ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
DOT National StandardEMT-Intermediate/85 Refresher
Welcome!
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.MEDICAL EMERGENCIES
HEAT EMERGENCIESheat crampsheat exhaustionheat stroke
• Perspective• Pathophysiology• Epidemiology• PE & Diagnostic
Findings• S/S• Differential
considerations• Tx
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
perspective• As a result, the combination of high
temperature & high humidity essentially blocks the two main mechanisms that the body uses to dissipate heat
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
• 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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives
– Pts w/ severe heat cramps may have hyponatremia and hypochloremia
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.Treatment
• 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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
• Perspective• Pathophysiology• Epidemiology• PE & Diagnostic Findings• S/S• Differential considerations• Tx
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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.
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
DOT National StandardEMT-Intermediate/85 Refresher
Welcome!
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.MEDICAL EMERGENCIES
HEAT EMERGENCIESheat crampsheat exhaustionheat stroke
• Pathophysiology• Epidemiology• Physical Exam
Findings• Diagnostic Findings• Signs and Symptoms• Differential
considerations• Treatment
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
perspective• As a result, the combination of high
temperature and high humidity essentially blocks the two main mechanisms that the body uses to dissipate heat
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
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 and >104F
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
• 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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives
• HEAT EXHAUSTION– Water depletion– Sodium depletion
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives
• HA• N/V• Malaise• Dizziness• Muscle cramps• Tachycardia• Orthostatic hypotension
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives
• Temperature may be normal or elevated (usually not above 104F)
• No signs of CNS impairment
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.Treatment
• 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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.Treatment
• 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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.Treatment
• 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.
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.Treatment
• 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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.Treatment
• 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.
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
• Pathophysiology• Epidemiology• Physical Exam Findings• Diagnostic Findings• Signs and Symptoms• Differential considerations• Treatment
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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.
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
DOT National StandardEMT-Intermediate/85 Refresher
Welcome!
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.MEDICAL EMERGENCIES
HEAT EMERGENCIESheat crampsheat exhaustionheat stroke
• Pathophysiology• Epidemiology• Physical Exam
Findings• Diagnostic Findings• Signs and Symptoms• Differential
considerations• Treatment
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
perspective• As a result, the combination of high
temperature and high humidity essentially blocks the two main mechanisms that the body uses to dissipate heat
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
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 and >104F
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
• 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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives
• 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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.s/s, physical exam & assessment, diagnostics, monitoring, management, pertinent positives
• Virtually any neurologic abnormality may be present– Irritability– Confusion– Bizarre behavior– Combativeness– Hallucinations– Posturing– Seizures– coma
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.Treatment
• 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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.Treatment
• 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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.Treatment
• 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.
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.Treatment
• 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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.Treatment
• 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.
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
are needed to see this picture.
• Pathophysiology• Epidemiology• Physical Exam Findings• Diagnostic Findings• Signs and Symptoms• Differential considerations• Treatment
ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training
QuickTime™ and a decompressor
are needed to see this picture.
QuickTime™ and a decompressor
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.