DOT National Standard EMT-Intermediate/85 Refresher

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training

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DOT National StandardEMT-Intermediate/85 Refresher

Welcome!





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






HEAT EMERGENCIESheat crampsheat exhaustionheat stroke

• Perspective• Pathophysiology• Epidemiology• PE & Diagnostic

Findings• S/S• Differential

considerations• Tx






perspective• When the external temperature rises to >95F,

the body can no longer radiate heat to the environment & becomes dependent on evaporation for heat transfer

• As humidity increases, the potential for evaporation heat loss decreases– Sweat that drips from the skin does not provide any

cooling benefit and only exacerbates dehydration






perspective• As a result, the combination of high

temperature & high humidity essentially blocks the two main mechanisms that the body uses to dissipate heat






perspective• The body tends to maintain its core

temperature between 96.8-100.4F

• Native thermal regulation mechanisms begin to fail at core temp. of <95F & >104F






• Physiologic response to heat stress occurs through 4 primary mechanisms– Dilatation of blood vessels, particularly the

skin– Increased sweat production– Decreased heat production– Behavioral heat control





are needed to see this picture.s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives

• HEAT CRAMPS– Painful, involuntary, spasmodic contractions of skeletal

muscles, usu. those of the calves (thighs & shoulder can happen too)

– These cramps usually occur in individuals who are sweating profusely & replace fluid losses w/ water or other hypotonic solutions

– They may occur during exercise or, more commonly, during a rest period after several hours of vigorous physical activity






– Pts w/ severe heat cramps may have hyponatremia and hypochloremia





are needed to see this picture.Treatment

• Scene Size Up• ABCs & spinal immobilization

• Secondary Assessment |Diagnostics-Monitoring-Management | Verbal Survey

• Cooling:– Remove pt from hot environment to a cool area if possible– Remove constricting and warm clothing– If ALOC or severe symptoms, begin evaporative cooling– Don’t let cooling delay transport

• Check glucose PRN






• Fluid and salt replacement (PO or IV) & rest in a cool environment

• For mild cases: 0.1% to 0.2% saline solution can be given PO. Two 10-grain (650mg) salt tablets dissolved in a quart of water provides a 0.1% saline solution

• Commercially available sport drinks can be used

• More severe symptoms should be treated w/ IV rehydration w/ NS






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





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.







Welcome!













• Pathophysiology• Epidemiology• Physical Exam

Findings• Diagnostic Findings• Signs and Symptoms• Differential

considerations• Treatment






perspective• When the external temperature rises to >95F, the

body can no longer radiate heat to the environment and becomes dependent on evaporation for heat transfer

• As humidity increases, the potential for evaporation heat loss decreases– Sweat that drips from the skin does not provide any cooling

benefit and only exacerbates dehydration







temperature and high humidity essentially blocks the two main mechanisms that the body uses to dissipate heat







temperature between 96.8-100.4F• Native thermal regulation mechanisms

begin to fail at core temp. of <95F and >104F













• HEAT EXHAUSTION– Water depletion– Sodium depletion






• HA• N/V• Malaise• Dizziness• Muscle cramps• Tachycardia• Orthostatic hypotension






• Temperature may be normal or elevated (usually not above 104F)

• No signs of CNS impairment






• Scene Size Up• ABCs & spinal immobilization• Secondary Assessment |Diagnostics-Monitoring-

Management | Verbal Survey• Cooling:

– Remove pt from hot environment to a cool area if possible– Remove constricting and warm clothing– If ALOC or severe symptoms, begin evaporative cooling– Don’t let cooling delay transport







• Oral fluids– Frequent small amounts of water w/ 1/4 tsp of salt or sport drink

• Adults: Give a total of 1-L• 1mo-14yrs: 10ml/kg to max of 1-L

• IV– Adults: 1-L LR/NS bolus, then maintenance rate (120ml/hr)– Pediatrics: 20ml/kg LR/NS bolus (max 1-L), then maintenance rate

(2ml/kg/hr)– All ages: if still symptomatic after initial bolus, give second bolus






• Seizures - GO TO PROTOCOL: Seizures• Many factors alter the body’s ability to regulate

temperature: age extremes, heart disease, medications (diuretics, beta blockers), antihistamines, alcohol, type and amount of fluid replacement, dehydration, acclimatization, humidity, altitude






• Judicious fluid replacement: in elderly pts, overzealous fluid replacement may be detrimental

• Cooling measures– Evaporative cooling: the most effective. Spray or wipe skin

with water and evaporate water with air using fan, fanning or wind. Applying a moist cloth that retains moisture (cotton) is effective

– Immersion: the next most effective but potentially dangerous. Use only if you can not provide evaporative cooling.






• Immerse pt in cool/cold water for 10 minutes, remove pt and recheck temperature. Be cautious! Keep pt’s head out of the water.

• It is difficult to protect an airway and manage a seizing pt in a stream!

• Also it is easy to make the pt hypothermic using this method. Cool only to goal temperature of 102.5F. Cooling will continue after you stop.

