Hypothermia
February 2013 CE
Condell Medical Center
EMS System
Site Code: 107200E-1213
Prepared by: Sharon Hopkins, RN, BSN, EMT-P
Rev: 2.11.13
1
Objectives
Upon successful completion of the program the EMS
provider will be able to:
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Describe the thermoregulatory mechanism.
Describe the mechanisms of heat transfer.
Identify risk factors that predispose a patient to an
environmental emergency.
Discuss the pathophysiology of cold emergencies.
Identify the normal and critically low body
temperatures.
2
Objectives cont’d
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List and describe the various cold disorders.
Describe signs and symptoms, and management of
cold disorders.
Describe differences of treatment of the arrested
patient with a normal body temperature versus a cold
presentation.
Actively participate in case scenario discussion.
Review use of a saline lock with and without IV
tubing.
Successfully complete the post quiz with a score of
80% or better.
3
Background Hypothermia

Body’s job is to maintain homeostasis

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A constant and suitable condition in which the
body functions
Normal body temperature is 98.60F (370C)
Hypothermia considered a core temperature
less than 950F

Unable to generate sufficient heat production to
return to a normal core temperature
4
Thermoregulatory Mechanisms


Body attempts to maintain/regulate the body
temperature
Core temperature

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Temperature of deep body tissues
Varies minimally from 98.60F (370C)
Can be measured via tympanic or rectal
thermometers (additional routes used in hospital)

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Tympanic and rectal can reflect core temperatures
Peripheral body temperature measured via oral or
axillary temperatures
5
Thermoregulatory Mechanisms cont’d

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Production and loss of heat maintained via a balance
between the nervous system and negative feedback
mechanisms (an action is stopped or negated)
Hypothalamus at base of brain regulates temperature

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When heat is sensed, heat generating mechanisms shut off
(i.e.: stop shivering)
When decrease in body temperature sensed, heat losing
mechanisms shut off (i.e.: stop sweating)
Thermoreceptors located peripherally (i.e.: skin and
certain mucous membranes) and centrally (deeper
tissues of body)
6
Hypothalamus – Thermoregulatory
Center

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Sits deep
in brain
Thermostat for
body
7
Thermoregulatory Mechanisms cont’d

Basal metabolic rate – BMR

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Metabolism that occurs when body completely at
rest
Continually adjusting based on the need of the body
Blood vessels constrict or dilate based on need to
conserve heat or dissipate heat

Can develop a difference between peripheral and core
body temperatures
 Core temperature is the crucial measurement with
major organs

Rectal temperatures will reflect core temperatures
8
Mechanisms of Heat Transfer
Heat flows from warmer to colder substances
 Conduction

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Convection

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Heat loss via infrared rays
Evaporation

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Heat loss to air currents passing over body
Radiation

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Direct contact
Change of liquid to vapor; sweat evaporation
Respiration

Via convection, radiation, and evaporation via lungs
9
Conduction

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Transfer of heat away from the warmer
surface to the cooler surface
Air is poor conductor of heat

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Still air is good insulator
Water conducts better than dry air
Example: Sitting on a cold bench at the
stadium you warm it up by your body
temperature conducting to the colder bench
10
Convection

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Heat lost to air currents passing over the body
Amount of heat lost depends on temperature
difference between your body and environment plus
speed which the air or water currents are moving

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Air in motion takes away a lot of heat
Body heat is first conducted to the air before
convection occurs
Example: Blowing on your food to cool it down
11
Radiation

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Direct emission of heat
Heat radiates from the warmer body and
clothing to the cooler environment
The greater the difference between the body
and environmental temperature, the greater
the heat loss
Example: On a hot summer day you can see
the heat radiating off the hot pavement
12
Evaporation


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Responsible for 20-30% of heat loss
Wet clothing enhances heat loss
Exhaled respiratory vapors add to the heat
loss

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Notice how you see your breath in cold weather?
Example: Stepping out of a shower on a cold
winter morning, you warm up immediately
after drying off
13
Review Question???

