CHAPTER
22
Environmental
Emergencies
Temperature
Regulation
The body tries to balance heat
loss and heat gain to maintain
normal temperature.
Exposure to Cold
If heat loss
exceeds heat
gain, hypothermia
(low body
temperature)
occurs.
Heat Loss
The body loses heat in 5 ways:
Conduction
Convection
Radiation
Evaporation
Respiration
Heat Loss from
Conduction
Heat Loss from
Convection
Heat Loss from Radiation
Heat Loss from
Evaporation
Heat Loss from
Respiration
Generalized Hypothermia
Predisposing Factors
Cold Environment
Cold water immersion
Cold air exposure
Generalized Hypothermia
Predisposing Factors
Age – Very Old
Failing body systems
Chronic illness
Lack of exercise
Certain medications
Generalized Hypothermia
Predisposing Factors
Age – Very Young
Large skin surface
area/less fat
Little or no shivering
Inability to put on or
take off clothing
Generalized Hypothermia
Predisposing
Factors
Medical Conditions
Shock (hypoperfusion)
Head/spinal cord injury
Burns
Generalized infection
Diabetes and
hypoglycemia
Drugs and poisons
Signs & Symptoms of
Hypothermia
Shivering in mild cases (lack of,
in more severe cases)
Numbness
Stiff or rigid posture
Drowsiness/mental status changes
Continued…
Signs & Symptoms of
Hypothermia
Breathing changes
Rapid (early)
Shallow, slow, absent (late)
Blood pressure (low to absent)
Poor motor function
Continued…
Signs & Symptoms of
Hypothermia
Pulse changes
Rapid (early)
Slow, weak, irregular, absent (late)
Muscle and joint stiffness
Continued…
Signs & Symptoms of
Hypothermia
Skin
Red (early)
Pale
Cyanotic
Stiff/hard (late)
Stages of Hypothermia
Core Body Temperature
Symptoms
99°F-96°F 37.0°C-35.5°C
Shivering.
95°F-91°F 35.5°C-32.7°C
Intense shivering, difficulty speaking.
90°F-86°F 32.0°C-30.0°C
Shivering decreases and is replaced by strong
muscular rigidity. Muscle coordination is affected
and erratic or jerky movements are produced.
Thinking is less clear, general comprehension is
dulled, possible total amnesia. Patient generally
is able to maintain the appearance of
psychological contact with surroundings.
85°F-81°F 29.4°C-27.2°C
Patient becomes irrational, loses contact with
environment, and drifts into stuporous state.
Muscular rigidity continues. Pulse and
respirations are slow and cardiac.
80°F-87°F 26.6°C-20.5°C
Patient loses consciousness and does not
respond to spoken words. Most reflexes cease
to function. Heartbeat slows further before
cardiac arrest occurs.
Passive vs. Active Rewarming
Passive
Allows body to rewarm itself.
Remove wet clothing.
Cover with blanket(s).
Active
Application of external heat sources
to patient.
Emergency Care of
Hypothermia
Remove patient from
environment and prevent further
heat loss.
Remove wet clothing and cover
with blanket.
Handle patient gently.
Continued…
Emergency Care of
Hypothermia
Do not allow patient to walk or
exert self.
Give high-concentration oxygen
(warmed and humidified).
If apneic, check pulse 30-45
seconds before starting CPR.
Continued…
Emergency Care of
Hypothermia
Do not allow patient to eat or
drink stimulants.
Do not massage extremities.
Transport patient.
Continued…
Emergency Care of
Hypothermia
If patient is responding appropriately,
rewarm actively:
Apply heat to groin, armpits, neck.
Warm trunk first.
Do not warm too quickly.
Increase heat in ambulance.
Warm bath if delayed transport.
Continued…
Emergency Care of
Hypothermia
If patient unresponsive or responding
inappropriately, rewarm passively:
Open airway; provide high-concentration
oxygen.
Apply blankets.
Increase heat in ambulance.
Transport.
Localized Cold Injuries
Predisposing Factors
Usually occurs in extremities and
exposed ears, nose, face
Clear boundary
separates injured/
uninjured areas
Signs & Symptoms of
Superficial (Early) Local
Cold Injury
Blanching of skin
Loss of feeling in affected area
Skin remains soft
When rewarmed, area tingles
Emergency Care of
Superficial (Early) Local
Cold Injury
Remove patient from environment.
Protect area from further injury.
Splint and cover extremity.
Do not rub or massage.
Do not re-expose to cold.
Signs & Symptoms of
Deep (Late) Local Cold Injury
Also known as frostbite
White, waxy skin
Firm or frozen on surface
Swelling and blisters may occur
Skin blotchy, mottled, or grayish
yellow or blue
Local Cold Injury
Emergency Care of Deep
(Late) Local Cold Injury
Remove patient from environment.
Protect area from further injury.
Administer high-concentration
oxygen.
Transport.
Emergency Care of Deep
(Late) Local Cold Injury
Do not:
Break blisters
Rub or massage area
Allow patient to walk on affected
extremity
Active Rewarming of Frozen
Parts
Seldom recommended
Perform only if:
Transport extremely delayed AND
Medical control orders it OR
Protocols allow it
Large potential to permanently injure
frozen tissue
Active Rewarming of Frozen
Parts
Fill container with 100-105°F water.
Remove jewelry, bands, clothing.
