Environmental Conditions

Objectives
 Define “environmental emergency” and list the major
types.
 Identify risk factors most predisposing to environmental
emergencies.
 Identify environmental factors that may cause illness or
exacerbate a preexisting illness and those that may
complicate treatment or transport decisions.
 Describe the mechanism of normal body temperature
regulation and identify normal, critically high and
critically low body temperatures.
 Describe several methods of temperature monitoring.
 Identify mechanisms by which the body loses and retains
heat.
 Objectives
 Discuss the pathophysiology, high risk groups, signs and
symptoms, and field treatment of the following:
 Heat cramps
 Heat exhaustion
 Heat stroke (classic and exertional)
 Define fever and discuss its pathophysiologic mechanism.
 Identify the fundamental thermoregulatory difference between
fever and heatstroke and discuss how one may differentiate
between the two.

 Discuss the pathophysiology, high risk groups, signs/symptoms,

field treatment and prevention of the following:
 Frostbite Hypothermia
 Superficial Mild
 Deep Severe
 Objectives
 Discuss the importance of attempting resuscitation in a
pulse less hypothermic patient.
 List factors that contribute to drowning.
 Differentiate between and describe the pathophysiology,
signs/symptoms and field treatment of drowning and near-
drowning.
 Differentiate between the effects of salt vs. fresh water on
the lungs and circulatory system in drowning.
 Discuss the incidence of “wet” vs. “dry” drowning and the
differences in their management.
 Describe the effects of cold water on drowning patients.
 Objectives
 Define self-contained underwater breathing apparatus.
 Describe the pathophysiology, signs/symptoms and field
treatment for the following diving emergencies:
 Decompression illness b. Air embolism
 Describe the function of the Divers Alert Network (DAN)
and how its members may aid in the management of
diving related illnesses.
 Describe the specific function and benefit of hyperbaric
oxygen therapy for the management of diving accidents.
 Scenario
You respond to an athletic field at 3:00
p.m. for a “person down.” It is hot and
humid. You know that the college football
team started practice this week. Your
patient is an unconscious 21-year-old, 230
pound male. His skin is wet and very hot.
Vital sign assessment reveals: BP 82/64
mm Hg; HR 136/min; R 28/min. As you
administer oxygen, he has a grand mal
seizure.
 Discussion
 What factors point to a heat-
related emergency on this call?
 What other emergencies should
you rule out?
 Describe additional assessments
that should be done
 Outline your priorities of care
based on your current information
 Environmental emergency
 Medical condition caused or
exacerbated by weather, terrain,
atmospheric pressure, or other local
factors
 A medical emergency resulting from
physical exposure to the environmental
elements – water, heat, humidity, cold,
altitude, wind
 Thermoregulation
 Regulatory center - Hypothalamus

 Peripheral thermoreceptors

 Central thermoreceptors
 Thermoregulation
 Body temperature increased or
decreased by:
 Regulation of heat production
 Thermogenesis
 Regulation of heat loss
 Thermolysis
Normal body temperature is 37 degrees Centigrade or
98.6 F, though it may range from 96.5-99.5o
(Recent studies show that 98.2o is more average)

Your body temp fluctuates daily – sleep vs exercise,

etc.
Extremely elevated body temperatures can cause
multisystem damage and physiological collapse:
(>105.8oF or 41oC)
Body temperatures below 90oF (32C) cause decreased
LOC, poor judgment, the cessation of shivering, and
uncoordination.
Body temperatures below 82.4oF (28C) usually result in
unconsciousness and possible vfib.
Regulating Heat Production
 Muscular
 Baseline muscular activity
 Exertion
 Shivering
 Metabolic
 Processing of food and nutrients
 Carbohydrates (sugars and starches)
 Fats
 Proteins
 Glycogen
 Endocrine
 Role of hormones in basal metabolic rate
 Regulating Heat Loss
 Radiation Heat waves rise off of our skin (head)
This starts to be ineffective above 88 degrees.
Most body heat is lost through the skin
 Conduction Heat loss by direct contact with colder
object- snow, ice
 Convection Heat loss by moving air (wind chill,
ceiling fans)
 Evaporation Any fluid absorbs heat from
surrounding objects and air. We lose heat by
sweating, being wet or in wet clothes, and from
respirations. This is why animals pant! Sweating is
only effective if humidity is low enough for the
water to evaporate! Evaporative rate decreases if
humidity is above 75%. At levels approaching
90%, evaporation essentially ceases.
 Hyperthermia Compensation