When a person is exposed to cold
temperatures and strong winds for extended
period of time, heat is lost mainly through:

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A. Radiation
B. Convection
C. Conduction
D. Evaporation
14
Answer: B - Convection

Convection occurs when heat is transferred to
circulating air (cool air moves across body
surface). If person is wearing light clothing
and standing in the cold, windy weather, lose
heat mostly by convection.
15
Respiration

As you breathe, you inhale ambient air

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In cold climates, this can cool the core
When you exhale you lose moisture and with it goes
heat
Heat is lost with ventilations via the processes of
convection, radiation, and evaporation via lungs
Expired air usually 98.60F (370C) and 100%
humidified
16
Heat Conserving Mechanisms

Vasoconstriction

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Piloerection – goose bumps

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Via sympathetic nervous system
Skin pale, cool
Evolutionary remnant
Increased heat production

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Shivering
Chemical thermogenesis (heat generation by body)
Increased thyroxine release
  rate of cell metabolism
17
Predisposing Risk Factors
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Age
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General health/ predisposing medical conditions

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Hypothyroidism, diabetes, Parkinson’s, malnutrition
Presence of fatigue

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Especially young children and older adults
 Less developed heat-generating mechanisms
Increases poor decision making skills
Duration of exposure
Coexisting weather conditions
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Wind chill
Altitude
Humidity level
18
Risk Factors cont’d
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Certain medications that interfere with heatgenerating mechanisms
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Narcotics
Alcohol
Phenothiazines
Barbiturates
Antiseizure meds
Antihistamines
Antipsychotics
Sedatives
antidepressants,
Pain meds like aspirin, acetaminophen, NSAIDS
19
Body Temperature Levels

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Normal 96 – 1000F (37.80C)
Mild hypothermia 90 (320C) – 950F (350C)
Severe hypothermia – below 900F (<320C)
Below 860F cardiac resuscitation possible;
more favorable above 860F (300C)
20
Complications Anticipated

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Dehydration from cold diuresis
Hypoglycemia
Decreased CNS electrical activity
Coagulopathy disorders – clotting problems
Non-cardiogenic pulmonary edema
Cardiac dysrhythmias
 Atrial fibrillation common
 VF at 820F (<280C)
 Asystole at 680F (<200C)
21
Fluid Balance

Cold induced vasoconstriction increases fluid thru
kidneys

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Respond with diuresis
Tubules reabsorb less water increasing more diuresis
Fluid shifts intravascular space extravascular
space intracellular space
Reverses on rewarming so intravascular volume may
increase 30% above normal volume
22
Cold or Heat Emergencies

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Difficult to determine mechanism of injury by
appearance of wounds– cold or heat exposure?
Obtaining history very important
Field treatment does not differ for wound care
23
Pathophysiology

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In response to exposure to cold and wet
environments, blood vessels vasoconstrict
Vasoconstriction results in a decreased blood flow to
tissues especially in the periphery
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Ears, nose, fingers, toes
Cellular waste is not cleared and builds up
Dehydration occurs easily in the cold especially if
physically active
Injuries can occur at freezing AND non-freezing
temperatures
24
Stages of Hypothermia

Shivering
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Body’s attempt to generate heat
Begins around 94-970F (34.4 -360C)
Does not function around 84-880F (29-310C)
Mild hypothermia – 93-970F

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Conscious but displaying poor judgment and irrational
behavior
 B/P, HR, RR to retain & generate heat
 Cools more by inhaling cold air and exhaling moisture
and heat with ventilations
Skin may be red, pale, or cyanotic
25
Stages of Hypothermia cont’d

Moderate hypothermia – 86-92.90F

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Cognitive abilities declined; does not respond to
painful stimuli
Progressive muscular rigidity
 B/P, HR, RR leading to cardiac dysrhythmias
Severe hypothermia – core below 860F

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Unconscious; no response to pain
VS barely or non-detectable
26
Review Question???

What does shivering in the presence of
hypothermia indicate?

