![Page 1: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/1.jpg)
Environmental Emergencies part 1 Dr Kirsty Dunn FACEM Ballarat Base May 2014
![Page 2: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/2.jpg)
Environmental Emergencies
Heat and Cold Exposure
Burns, Electrical and Lightening injuries
Near Drowning and Submersion Syndromes
Barotrauma
Altitude
Envenomation
![Page 3: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/3.jpg)
Heat & Cold Exposure
Febrile Pt has huge DDx:
• Infection / sepsis / SIRS
• Toxicological – drugs of abuse / serotonin syndrome / neuroleptic malignant syndrome / malignant hyperthermia / delirium tremens
• Exposure – NAI (mandatory reporting)
• Exertional – heat exhaustion / heatstroke
![Page 4: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/4.jpg)
Hyperthermia
Heat Exhaustion
Heat Stroke
Heat Syncope
Heat Tetany
Heat Cramps
Prickly Heat
Heat Oedema
![Page 5: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/5.jpg)
Heat Exhaustion
Most common heat-related illness
Water and salt depletion
Dehydration without adequate fluid intake (ave. adult only drinks 2/3 losses due to perspiration)
Salts – sweat replaced by hypotonic soln
• hyponatraemia, hypochloraemia, low urinary chloride and sodium
Body Temp near NORMAL
![Page 6: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/6.jpg)
Heat Exhaustion
Ax- Lightheaded, fatigue, N, V, headache, myalgia, syncope, orthostasis, Sinus tachy, tachypnoea, diaphoresis, NORMAL mental status
Ix (not usually indicated) – transaminase elevn in 1-2000s eg marathon runners
Mx – rest out of sun, hydrolyte / Gatorade etc., ivf if vitals off. Home if young and well, admit if elderly for slow correction osmolarity 2 mOsm/hr
(cerebral oedema, hyponatraemia)
![Page 7: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/7.jpg)
Heat Stroke
Medical EMERGENCY
Definition is a TRIAD • Core temp >40
c
• CNS dysfunction
• Anhydrosis
Epidemics common in Australia
Fatalities every year – poor, elderly, alcoholics, schizophrenics.
![Page 8: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/8.jpg)
Predisposing RF’s Heat Stroke
Inc Heat Production
• Exertion, febrile illness, drugs (amphetamines, cocaine, aspirin)
External Heat Gain
• Hot and humid
Reduced ability to lose heat
• Dehydration, extremes age, obesity, neglect / inappropriate clothing
![Page 9: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/9.jpg)
Heat Stroke in the ED
Ax – irritable, bizarre behaviour, combative, hallucination ,seizure, coma, death.
Vitals – tachy, hypoT, Right heart Failure, +/- sweating *doesn’t differentiate b’wn H. exhaustion and H. stroke.
ARDS, encephalopathic, MOF, DIC, rhabdo, shock liver.
![Page 10: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/10.jpg)
Heat Stroke
Ix – FBC (haemoconcentration) • U&E )hyponatraemia, hypochloraemia, H/L
K, ARF
• LFT – transaminitis
• CK – rhabdo.
• FWT – myoglobinurea
• Coag’s – DIC
• Lactate – HAGMA
• ABG – resp. alkalosis
• CTB – r/o coagulopathic bleed / alternative Dx
![Page 11: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/11.jpg)
Heat Stroke
Mx – ABC’s, IVC, IVF, active cooling, core temp, avoid shivering
AIM is only 39
C to avoid overshoot
HDU admit
(Do not immerse in ice bath)
![Page 12: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/12.jpg)
Hypothermia
Mild 32-35
Moderate 28-32
Severe <28
![Page 13: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/13.jpg)
Key Temps in Hypothermia <32
C Osborne waves and shivering artefact
<30
C Lose ability to shiver
<29
C ACS and pupillary dilation Bradycardia / slow AF w resistance to pressors / adrenaline / atropine
<28
C paralysis – knee jerk last to go / 1st return
<23
C no corneal reflex (or oculocephalic)
<22
C VF
18
C asystole
13
C lowest accidental hypothermia survived
![Page 14: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/14.jpg)
ECG
Osborne /J waves. Nb T waves suggestive hyperK not reliable in
HypoThermia
![Page 15: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/15.jpg)
Slow AF with slow ventricular response
![Page 16: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/16.jpg)
Osborne Waves
Not pathognomonic for hypothermia
Also in SAH, cerebral injuries, myocardial ischaemia
Very similar to epsilon wave or ARVC
![Page 17: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/17.jpg)
Modifications to ACLS for Hypothermia
A – warm (40
), humidified O2, intubate prn
B – Consider ICC’s pleural lavage (if ECMO>6/24 away)
C – IVF 40
C, unresponsive to antiarrhythmics, defib., external pacing
SB is physiological response – don’t pace
VF/VT – single defib. and 1Ad attempt only
CPR until core temp >30
C
D - ?neuroprotective
r/o 2nd hypothermia – ICH, AMI, toxicological
E – BSL may be H/L – must give some dextrose.
- use low reading core temp probe.
![Page 18: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/18.jpg)
Pearls in Hypothermia
Ignore transient ventricular arrhythmias Leave slow AF and bradycardias Consider magnesium Gentle-handling over-emphasised Punctures will ooze (nb. post-CAGS pts) Ways to re-warm:
• External – heat lamp, bair hugger, warm blankets (4 x faster than passive alone)
• Invasive – severe hypothermia – warmed, humidified O2, IVF warmer (insulate lines), ECMO (10 x faster) – as effective as hot bath!
Note the AFTERDROP
![Page 19: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/19.jpg)
Non-Salvable Hypothermia
K >12mmol/L
Core T <6 (<15 if CPR >2/24)
pH <6.5
ECMO unsuccessful
Clots in myocardium
**cannot terminate effort alone**
![Page 20: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/20.jpg)
EMRAP Jan ‘14
Who is cold and salvageable and who is
cold and dead? There are 5 criteria you can use to determine if they are dead. • 1) A clear history of cardiac arrest prior to
cooling. • 2) If you have a core temperature greater than
32 degrees Celsius (89.6 degrees Fahrenheit) and they are in asystole, hypothermia is not the cause.
• 3) If they are frozen solid and the chest is not compressible.
• 4) They have potassium greater than 12 mEq/L. • 5) Special circumstances: trauma, drowning
and avalanche burial.
![Page 21: Emergencies part 1 - BHS Education Resourceeducationresource.bhs.org.au/library/file/373/Environmental... · Emergencies part 1 Dr Kirsty Dunn ... Definition is a TRIAD • Core temp](https://reader031.vdocuments.net/reader031/viewer/2022020204/5b26c9647f8b9a09628b5056/html5/thumbnails/21.jpg)
Don’t forget to seek and treat the following
T 65.5-4 Roppolo,
Rosen