 Hyperthermia compensation
 Increased heat loss
 Vasodilation of skin vessels
 Sweating

 Decreased heat production

 Decreased muscle tone and voluntary activity
 Decreased hormone secretion

 Decreased appetite
Hypothermic Compensation

 Decreased heat loss

 Peripheral vasoconstriction
 Reduction of surface area by body position

(or clothing)
 Piloerection (not effective in humans)
 Hypothermic Compensation

 Increased heat production

 Shivering
 Increased voluntary activity
 Increased hormone secretion
 Increased appetite
External Environmental Factors

May contribute to a medical

emergency
 Climate
 Season
 Weather
 Atmospheric pressure
 Terrain
 Predisposing Factors
 History of exposure
 Poor planning, preparation, education
 Conditioning, health, nutritional status, other
illnesses or associated trauma
 Age
 Use of alcohol, drugs, and prescription
medications
 Poverty
 Environmental Factors
Heat Humidity
Cold Water
Wind Altitude

Possible remote location and delay in identifying

problem
(lost person) and accessing EMS

Difficulty in accessing or extricating patient

(identifying lack of contact with elderly who lives alone
in a
common urban scenario)
 Hyperthermia
 Thermoregulatory mechanisms
overwhelmed by:
 Environmental conditions
 Heat stress
 Excessive exercise in moderate to extreme

environmental conditions
 Failure
of thermoregulatory
mechanisms
 Older adults or ill or debilitated patients
 Either may result in heat illness
 Heat Cramps
 Brief, intermittent, often severe
muscular cramps occuring in
muscles fatigued by heavy work or
exercise. Caused primarily by a
rapid change in extracellular fluid
osmolarity resulting from sodium
and water loss.
 Heat Cramps
1-3 L of water per hour may be lost through
Sweating.
Each liter contains between 30 and 50 mEq
of sodium chloride.
Muscle cramping is caused by the water and
sodium loss.
 Signs & Symptoms
 Alert, hot, sweaty skin, localized
muscle cramps in extremities,
occasionally in abdomen.
 Vital signs normal with tachycardia,
BODY TEMP NORMAL; skin cool or
slightly warm
 Field treatment: remove from hot
environment, replace the sodium and
water (sodium especially), IV NaCl
 HEAT EXHAUSTION

Usually caused by exercising or

exertion in hot ambient temperature,
more severe water and salt
deficiency occurs. This electrolyte
imbalances causes vasomotor
regulatory disturbances and
inadequate cerebral and peripheral
perfusion.
 Heat Exhaustion
 More severe form of heat illness
 Temperature elevation (<103° F [39° C])

 Mental status changes

 Nausea, headache
 Sweating
 Management
 Remove from heat
 Oral or IV fluids
 Signs & Symptoms
 Minor aberrations in mental status, such as
irritability, confusion, poor judgment,
headache, or light-headedness. Skin pale
with excessive sweating, slight or no
temperature increase (<103 degrees)
Tachycardia, BP normal or slightly decreased,
increased respiratory rate
 Field treatment includes removing the
patient from the hot environment, oxygen, IV
 HEAT STROKE

Syndrome occurring when the

thermoregulatory mechanisms that
normally cool the body fail
completely.
This results in a body temperature of
usually > 105.8o. Damage occurs
to the hypothalamus itself as a result
of prolonged exposure to heat.
 Heat Stroke
 Thermoregulatory mechanisms fail
 Body temperature >105.8° F [41° C])
 Multisystem tissue damage
 Physiological collapse
 Medical emergency
 Two types
 Classic heat stroke
 Exertional heat stroke
 Classic Heat Stroke
 High temperatures and humidity
 Risk factors
 Age
 Infants, elderly
 Chronic illness
 Diabetes, heart disease, alcoholism
 Medications
 Psychotropics, diuretics, antihypertensives
 Exertional Heat Stroke
 Young, healthy patients

