warm weather emergencies firework injuries legal review of intoxicated person
TRANSCRIPT
Warm Weather EmergenciesFirework Injuries
Legal Review of Intoxicated Person
Definition and description Immersion Submersion Drowning
Immersion syndrome Sudden cardiac arrest caused by massive
vagal stimulation after sudden exposure to cold water
Postimmersion syndrome Delayed deterioration of a previous
asymptomatic or minimally symptomatic patient
Shallow water blackout Unconsciousness after submersion
Epidemiology & demographics Second leading cause of accidental death
in US Leading cause of accidental pediatric
death Teenagers second major group Elderly third highest group
Etiology Classic sequence starts with panic
Victim can no longer hold breath, reflexively takes a breath, and water enters mouth
Victim takes several violent intakes of air and water while flailing
Etiology Water intake hits posterior oropharynx
Laryngospasm Bronchospasm Severe hypoxia Acidosis Cardiac disturbances CNS anoxia Coma
Physical findings Often accompanied by trauma Cardiac disturbances common Hypothermia common
Differential diagnosis Trauma Spinal injury Cardiac disturbances Hypothermia Hypoglycemia CNS disturbances Metabolic abnormalities
Therapeutic interventions Priority is reversing hypoxia If any resuscitation is required, patient
must be transported
Complications Sudden respiratory arrest ARDS Release of fluid into alveoli Inflammation of alveoli and lung tissue Loss of surfactant Atelectasis Aspiration pneumonia Pneumothorax
Homeostasis State of equilibrium
Homeotherm Body that strives to stay within 1° of norm
Thermoregulation Thermoreceptors Brain Skin Spinal cord Abdominal viscera Great vessels
Metabolism Increases to generate heat
External mechanisms of heat and cold response Radiation Exchange heat with surroundings Convection Air movement moves heat being radiated Conduction Direct contact with an object Evaporation Heat transfer mechanisms in tandem
External mechanisms of heat and cold response Involuntary responses
Perspiration Blood vessels Metabolism Piloerection
External mechanisms of heat and cold response Voluntary responses
Seek shelter from cold or heat Add or remove insulation
Outside contributors Wind velocity Humidity
External mechanisms of heat and cold response Predisposing factors
Age Health Medical history Shock CNS insult Burns Medications Skin conditions Mental history
Measures to prevent heat and cold injury Cold
Avoid long periods of exposure Cover exposed body surfaces Layer clothing Keep clothing and body dry
Measures to prevent heat and cold injury Heat
Avoid long periods of exposure Drink plenty of clear fluids Use shade to reduce heat Avoid using diuretics Avoid using amphetamines Limit alcohol intake
Heat cramps Muscle spasms Poor fluid level Overexertion with fatigue Sodium and electrolyte loss Extended exertion in heat
Heat cramps Physical findings
Cramps in fingers Arms Legs Abdomen
Heat cramps Differential diagnosis
Tetany Other heat emergency Simple muscle cramps
Therapeutic interventions Remove from heat Oral hydration of electrolytes IV solutions – nacl or LR
Heat exhaustion Dehydration & compensated hypovolemia Sweating Sodium & electrolyte loss Vasodilation with venous pooling Extended exertion in heat
Heat exhaustion Physical findings
Rapid shallow breathing Weak rapid pulse Flushed or pale skin Cool clammy skin Heavily sweating Normal core temp which can rise to 100-105° F May present with dehydration
Heat exhaustion Differential diagnosis
Uncomplicated dehydration Hypoglycemia Infection Intoxication Fatigue
Heat exhaustion Therapeutic interventions
Similar to heat cramps Remove from heat Supine Oral hydration of fluids/electrolytes IV solutions – nacl of LR Manage core temp
Heat stroke Increase in core temp over 105°F with
decreased LOC Hypothalamic temperature regulation lost Chain reaction within tissue Cellular death of brain, kidneys, liver Hallmark is altered mental status Metabolic acidosis Hyperkalemia
Heat stroke Classic heat stroke
Long periods of heat and humidity exposure Affects very young, very old, diabetics,
alcoholism and cardiac history Risks from diuretics, psychotropics,
anticholinergics Late sign – hot red dry skin
Heat stroke Exertional heat stroke
Sudden rise in core temp during exertion All age groups susceptible Patient not fluid deprived Skin may be sweaty
Heat stroke Physical findings
Altered LOC – disorientation, combative Unconsciousness Hallucinations Seizures Core temp above 40.6°C or 105°F Ataxia Tachycardia that slows near death Tachypnea progressing to bradypnea Hypotension often lacking diastolic
Heat stroke Differential diagnosis
CVA Hypoglycemia Infection Uncomplicated dehydration Intoxication Neuroleptic malignant syndrome
Heat stroke Therapeutic interventions
Goal -cooling core temperature Goal –replenish fluid Airway management Cardiac monitoring
NFPA Statistics In 2011, 9600 firework related injuries
treated in emergency rooms 8 out of 9 (89%) of injuries involved
“consumer use” fireworks In 2011, 17,800 reported fires were started
by fireworks
26% of victims were under 15 years old Injury rates apply to a range of ages;
the greatest being 5-19 years old and 25-44 years old
Males account for 68% of firework related injuries
61% to extremities 46% to the hands or
finger 11% to the legs 4% to the wrist
34% to parts of the head including the eye (17% of the total)
Sparklers, fountains, and novelties accounted for one-third (34%) of ER visits
More than half are thermal (burn) related
One quarter resulted in bruises or lacerations
3% of injuries occur as people are trying to escape an area of danger; sustaining a fracture or sprain
SCENE SAFETY is always the priority Assess trauma triage criteria
Burns >10% BSA of 2nd or 3rd degree should be considered
Burns with involvement to head, neck, or airway are high priority patients
Impaled objects through the abdomen or airway
Amputation of digits or extremities Spinal cord injuries associated with blunt
trauma or falls
Establish level of responsiveness Immobilize c-spine if indicated
check the neck prior to placing c-collar Airway assessment for patency Get good lung sounds if risk of inhalation,
assess work of breathing Identify and treat any life threatening
hemorrhages Check for neurological deficits
AVPU Motor & Sensory Pupils
SMO’s Code 22 (Thermal) Initial trauma care 100% Oxygen for stridor, hoarseness, or wheezing
(accelerated transport) Check for distal pulses in extremity burns Burn wound care
Use sterile gloves and mask if available Cool burns with sterile water or saline (<20% BSA) Dry sterile dressing or burn sheets for >20% BSA
Consider pain management Nitrous Oxide inhalation Morphine Sulfate 5-10mg IVP in 5mg increments every 5
minutes, if SBP>90. Do not give Morphine IM.