Completely immerse the frozen part.
Maintain warm temperature until
completely thawed.
Immerse affected
part in warmwater bath.
Active Rewarming of Frozen
Parts
Remove when part no longer feels
frozen and begins to turn red or
blue.
Dress area with dry, sterile
dressings.
Continued…
Active Rewarming of Frozen
Parts
Protect against refreezing.
Expect complaint of severe pain.
Reassess and transport.
Frostbite
A case study from “Facebbok”
This is 2 days post-injury, after the blisters were debrided (cut off). Foot
is very swollen and mildly infected.
I REALLY wish I would have taken a picture of the blisters, they were
about an inch thick and covered the entire bottom of the foot, plus the
toes.
This is 9 days. Note black tissue forming at edges of wound, and white
areas near heel which are the 3rd degree burns. Also note the blisters
on the toes which are more visible now. I think this is when it looked the
worst.
Had to add this for the fun factor. Dog bite and frostbite
together! This is also 9 days into healing. Eric is doing
hyperbaric oxygen therapy 5 days/week at this point to
keep infection away, reduce swelling, and speed healing.
16 days post-injury. The rest of the toes have been debrided and the
big toe is well on its way to healing. The more severely burned areas
have turned black. The black area does not feel like a normal scab- it's
sort of leathery.
Done with hyperbarics.
1 month post-inury. Medial areas have new pink skin and black areas
are slowly receding. Lateral edge (near the outside edge of black
tissue) is irritated and red, might be mildly infected since he d/c
antibiotics last week.
Note my little Shizzy dog in the background!
5 weeks. You can see the black areas sloooooowly receding and being
replaced first by the red granulation tissue, which is the immature skin
cells, then eventually layers of pink normal skin build on top of that. The
black area is starting to look drier and crispier (for lack of a better term).
Hopefully that means that it's thinning out because viable skin
underneath is pushing it out.
Close-up shot taken by Jacob at 5 wks.. It really does look
like something that got left on the barbecue a bit too long.
6 weeks and 2 days. Note the upper black section has been removed
by Dr.... good granulation tissue underneath, hooray! Bottom black part
is not doing much and Dr. said this week to re-think skin graft.
7 weeks. Note how the black area at the bottom is starting to narrow
and turn yellow at the sides, good! Since this was the most severe
area, it's really encouraging to see it making progress on its own.
7 weeks again, you can really see how much tissue has
completely healed in this one. The whole pink area was
burn.
8 weeks. Wound care Dr. removed a lot of the black scabby
stuff today- that is the yellow sloughy areas you see.
8 weeks. Believe it or not, this is progress.
8 wks. Yes, this is what you think it is. Eric got so attached
to his scabs that he brought them home in a specimen cup.
(the knife is for size comparison- we didn't do a home job)
10 wks. Foot is inflamed and red because Eric decided he
should walk on it for a day since he's going to have surgery
anyway, right ? Wrong.... Yellow areas are fat, red is
granulation tissue.
10 wks- at this angle you can really see how much tissue
has completely healed. The remaining tissue is progressing
very slowly compared to the rest of the foot and the toes,
since deeper layers of tissue were damaged.
This is the donor site on Eric's Thigh, it is 7 inches long. It
looks shiny cause it's covered in a plastic bandage
wide shot of thigh
Foot is splinted for 1 week- surgeon will take it off next
Monday and see if the graft is taking.
6 days post-graft. Gauze pads were stapled TO the foothow rude!! This is the gauze/staple-removing process.
Now removing about half of the staples that attach the graft
to the foot. Other half will come out next week.
And here's the glorious graft, looking like a good graft
should. Big fat sigh of relief.
Eric's very sexy leg. His skin started reacting to the
adhesive and is all welted up around the donor site.
Extreme close-up of the extreme foot makeover. (for those of you who
desire more detail)
The criss-cross pattern is the skin- it gets run through a press-type
machine that stamps it into the mesh pattern. This gives the skin the
ability to drain out blood from underneath, increasin the chances of
adhesion
19 days post op- WE HAVE SKIN !! Note the area to the
right (top of the wound) where it appears white. This is a
thin layer of skin, hooray yippee!
19 days post op again, heel area. The little islands of white puffy tissue
are more skin!! The little red buds are granulation tissue which are the
buds which skin cells will proliferate from. Black around the edges is
normal- just dead skin where the surgery was cauterized.
21 days. Started using an herbal wound salve and a wheatgrass juice
spray extract directly on the wound the day before. The difference in
the amount of pink skin is pretty amazing when you compare this to the
previous picture 2 days ago.
25 days. continue to use herbals and Eric has done 2 hyperbaric dives.
There is now more mature pink epithelium than there is immature red
granulation tissue, and the black dead skin around the edges of the
wound is falling off.
25 days. Look how much the really deep indented area has
healed here compared to 4 days ago, and when you
compare it to the photo at 19 days it's freakin amazing!
31 days. Love that pretty pink skin.
31 days. That deep area mid-foot is going to be the last to
heal, it still has a bit of tissue to fill in.
7 wks post-op. So close! The remaining areas are pretty
shallow. Have follow up appt with the surgeon in 2 days to
see if Eric can start bearing full weight on it again.
Eric's favorite hyperbaric chamber.
Fasten your seat belt...sorta looks like the beginning of
Space Mountain