 Athletes, military recruits

 Vigorous exercise in high heat

 Inadequate hydration

 No acclimation
 Signs & Symptoms
 Dizzyness, headache, bizarre or
unusual behavior, seizures, coma.
 Vital signs include a normal or
decreased BP, tachycardia with a
bounding pulse, tachypnea.
 Skin is usually hot, red, and dry, but
may be wet or have wet clothing if
exertional heatstroke. Temp is highly
elevated!
 Heat Stroke—Assessment
 Confusion, coma, seizures
 Skin flushing
 Dry skin (25% sweat)
 Tachycardia, hypotension
 Pulmonary edema
 Other systems affected
 Heat Stroke—
 Move toManagement
cool location
 Maintain airway, oxygen, ventilation
 Active cooling
 Fan wet skin
 Ice Paks
 IV fluid: 500 mL over 15 min
 For hypotension
 Medications as prescribed
 Sedation, seizure control
 ECG -
 FEVER
 Increased body temperature kills many
microorganisms and has adverse effects of the
growth and replication of others

 Body temperature decreases serum levels of

iron, zinc, and copper, all of which are needed for
bacterial replication

 Body temperature causes lysosomal breakdown

and autodestruction of cells, thus preventing
viral replication in infected cells
 FEVER
 ↑ body temperature (heat) increases
lymphocytic transformation and
motility of polymorphonuclear
neutrophils, thus facilitating the
immune response
 ↑ body temperature enhances
phagocytosis
 ↑ body temperature may augment the
production of antiviral interferon
 Hypothermia
 Hypothermia
Marked decrease in the body’s core
temperature. (or systemic cooling)
 Frostbite
Localized hypothermia (or freezing) of the
body’s tissues; more common in lower
extremities than upper, also seen in nose,
ears, cheeks CBT less than 93.2° F [34° C]
 Hypothermia—
Pathophysiology
 Vasoconstriction
 Sympathetic discharge
 Shivering, tachycardia
 Shivering stops: Rapid cooling
 Respiration, pulse, BP decrease
 ECG changes
 Respiratory and cardiac arrest
 Hypothermia
 Progression of signs and symptoms
 Mild
 Core temperature 93.2°-96.8° F (34°-36° C)
 Moderate
 Core temperature 86°-93° F (30°-34° C)
 Severe
 Core temperature below 86° F (30° C)
 Hypothermia—Risk
Factors
 Outdoor enthusiasts

 Older adults, young children

 Medical/psychiatric illness
 Trauma
 Medications
 Alcohol, antidepressants
 Antipyretics, phenothiazines
 Hypothermia—
Management
 High index of suspicion
High index of suspicion
 Evacuate to warmth
 Remove cold, wet clothes
 Cover with warm blankets
 Rapid transport
 Hypothermia—

Management
Passive rewarming
 Move to warm environment and remove wet
clothes
 Active external rewarming
 Radiant heat
 Forced hot air
 Warm IVF
 Active internal rewarming
 Warmed oxygen
 Lavage
 Cardiopulmonary bypass
 Mild Hypothermia—
Treatment
 Passive rewarming
Passive rewarming
 Warm drinks
 With sugar
 External hot packs
 No alcoholic beverages
 Warm, heated oxygen
Moderate Hypothermia—
Treatment
 Can’t shiver or perform tasks
 Passive rewarming first
Keep patient at rest
 External rewarming
 Cover warm packs to prevent burns
 Transport for evaluation
 Severe Hypothermia
 Support airway, ventilation and circulation

 Passive and external rewarming

 Oxygen

 If ventricular fibrillation - start CPR and

shock once

 Rapid transport
 Considerations in
Hypothermia
 Assess for vital signs for 30-45 sec
 If presence of pulse questionable - start
CPR
 Intubate
 Sinus bradycardia may be protective
 Pacing usually not indicated
 Withhold IV drugs until T>30C
 If T>30C increase time between doses
 Frostbite
 Localized injury
 Freezing of body tissues
 Pathophysiology
 Predisposing factors
 Frostbite—
Classification/Symptoms
 Superficial frostbite (frostnip)
 Minimal tissue loss

 Deep frostbite
 Significant tissue loss even with
appropriate therapy
 Superficial Frostbite
 Some freezing of epidermal tissue

 Initial redness followed by blanching

 Diminished sensation
 Deep Frostbite
 Freezing of epidermal and
subcutaneous layers
 White appearance
 Hard (frozen) to palpation
 Loss of sensation
 pale, cold, yellow, blue
numb
 decreased movement
 Field Management
 Remove patient from cold environment
 Support the patient’s vital functions (be wary
about systemic hypothermia)
 Rewarm in tepid (105o) H2O; no contact with
container
 No rewarming if a possibility of refreezing
 No walking on frozen extremities
 No coffee, alcohol, nicotine
 No rubbing
 Remove wet and/or tight clothing
 Wrap affected extremities in dry, sterile
dressings; then immobilize
 Frostbite

