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DOT National Standard
EMT-Intermediate/85 RefresherDOT National Standard
EMT-Intermediate/85 Refresher
Welcome!
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• 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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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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• 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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• 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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– 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.