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A. Musculoskeletal system damaged
B. Nerve endings are damaged causing loss of
muscle control
C. Body is trying to generate more heat thru
muscular activity
D. Thermoregulatory system has failed and body
temperature is falling
27
Answer: C – Generating more heat

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Shivering in presence of hypothermia
indicates that body is trying to generate more
heat (thermogenesis) through muscular
activity
In early hypothermia, shivering is voluntary
attempt to produce heat
As hypothermia progresses, shivering is
involuntary
28
Frostnip
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Skin freezing but deeper tissues unaffected
Usually affects ears, nose, fingers
Usually not painful until rewarming
Skin pale, cold to touch
May report loss of feeling and sensation to
injured areas.
29
Progression of Frostbite Damage
2 weeks

Initial insult
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4 weeks
30
Trench Foot

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1st noted in Napoleon’s army 1812
Particular problem in trench warfare during
winters

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Has even occurred at winter festivals
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WW I, WWII, Vietnam War, Falkland’s War 1982
1998, 2007, 2009, 2012
Can lead to gangrene and amputation
31
Trench Foot

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Feet are cold and wet while wearing
constrictive footwear
Temperatures do not need to be freezing

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Has occurred in 600F temperature with 13 hour
exposure
Keeping feet cold and wet for extended periods is
the key causative factor
Excessive sweating is a contributory factor
Prevention – keep feet warm and dry!!!
32
Trench Foot

Exposure followed by blistering
33
Frostbite

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Freezing of tissue,
usually skin, when
blood vessels
contract
Blood flow and
oxygen is reduced
to affected body
tissues
34
Frostbite

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There are three degrees of cold injury
Classified by depth of injury and clinical presentation

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Frostnip
Superficial frostbite
Deep frostbite
Ice crystals form; expand and damage surrounding
tissue
Damage dependent on length of exposure and depth of
damage
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If frozen tissue dies, would lead to amputations
35
Frostbite

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Normal sensation is lost; area becomes numb
Color change noted in tissues
Most affected are body parts farthest from the
core
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Highest risk population
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Nose, ears, fingers, hands, feet, and toes
Children, elderly, those with circulation problems
Majority of cases in adults 30-49 year-old
36
Frostbite

Don’t break blisters

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Is this a problem???
Serve as protective
bandaging
Treat as a burn

Can’t tell if
wounds are from
cold or heat
exposure without
knowing the
history
Frostbite on a climber parts of digits eventually needed
amputation
37
Preparing Site for Treatment

Any constrictive jewelry or other pieces
MUST be removed

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As extremities/digits swell, any circumferential
articles will further constrict blood flow
Any article removed from patient MUST be
documented that they were removed
Document what you did with the articles

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Given to patient/significant other?
Turned over to ED staff?
38
Pain Management

Rewarming is a VERY PAINFUL!!! process
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Once started, rewarming must continue regardless
of the pain the patient is experiencing
Superficial frostbite is rewarmed over
approximately 20- 40 minutes
Deep frostbite may take an hour to rewarm
Constantly reassess pain levels and document
39
Dressing Application

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Use fluffy, loosely wrapped dressings
Separate digits with gauze

Do not want skin on
skin – may become
stuck together and
separating will cause
more tissue damage
40
Adult Hypothermia/Cold Emergencies

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Adult Routine Medical Care (Region X SOP)
Frostbite
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Move patient to a warm environment
Rapidly rewarm frozen areas (of frostbite) with warm
water if available (1000 – 1080F)
OR
Hot packs wrapped in a towel (not with direct contact to
fragile tissue)
Handle skin like a burn
 Light, dry sterile dressing; skin surfaces not to rub
together
 Elevate and immobilize
Manage pain appropriately
41
Rewarming Shock

Hazard of rewarming extremities

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Drop in core temperature if extremities rewarmed
pushing colder blood into core
Recommended to rewarm thorax only and not
hands or feet with hot packs
Occurs due to peripheral reflex vasodilation

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Cooled blood returns to core and metabolic acid
(wastes) from extremities
May have paradoxical drop in core temperature
further worsening hypothermia
42
Pain Management Region X SOP

Fentanyl 0.5 mcg/kg IVP/IN/IO

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May repeat in 5 minutes
Same dose as initial dose
Max total dosing of 200 mcg
 FYI - A 450 pound patient would get 200 mcg by 2 doses
Synthetic narcotic
Less cardiovascular side effects than experienced with
Morphine
Availability of IN route is advantage
43
Basic Principles to Interventions