Edema and blister formation 24 hrs after

frostbite injury in area covered by tightly fitted boot
 Frostbite
Gangrenous necrosis 6 wks after frostbite injury
 Pulseless Hypothermic
Patient.
 Hypothermic patients who appear dead
may still be successfully resuscitated.
 The lowest recorded temperature that an
adult patient has survived in accidental
hypothermia is 61oF.
 Children especially have a better chance of
survival, some believe due to the
mammalian dive reflex.
 Drowning
 Fifth-leading cause of unintentional death
 85% male, ⅔ don’t know how to swim
 Drowning
 Process that results in primary respiratory
impairment
 Caused by submersion/immersion in liquid
 Liquid/air interface at airway prevents breathing
 Factors Contributing To
Drowning
 ETOH, drugs
 Trauma
 Inability to swim
 Stupidity, overconfidence
 Exhaustion
 Muscle cramps
 Fear, panic
 Salt vs Fresh water

SALTWATER
Hypertonic to body fluids; draws water
to it.
Plasma and fluid move into the alveoli,
resulting in pulmonary edema, poor
ventilations of alveoli, hypoxia.
 Salt vs. Fresh Water
FRESHWATER
Hypotonic to body fluids; moves out of
alveoli into circulation. Blood volume can
increase, causing RBCs to rupture
(hemolysis), and electrolyte abnormalities.
Surfactant is “washed out” or diluted,
causing atelectasis, then hypoxia in the
alveoli.
 Submersion Incident -
Pathophysiology
 Wet vs. dry drowning
 Fluid in posterior oropharynx stimulates
laryngospasm
 Aspiration occurs after muscular relaxation
 Suffocation occurs with or without aspiration
 Aspiration presents as airway obstruction

 Fresh versus saltwater considerations

 No difference in prehospital treatment
Progression of a Drowning Incident
 Drowning vs. Near-
drowning

Drowning
Asphyxia after submersion (death <24
hours)
Near-drowning
Submersion accident where the patient
survives for at least 24
 Drowning
 Hypothermic considerations
 Common concomitant syndrome
 May be organ protective in cold water
submersion
 Treat hypoxia first
 Treat all submersion patients for
hypothermia
 Factors that Affect Clinical
Outcome
 Water temperature

 Length of submersion

 Cleanliness of water

 Age of patient
 Submersion Incident—
 ABCs
Management

 Trauma considerations
 Spinal precautions if MOI suggests injury
 Post resuscitation complications
 Adult respiratory distress syndrome (ARDS)
or renal failure often occurs
postresuscitation
 Symptoms may not appear for 24 hrs
 Transport all submersion patients
 Diving Emergencies
 Incidence
 Medical emergencies caused by:
 Mechanical effects of pressure
 Barotrauma
 Air embolism
 Breathing of compressed air
 Decompression sickness
 Nitrogen narcosis
Mechanical Effects of Pressure
 Basic properties of gases
 Increased pressure dissolves gases
into blood
 Oxygen metabolizes; nitrogen
dissolves
 Boyle’s Law
 When pressure is doubled, volume of gas
is halved
 PV = K
 P = Pressure
 V = Volume
 K = Constant
Trapped gases expand as pressure
decreases
 Dalton’s Law
 Pressure from each gas in a mixture of
gases is the same as it would be if that gas
alone occupied the same volume
 Pt - PO2 + PN2 + Px
 Pt = Total pressure
 PO2 = Partial pressure of oxygen
 PN2 = Partial pressure of nitrogen
 Px = Partial pressure of remaining gases
 Henry’s Law
 At constant pressure, solubility of gas
in liquid is proportionate to partial
pressure of gas
 %X = Px/Pt x 100
 %X = Amount of gas dissolved in liquid
 Px = Partial pressure of gas
 Pt = Total atmospheric pressure
Barotrauma of Descent
”Squeeze”
 Pain
 Sensation of fullness
 HA, disorientation
 Vertigo
 Nausea
 Bleeding from nose or ears
Pre-hospital care
 Supportive
 Barotrauma of Ascent
 Reverse squeeze
 Breath holding during ascent
 POPS
 Alveolar rupture
 Pneumomediastinum
 Subcutaneous emphysema
 Air embolism
 Administer oxygen