Secure object in place using whatever you can, however you can!
NEVER remove an impaled object unless it interferes with the patients airway, or EMS airway management
Think of “what lies below” to determine potential internal injuries, risk of hemorrhagic shock
“Intoxicated” may include Alcohol (ethanol) Illicit drugs (LSD, heroin, cocaine, GHB,
ecstasy, methamphetamine, etc.) Legally prescribed
medications(Hydrocodone, Oxycontin, Valium, etc.)
Mind altering substances such as inhaled chemicals, etc. (720 ILCS 690/ Use of Intoxicating Compounds Act)
Legal definition “The state of being poisoned; the condition
produced by the administration or introduction into the human system of a poison. But in its popular use this term is restricted to alcoholic intoxication, that is, drunkenness or inebriety, or the mental and physical condition induced by drinking excessive quantities of alcoholic liquors, and this is its meaning as used in statutes, indictments, etc.”
Black’s Law Dictionary
Medical definition Substance intoxication: “Reversible,
substance-specific, maladaptive behavioral or psychological changes directly resulting from physiologic effects on the central nervous system of recent ingestion of or exposure to a psychoactive substance, particularly alcohol”
http://medical-dictionary.thefreedictionary.com/intoxication
Both definitions refer to “alcohol” as a primary substance leading to intoxication
Both refer to a diminishment in psychomotor and cognitive function
Neither refer to any risk of harm
Assumption: There is some degree of Altered Mental Status
1. Is there a non-alcohol cause for Altered Mental Status?
2. Is there risk of harm?3. Does the individual have capacity to refuse
care?4. Is there someone who can take responsibility
for the patient?
Thorough history and physical examination
Blood glucose level Pulse oximetry EtCO2 if available
ANY history of trauma ANY suicidal threats or depression ANY significant co-ingestants ANY alcohol ingestion in the last hour ANY significant medical complaints ANY combative behavior ANY involvement of less-than-lethal
devices
ANY evidence of trauma beyond minor extremity
ANY significant derangement of blood glucose
ANY evidence of airway compromise ANY significant hypoxia/hypercarbia ANY abnormal vital signs
Is there a responsible caretaker? Is there an inherent danger in refusal? Is there a possibility of worsening BAL? Alcohol consumption history
What was consumed? What was the time period of consumption?
Trauma Rage (combative)
Airway compromise Narcotics/Co-ingestants Suicidal/Depression/Psychotic Pain (chest/abdomen/other medical
complaints) Oxygen low or CO2 high Risk of harm to self or others TASER (other less-than-lethal devices)
Ingestion recent/Extremely large (EtOH) Not normal vital signs Glucose low or high
Adult or qualified minor Alert and oriented GCS 15 Must appreciate the situation Must understand the medical
concern/diagnosid Must understand the consequences of
refusing care
EMS and the Hippocratic Oath
•We are not bound by Oath to “DO NO HARM”•As licensed agents through the Illinois Department of Public Health, and our EMS System Physicians, we are required to be competent in action and decision•Medical Control is NOT in place to defer provider risk•Regardless of Medical Control’s advice, ALL parties involved in patient care are responsible for outcome
•Using the combination of “Determining Capacity” and “Risk of Harm” will lead you to the right decision.
•This is the most subjective decision any EMS professional has to determine
•If there is ever any doubt, your best defense is to act in the best interest of the patient
You are summoned to a possible overdose. You assess and treat a 25 yr old male that is unresponsive with gasping respirations at 6/min. After administration of Narcan, the patient regains full sensorium; is alert and oriented to person, place, time, and events; admits to overdosing on heroin; and is refusing further care or transportation to a medical facility.
What lasts longer, the effects of Narcan or heroin?
What is his Determining Capacity? Are there any Risks of Harm to the
patient if he is allowed to refuse care?
Discussion……
Any Questions???