Move the patient to a warmer environment
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Remove any wet clothing
Do not allow any body part to refreeze after
warming
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Get out of the elements of wind, wetness, and cold –
prevent further heat loss
A freeze, thaw, refreeze cycle is more damaging to tissue
than prolonged freezing alone
Do not massage tissues
Do not allow patient to walk
44
Systemic Hypothermia SOP
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Avoid rough handling and excess activity
Apply heat packs to axilla, groin, neck, thorax
Assess for presence of pulse

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If present, continue assessment
If absent, cannot withdraw resuscitative efforts
until warmed
45
EKG Changes in Hypothermia

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Prolongation of the PR interval; then QRS;
then QT interval
J waves (Osborn waves) can occur at any
temperature less than 900F (32.30C)

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Most frequently seen in Lead II and V6
As temperature drops, J wave increases
 Can be confused with ST elevation indicating
acute MI
46
J wave (Osborne waves) –
Development in Hypothermia
47
Severe Hypothermia

Signs and symptoms
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Absence of shivering
Dysrhythmia
Loss of voluntary muscle control
Decrease blood pressure
Undetected pulse and respirations
Cardiac arrest
48
Systemic Hypothermia SOP cont’d

No pulse

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Begin CPR
Evaluate extremities – can they be flexed?
If no,
 Follow appropriate cardiac protocol based on
rhythm noted
 If defibrillation required, limit to one shock
 Do not administer medications – they will
not circulate effectively
49
Systemic Hypothermia SOP cont’d

No pulse

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Begin CPR
Evaluate extremities – can they be flexed?
If yes,
 Follow appropriate cardiac protocol based on rhythm
noted
 If defibrillation required, repeat as core temp rises
 To administer medications – extend time between
medications

Distribution slowed in the cold state
50
Active vs Passive Rewarming

Passive

Using person’s own heat generating abilities

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Moving to warm environment
Blankets
Dry clothing
Active

Applying warming devices externally

Hot packs or heating pads placed in areas with
superficial blood flow
 Neck, arm pits, groin
51
Question

Which of the following is NOT an example of
passive rewarming?


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A. Removing cold, wet clothing
B. Administration of fluids by mouth
C. Turning up heat in ambulance
D. Covering patient with a blanket
52
Answer: B – Fluid by mouth

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Passive rewarming involves allowing a
patient's body temperature to rise gradually
and naturally.
Remove wet clothing
Turn up heat in ambulance
Cover with a blanket
Drinking warm fluid is active rewarming
53
Induced Hypothermia in ROSC



Research indicates controlled induction of
hypothermia could be protective to the brain
and other organs
General consensus is to cool patient to
32 – 34 0C for 12-24 hours (89.6 – 93.20F)
Patient can be placed on ventilator while being
cooled and taken to the cath lab

Cooling does not interfere with these interventions
54
SOP- ROSC Hypothermia Induction

Indications
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Any patient after out of hospital cardiac arrest
Remains unconscious and unresponsive
ROSC greater than 5 minutes
Able to maintain systolic B/P>90 with or without
vasopressors
Airway secured
Presumed cardiac etiology
55
SOP- ROSC Hypothermia Induction

Relative Exclusions
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Major head trauma or traumatic cardiac arrest
Recent major surgery within 14 days
Systemic infection
Coma from other causes such as drug induced or overdose
Active bleeding
Hypothermia is not recommended for isolated respiratory
arrest
Suspected hypothermia already present 340C/93.20F
56
SOP- ROSC Hypothermia Induction
If patient meets inclusion criteria with no relative
contraindications, induce pre-hospital
therapeutic hypothermia
 Place ice packs in axilla and around neck and
groin
 Place an ice pack over the IV/IO site
 If shivering, contact Medical Control for
possible medication order
57
Cooling after ROSC

Ice paks place under neck, in armpits, in groin
58
Marine Corps “COLD” Protection
Principle & Preventive Measures

