisposes to vomiting and aspiration ; most patients do not have any aspiration ; most patients do not have any removable fluid in their airway)removable fluid in their airway)

Case 19Case 19Allergic ReactionAllergic Reaction

29 year old male 29 year old male Stung by wasp on left hand 15 Stung by wasp on left hand 15 minutes agominutes ago

Now complaining of throat Now complaining of throat tightness, difficulty breathing, and tightness, difficulty breathing, and diffuse itchy rashdiffuse itchy rash

Skin shows diffuse hivesSkin shows diffuse hivesLeft hand is very swollen and redLeft hand is very swollen and redPulse 124, resps. 22, BP 92 / 64Pulse 124, resps. 22, BP 92 / 64

Allergic ReactionAllergic ReactionCritical ActionsCritical Actions

ABC assessmentABC assessmentStart oxygen if in shockStart oxygen if in shockRemove stinger or insect if still imbeddedRemove stinger or insect if still imbeddedAdminister injectable epinephrine if patient Administer injectable epinephrine if patient has a self-treatment kithas a self-treatment kit

Administer oral antihistamine med if Administer oral antihistamine med if availableavailable

Administer aerosol treatment if wheezingAdminister aerosol treatment if wheezingIce pack to sting siteIce pack to sting siteRapid transport to medical facilityRapid transport to medical facility

Allergic ReactionAllergic ReactionPitfalls to AvoidPitfalls to Avoid

Not recognizing risk for airway Not recognizing risk for airway obstructionobstruction

Not stopping further exposure of Not stopping further exposure of the patient to the allergenthe patient to the allergen

Not rechecking the patient's vital Not rechecking the patient's vital signs frequentlysigns frequently

Case 20Case 20SeizureSeizure

18 year old male18 year old maleWas in a store when he was seen Was in a store when he was seen to fall to the floor and started to fall to the floor and started having a tonic-clonic gran mal having a tonic-clonic gran mal seizure which lasted about 5 seizure which lasted about 5 minutesminutes

No other history availableNo other history availableNow very drowsy with snoring Now very drowsy with snoring respirationsrespirations


SeizureSeizureCritical ActionsCritical Actions

ABC assessmentABC assessmentMay benefit from nasal airwayMay benefit from nasal airway

Assess for associated trauma (such as tongue Assess for associated trauma (such as tongue lacerations) and immobilize neck and spine if lacerations) and immobilize neck and spine if possible injury from fallpossible injury from fall

Check for hypoxia and hypoglycemiaCheck for hypoxia and hypoglycemiaPosition the patient to prevent injury if seizure Position the patient to prevent injury if seizure recursrecurs

Determine if any prior history of seizures or drug Determine if any prior history of seizures or drug or alcohol useor alcohol use

Transport to medical facility if patient not Transport to medical facility if patient not quickly back to normal mental status or if new quickly back to normal mental status or if new onset seizureonset seizure

SeizureSeizurePitfalls to AvoidPitfalls to Avoid

Not checking for associated Not checking for associated traumatrauma

Not starting oxygen if potentially Not starting oxygen if potentially hypoxichypoxic

Not determining what medications Not determining what medications or drugs the patient may have or drugs the patient may have takentaken

Failing to position the patient so Failing to position the patient so he will not injure himself if the he will not injure himself if the seizure recursseizure recurs

Overly aggressive use of a bite Overly aggressive use of a bite block thus damaging the teethblock thus damaging the teeth

First Responder WorkshopFirst Responder WorkshopSummarySummary

Always consider scene safety firstAlways consider scene safety firstThen always perform an "ABC" pattern Then always perform an "ABC" pattern patient assessmentpatient assessment

Try to quickly gather all relevant Try to quickly gather all relevant information about the patient at the scene ; information about the patient at the scene ; consider searching the scene for medication consider searching the scene for medication bottles to bring alongbottles to bring along

Decide on the medical facility destination Decide on the medical facility destination based on its capabilities to manage the based on its capabilities to manage the patientpatient

Notify the receiving facility earlyNotify the receiving facility early

first responder workshop 2010 jim holliman, m.d., f.a.c.e.p. program manager, afghanistan healthcare...

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