 Transport for possible hyperbaric care

 Air Embolism
 Complication of pulmonary
barotrauma
 Expanding air disrupts tissues
 Air forced into circulatory system
 Air passes through left side of heart
 Lodges in small arterioles
 Blocks distal circulation
 Air Embolism
 Paralysis or sensory change
 Aphasia
 Confusion
 Blindness
 Convulsions
 Loss of consciousness
 Signs & Symptoms
History of a recent dive
Change in LOC
CVA-
ICP
MI
 Air Embolism—Care
 Maintain ABCs
 Remove wet clothing and keep warm
 Oxygen, IV, EKG
 Initially- place on left side trendelenberg
position
 After 30-60 minutes, place supine to prevent
the worsening of cerebral edema
 Transport to hospital with hyperbaric chamber
 Decompression Sickness
 Bends, dysbarism, caisson disease,
and diver's paralysis
 Multisystem disorder
 Nitrogen in compressed air converts
from solution to gas
 Forms bubbles in tissues and blood
Decompression Sickness
 Dyspnea  Vertigo
 Itch  Paresthesias
 Rash  Paralysis
 Joint pain  Seizures
 Crepitus  Unconsciousness
 Fatigue
 Decompression Sickness

Symptoms 12-36 hrs after dive

 Pre-hospital care
 Support vital functions
 High-concentration oxygen
 Fluid resuscitation
 Rapid transport for recompression
 Nitrogen Narcosis
“Rapture of the deep”
Nitrogen dissolved in blood
High atmospheric pressure
Impaired judgment
Slowed motor response
Euphoria
Potential memory loss
 Nitrogen Narcosis
 Supportive care

 Assess for injuries

 Transport
 High-Altitude Illness
 >8000 ft above sea level
 Reduced atmospheric pressure
 Hypobaric hypoxia
 Associated with:
 Mountain climbing
 Aircraft or glider flight

 Hot-air balloons

 Low-pressure or vacuum chambers

 High-Altitude Illness—
Prevention
 Gradual ascent
 Limit exertion
 Decrease sleeping at altitude
 High CHO diet
 Medications
 Controversial
Acute Mountain Sickness (AMS)

 Rapid ascent of unacclimatized

person to high altitudes
 4-6 hrs after reaching high altitude
 Maximal within 24-48 hrs
 Abates on 3rd or 4th day
 Gradual acclimatization
Acute Mountain Sickness (AMS)
 Headache
 Nausea, vomiting
 Dizziness, irritability
 Dyspnea on exertion
 Tachycardia or bradycardia
 Ataxia
 Altered
 vomiting
 postural hypotension
Acute Mountain Sickness (AMS)
 Pre-hospital
 Oxygen
 Descent

 Hospital
 Diuretics
 Steroids
 Hyperbaric therapy
 High-Altitude Pulmonary Edema
(HAPE)
 Increased pulmonary artery pressure
develops in response to hypoxia
 Leukotrienes released
 Increase pulmonary arteriolar permeability
 Leakage of fluid into extravascular spaces
 24-72 hrs after reaching high altitudes
 Often preceded by exercise
HAPE Signs & Symptoms
 Hyperpnea
 Crackles, rhonchi
 Tachycardia
 Hyperpnea (deep, rapid breathing)
 Cyanosis
 Immediate descent to a lower altitude
 Shortness of breath, cough
 Weakness, lethargy
 Crackles, rhonchi
 Decreased LOC as hypoxia sets in
 High-Altitude Cerebral Edema
(HACE)
 Severe acute high-altitude illness
 Global cerebral signs with AMS
 Related to increased intracranial pressure
 From cerebral edema and swelling

 Distinctions between AMS and HACE are blurred

 Mild AMS to unconsciousness with HACE

occurs within 12 hrs
 1-3 days of exposure to high altitudes

 Same as AMS, headache to decreased LOC

 Hallucinations, stupor, coma, death

 HACE
 Urgent management to prevent
 Coma
 Death
 Airway, ventilation, circulation
support
 Descent to lower altitude
 Conclusion
Many emergencies result from exposure to
environmental elements. The paramedic
must be able to recognize and manage
these conditions by understanding their
causative factors and underlying
pathophysiology.
Questions?