C – clothing free of dirt & oil


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O – avoid overheating that causes you to
sweat wetting clothing
L – layer correctly to trap air between layers

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Insulation capability declines
Avoid constrictive clothing
D – keep clothing dry

Wet clothing means wet skin
59
Review of Initiating IV Access

Under Routine Medical Care, IV access is
established based on patient's condition


If stable, may establish saline lock
Develop habit of always adding the saline
lock/extension tubing to the IV catheter

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Exact saline lock device may be different
depending on where you replace your supplies
They all work on the same principle
60
Establishing Saline Lock

Equipment

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IV start pack
IV catheter
Saline lock
Saline flush
IV bag if
indicated
61
IV Site Prep



Skin prep applicator contains antiseptics
chlorhexidine and isopropyl alcohol
Cleanse site for 30 seconds
Allow to air dry for 30 seconds


Do not blot or wipe away antiseptic
FYI – some hospitals have a policy to
automatically change in-field IV sites

Consider IV’s started in less than the best,
cleanest conditions
62
Benefit Saline Locks/Extension Tubing


Gain IV access in case of patient deterioration
If IV tubing connected, easier on the patient for staff
to change the IV tubing avoiding manipulation of the
IV catheter at the site of insertion


Reduces the incidence of irritation that could lead to
phlebitis at the site
IV can be started with or without use of the saline
lock – some ED staff prefer the additional length of
tubing the saline lock provides
63
Mechanical Skills Using Equipment


Personnel preference starting IV with saline lock
Place IV catheter




Then add individual pieces to the line
 Saline lock, flush, remove syringe, attach IV tubing
OR
Attach saline lock to IV tubing; prime the whole line; then
attach to IV catheter
Neither way is more right/wrong than other
Just another way to get to the same end result
64
Adding IV Bag of Fluid – 1 Method


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
Pre-connect saline lock to IV tubing
Spike IV bag
Run through IV tubing AND saline lock as one unit
Keep cap on distal end of tubing to keep tip sterile
Initiate IV
Connect primed IV tubing, with saline lock attached,
to IV catheter
Check for patency and adjust IV flow rate
Secure tubing
65
IV Start with Saline Lock – Alternate
Method

Spike IV bag and run out IV tubing, set aside







Keep cap on distal end of tubing to keep tip sterile
Flush saline lock; can leave flush syringe attached
Initiate IV
Connect saline lock to IV tubing
Flush the line and check for infiltration, remove
syringe
Swab port and connect primed IV tubing to saline
lock; confirm IV flow rate
Secure tubing
66
IV Don’ts



Don’t add gauze under the tape - increases the
risk of infection
Don’t leave site wet with blood if possible
Do not leave large loops of tubing that could
be inadvertently pulled
67
IV Tips

Cover insertion site with op-site type product


Site can be observed for changes
Entire catheter tip should be inserted up to hub
68
Infection Control



The main risk factor for infections is the
presence of a medical device in a patient
Field environments usually less than optimal
compared with healthcare facilities related to
sterility of equipment
Hand hygiene is the first step in infection
control


Handwashing before and after every patient
Clean gloves used for invasive skills
69
Routes of Infection with Catheter Use


Migration of organisms on patient’s skin from
site of insertion, along catheter, to catheter tip
Contamination of equipment via direct contact

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
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Improperly cleaned hands/glove use
Improper handling of equipment
Contaminated injection ports not cleaned prior to
use for injection
Contamination of IV solution – rare
occurrence
70
Infection Prevention



Have you contaminated the IV catheter?
Have you kept the distal tip of the IV tubing
covered?
If you rip your tape early, where did you put
it?