• If first attempt not successful then continue with 5 minute cycles, rechecking temperature 5 minutes after each immersion






• Adjunctive measures: placing ice or cool towels in areas of high blood flow (neck veins, armpits, groin) works but is much less effective

• AVOID cooling below 102.5F and stop if pt starts shivering (hypothermic overshoot). Shivering increases body temperature and reflects overcooling

• Transport any pt w/ signs of severe heat exhaustion or heat stroke.





are needed to see this picture.Differential Dx

• Drug OD (amphetamines, antihistamines, tricyclic antidepressants, ASA)

• Alcohol withdrawal• Sepsis, febrile illness• DKA• Meningitis, encephalitis• Thyroid storm (hyperthyroidism)• Cerebral hemorrhage• Medication reaction (antipsychotics, e.g., Haldol)• Status epilepticus






• Pathophysiology• Epidemiology• Physical Exam Findings• Diagnostic Findings• Signs and Symptoms• Differential considerations• Treatment















Welcome!













• Pathophysiology• Epidemiology• Physical Exam

Findings• Diagnostic Findings• Signs and Symptoms• Differential

considerations• Treatment






perspective• When the external temperature rises to >95F, the

body can no longer radiate heat to the environment and becomes dependent on evaporation for heat transfer

• As humidity increases, the potential for evaporation heat loss decreases– Sweat that drips from the skin does not provide any cooling

benefit and only exacerbates dehydration







temperature and high humidity essentially blocks the two main mechanisms that the body uses to dissipate heat







temperature between 96.8-100.4F• Native thermal regulation mechanisms

begin to fail at core temp. of <95F and >104F













• HEAT STROKE– Acute life-threatening emergency w/ mortality rates as

high as 30%-80% and is universally fatal if left untreated.

– The cardinal features of heat stroke are hyperthermia [>104F] and altered level of consciousness

– Classic (non-exertional) heat stroke may exhibit anhidrosis

– The absence of sweat is not considered a diagnostic criteria, because sweat is present in over half of pts with heat stroke






• Virtually any neurologic abnormality may be present– Irritability– Confusion– Bizarre behavior– Combativeness– Hallucinations– Posturing– Seizures– coma






• Scene Size Up• ABCs & spinal immobilization• Secondary Assessment |Diagnostics-Monitoring-

Management | Verbal Survey• Cooling:

– Remove pt from hot environment to a cool area if possible– Remove constricting and warm clothing– If ALOC or severe symptoms, begin evaporative cooling– Don’t let cooling delay transport







• Oral fluids– Frequent small amounts of water w/ 1/4 tsp of salt or sport drink

• Adults: Give a total of 1-L• 1mo-14yrs: 10ml/kg to max of 1-L

• IV– Adults: 1-L LR/NS bolus, then maintenance rate (120ml/hr)– Pediatrics: 20ml/kg LR/NS bolus (max 1-L), then maintenance rate

(2ml/kg/hr)– All ages: if still symptomatic after initial bolus, give second bolus






• Seizures - GO TO PROTOCOL: Seizures• Many factors alter the body’s ability to regulate

temperature: age extremes, heart disease, medications (diuretics, beta blockers), antihistamines, alcohol, type and amount of fluid replacement, dehydration, acclimatization, humidity, altitude






• Judicious fluid replacement: in elderly pts, overzealous fluid replacement may be detrimental

• Cooling measures– Evaporative cooling: the most effective. Spray or wipe skin

with water and evaporate water with air using fan, fanning or wind. Applying a moist cloth that retains moisture (cotton) is effective

– Immersion: the next most effective but potentially dangerous. Use only if you can not provide evaporative cooling.






• Immerse pt in cool/cold water for 10 minutes, remove pt and recheck temperature. Be cautious! Keep pt’s head out of the water.

• It is difficult to protect an airway and manage a seizing pt in a stream!

• Also it is easy to make the pt hypothermic using this method. Cool only to goal temperature of 102.5F. Cooling will continue after you stop.

• If first attempt not successful then continue with 5 minute cycles, rechecking temperature 5 minutes after each immersion






• Adjunctive measures: placing ice or cool towels in areas of high blood flow (neck veins, armpits, groin) works but is much less effective

• AVOID cooling below 102.5F and stop if pt starts shivering (hypothermic overshoot). Shivering increases body temperature and reflects overcooling

• Transport any pt w/ signs of severe heat exhaustion or heat stroke.





are needed to see this picture.Differential Dx

• Drug OD (amphetamines, antihistamines, tricyclic antidepressants, ASA)

• Alcohol withdrawal• Sepsis, febrile illness• DKA• Meningitis, encephalitis• Thyroid storm (hyperthyroidism)• Cerebral hemorrhage• Medication reaction (antipsychotics, e.g., Haldol)• Status epilepticus






• Pathophysiology• Epidemiology• Physical Exam Findings• Diagnostic Findings• Signs and Symptoms• Differential considerations• Treatment









DOT National Standard EMT-Intermediate/85 Refresher

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