Are you sure the side of the cot is clean???
Are you sure the side rails of the cot are clean all
the way around???
71
Scenario Discussions




Participate in discussions of the following
cases
Determine your general impression
Decide on treatment/interventions you would
initiate
Review outcomes
72
Scenario #1


24 year old male found unresponsive outdoors
Ambient temperature late afternoon – 450F


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
Cloudy
71% humidity
Winds calm
Background information:




Unknown length of time down
O-O-O
Monitor showed ventricular fibrillation
Patient worked as a full arrest
73
Scenario #1 – Time of year - January




Found by passer-by unresponsive laying face
down in mud 200´ off road
Rolled over prior to EMS arrival
Found cold, pale, apneic, pulseless, pupils
fixed and non-reactive
O-O-O
What would you do if this were your call?
74
Scenario #1 - Narrative



“Moved to ambulance; c-collar and back board
applied; clothes removed; CPR started with
active warming process”
“Rapid trauma assessment no trauma found”
What else do you need/want to know for
assessment information that would help guide
decision making for care of this patient?

Do extremities flex or not?
75
Scenario #1

Skills as listed in Image Trend

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BVM
Airway clearing
Spinal immobilization
Warming with hot packs
Defibrillation x5
King airway
IO access lower left extremity
Medications: Epinephrine, Amiodarone, Narcan
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Scenario #1 – Questions


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


Hypothermic patient – Could extremities be flexed?
BVM – What rate???
Airway cleared – Why? What method?
Spinal immobilization – What method/equipment?
Hot packs – Where were they placed?
Defib- When was each individual one delivered?
King airway – What size? Placement confirmed?
IO access – What length and size needle? Was
patient banded?
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Scenario #1 - Medications

VF per monitor
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
Epinephrine 1;10,000 – 1 mg IO
Epinephrine 1;10,000 – 1 mg IO
Amiodarone 300 mg IO
Epinephrine 1;10,000 – 1 mg IO
Epinephrine 1;10,000 – 1 mg IO
Narcan 2 mg IO
What do you think of the medication order for
VF?
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Scenario #1 Follow-up


Patient was resuscitated, admitted to ICCU
Patient regained consciousness


Protected by hypothermia and sedation of selfadministered drugs
Patient survived to discharge

Awake, oriented, able to care for self (eat, dress, walk)
Unbelievable but true!!!
And a VERY lucky gentleman
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Scenario #2
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43 year old female developed chest pain 7/10
while at work
History hypertension
VS: B/P 153/100; P – 86; R-16; SpO2 99% RA
Unable to establish IV
Given 4 baby ASA to chew
Administered 1 NTG sl due to the pain
Then obtained 12 lead EKG
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Scenario #2 – Any ST elevation?
II, III, aVF
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Scenario #2


Were the interventions appropriate?
How would you have handled the call?


If unable to obtain IV access, need to contact
Medical Control prior to administration of NTG
Need to obtain a 12 lead EKG prior to NTG
 Need to review for ST elevation
 If ST elevation in II, III, aVF (inferior
leads), need to contact Medical Control
prior to administration of NTG
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Scenario #2




In the field, no negative effects from NTG
dose
In the ED, 12 lead EKG was normal
Taken to cath lab based on EMS 12 lead
During procedure, might have seen distal
blockage that resolved


Catheter maneuvers may have dislodged a clot
and reopened a vessel
Patient to undergo further testing
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Scenario #3



A 19 year-old female had walked several
miles in a frozen field
Feet are white, hard, and cold to touch
You determine that she has frostbite in both
feet
What would you do if this were your call?
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Scenario #3 – Pick the best answer:
Treatment at the scene should include:
A. Rubbing feet gently with your warm hands
B. Having her walk around to restore circulation
C. Removing her wet clothing and rubbing her
feet briskly with a warm, wet cloth
D. Removing her wet clothes and covering her
feet with dry, sterile dressings
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Scenario #3 – Answer D

Rationale #D




To treat frostbite, remove any wet clothing
Cover injured area with dry, sterile dressings
Do not break any blisters
Do not apply heat to rewarm area if there is any
chance of refreezing
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Scenario #3 – Explanations of wrong
answers:
#A - Do not rub or massage frostbitten areas

Increases tissue damage
#B – Walking on frostbitten feet increases tissue
damage

Ice crystals have formed in the tissues and
movement, rubbing, massaging increase damage
to surrounding tissue
#C – Never rub cold injured skin; if allowed to
freeze, thaw, freeze, increase in damage to
tissues occurs
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Scenario #4
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

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
30 year old male who fell through the ice
In water 20 minutes; exposed additional 10
minutes while getting to shore
VS: 158/84; P – 120; RR – 30; SpO2 99% RA
GCS 15
Denies pain
IV access; cardiac monitor
88
Scenario #4


Pt wearing snow mobile suit and helmet while in the
water
In ambulance, clothing removed


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Dried
Covered with blankets
Hot packs applied
Pt red, shivering
Complained of no feeling in right foot; all
extremities move well
89
Scenario #4

What do you think – care and documentation?




What was the ambient temperature?
What did the monitor show?
Was a hot pack placed over the IV site?
What does it mean when a patient shivers?
90
Scenario #4

Shivering indicates the patient is still capable
of generating heat through the action of
shivering

Passive rewarming used patient’s own body heat




Removed from cold environment
Removed wet clothing
Covered with a blanket
Active rewarming

Hot packs placed in the neck, armpit, and groin areas
91
Scenario #5



You are called to the scene for a 27 year-old
male who immediately became unconscious
after being elbowed in the chest
Upon arrival CPR is being performed; patient
confirmed to be 0-0-0
With this initial rhythm, what is your action?
Ventricular fibrillation
92
Scenario #5




When confirming a patient is in VF, provide CPR
First action with arrival of equipment is to get
monitor on patient to view rhythm
 Rhythm viewed with patient presentation drives
decision making
As soon as monitor is ready, stop CPR
If VF/pulseless VT seen, immediately defibrillate
 Immediately resume CPR after defibrillation
starting with compressions
93
Scenario #5 – Following Region X
SOP’s




First shock delivered
CPR resumed; attempting to establish IV access
After 2 minutes, CPR paused for max of 10
seconds to reevaluate rhythm
What is your next action when seeing this on the
monitor?
Check for a pulse!!!
94
Why Limit CPR Pause to <10 sec?

When compressions interrupted, blood flow
drops rapidly



Decrease in intrathoracic pressures
Takes awhile to regenerate adequate perfusion again
Maintain a rate of at least 100 compressions per
minute



30:2 in 1 man and 2 man adult CPR
Once intubated, compressor stops only after 2
minutes of CPR for rhythm check
Ventilations are asynchronous
95
Importance of Adequate Compression
Rate During CPR


Lengthy pauses in CPR detrimental to blood
flow and ultimately the patient
Takes a few compressions to build up enough
pressures to be effective after each pause
96
Negative Effects of Hyperventilation


Hyperventilation blows off CO2
Decreased CO2 causes reflexive vasoconstriction


Excessive ventilation can result in gastric inflation



Increases risk of vomiting and aspiration
Excessive ventilation rate increases intrathoracic
pressures


Limits volume of oxygenated blood perfusing to the brain
Can compromise venous return to the heart and diminish
cardiac output
Ventilate once every 5-6 seconds with BVM
Ventilate once every 6-8 seconds via ETT or King
97
Scenario #5



When viewing a rhythm that should generate
a pulse, including VT, NOW appropriate to
check for a pulse
If no pulse, rhythm PEA, resume CPR
If pulse, reevaluate patient




Responsiveness
Airway/ventilation status
Blood pressure
12 lead EKG
98
Scenario #5 – Any ST elevation?
Sinus Tach - NO ST elevation
99
Scenario #5

So why did this patient arrest?


Commotio cordis – concussion of the heart
 Instant cardiac arrest from a non-penetrating blow to
the chest wall
 Diagnosis made by exclusion of other etiologies
 If blow made immediately before peak of T wave, VF
can develop
 Improved survival rates to immediate CPR and rapid
defibrillation
See October 2012 CE for additional discussion
100
Bibliography






American Heart Association. 2010 Guidelines for
CPR and ECC. 2010.
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles & Practices, 4th edition. Brady. 2013.
Siegel, M., Kraemer-Cain, J. PICC Line Care at
Home. Advance for Nurses. September 26, 2011.
Region X SOP’s; IDPH Approved January 6, 2012.
http://www.cdc.gov/niosh/docs/2010-115/pdfs/2010115.pdf
http://en.wikipedia.org/wiki/Hypothermia
101