Drill of the Month Developed by Gloria Bizjak

1. Drill of the MonthDeveloped by Gloria Bizjak Recognizing and Managing Cold Emergencies: Frostbite and Hypothermia

2. Recognizing and Managing Cold Emergencies: Frostbite and Hypothermia Student Performance Objective: Given information, resources, and opportunity for discussion and practice, EMTs will be able to: • Describe types of frostbite and hypothermia • Describe signs and symptoms • Demonstrate patient assessment and care EMTs will follow acceptable Maryland medical practice and Maryland Medical Protocols for Emergency Medical Providers. Drill of the Month

3. Altered Mental Status: Assessing and Managing Seizure Patients Overview • Frostbite description and classifications • Frostbite signs and symptoms • Frostbite assessment and emergency care • Hypothermia description and classifications • Hypothermia signs and symptoms • Hypothermia assessment and emergency care • Practice assessment and care Drill of the Month

4. Frostbite • Description • Freezing of a distal or small body part from prolonged cold exposure • Cold air • Contact with a cold object • Wind and/or water chill Drill of the Month

5. Frostbite • Description • Local cooling injuries to extremities • Feet and toes • Hands and fingers • Face: nose and cheeks • Ears Drill of the Month

6. Frostbite • Description • Known by several names • Frostnip • Immersion foot (trench foot): Injury to skin, blood vessels, and nerves of the feet from continuous immersion in water, even in above freezing conditions • Chilblains (pernio): Inflammation of the hands and feet from repeated exposure to cold and moisture Drill of the Month

7. Frostbite • Description • A result of prolonged cold exposure, outdoors as well as indoors, constricting blood vessels in the extremities, which diverts warm blood flow and oxygen to central vital organs • Constriction cycles with dilation to preserve functions of extremities Drill of the Month

8. Frostbite • Description • As the body temperature continues to drop, the brain permanently constricts vessels in extremities to maintain warmth in vital organs: frostbite begins • Cell death due to exposure • Ice crystals form in the space outside cells • Cells become dehydrated Drill of the Month

9. Frostbite • Description • Cell deterioration from of lack of oxygen and water • Lining of blood vessels is damaged • Blood leaks from vessels on rewarming • Small clots form causing blood flow problems and inflammation • Inflammation causes further tissue damage Drill of the Month

10. Frostbite • Classifications • Superficial (early stage) • Blood flow is restricted to body parts • Body parts freeze • Ice crystals form inside tissues • Deep (late stage) • Gangrene sets in due to cell dehydration and oxygen loss • The part may have to be amputated, even after months of trying to heal Drill of the Month

11. Frostbite Signs and Symptoms • Superficial (early stage) • Patient may complain of burning, numbness, tingling, itching, or cold in affected areas • Affected part first appears red, then turns mottled, bluish, white, or grey as the flesh continues to freeze • Dark skin: the skin color lightens, then blanches and will quickly turn bluish or grey • Skin feels frozen/stiff/rigid; has some pliability when pressed Drill of the Month

12. Frostbite Signs and Symptoms • Deep (late stage) • Patient may complain of decreased sensation, then lose all sensation or feeling • Affected part swells, develops blood-filled blisters over white/yellowish waxy-looking skin • Skin feels hard with no pliability when pressed • Affected part may appear black Drill of the Month

13. Frostbite Signs and Symptoms • Deep (late stage) • On rewarming • Affected part turns purplish-blue • Painful aching as blood flow returns to tissues • Throbbing begins in 2 – 3 days; may last months • Part may never heal and may require amputation Drill of the Month

14. Frostbite Assessment and Care • Assessment: Perform General Patient Care (Maryland Protocols) • Size up the scene; gather info on approach • Perform initial assessment • Superficial • Look for color changes: light skin reddens; dark skin lightens; both blanch followed by color changes • Feel area for pliability • Ask patient how it feels: patient may report numbness, tingling, burning, etc. Drill of the Month

15. Frostbite Assessment and Care • Assessment: Perform General Patient Care (Maryland Protocols) • Size up the scene; gather info on approach • Perform initial assessment • Deep • Check skin appearance: white, waxy skin turns mottled or blotchy, then to grayish yellow to grayish blue • Look for swelling and blistering • Gently palpate: Does surface feel frozen w/no pliability in underlying tissue? Do not squeeze affected part • Ask patient how it feels Drill of the Month

16. Frostbite Assessment and Care • Assessment: Perform General Patient Care (Maryland Protocols) • Perform focused history and physical exam • Follow treatment protocols • Communicate with hospital or other response personnel • Disposition: determine priority and mode of transport Drill of the Month

17. Frostbite Assessment and Care • Emergency care (adults or peds) • Remove patient from cold environment • Outside: Place patient in heated ambulance, wrap in blankets • Inside: Turn up heat while working in patient’s home, wrap in blankets, move to heated ambulance Drill of the Month

18. Frostbite Assessment and Care • Emergency care (adults or peds) • Gently handle frostbitten areas • Do not rub affected areas • Ice crystals in tissues cause further damage • Wrap affected area gently, loosely with gauze • Patient may complain of tingling/burning: these are normal sensations Drill of the Month

19. Frostbite Assessment and Care • Emergency care (adults or peds) • If patient does not respond to simple treatment, begin care for deep frostbite • Provide high-concentration oxygen • Provide rapid transport • If transport is delayed, re-warm affected part only on medical direction • Do not allow patient to smoke or consume caffeine or alcohol (vasoconstrictors, raise blood pressure) • Do not allow patient to use affected part or walk on affected feet Drill of the Month

20. Frostbite Assessment and Care • Emergency care (adults or peds) • Maintain a warm environment: do not re-expose patient to a cold environment • Reassess: recheck vital signs, recheck injury treatments and medical status • Transport/transfer/transition patient and information Drill of the Month

21. Hypothermia • Description • Generalized body cooling as a result of prolonged cold exposure • Reduces body heat • Prevents body from maintaining proper core body temperature • Can be life-threatening Drill of the Month

22. Hypothermia • Description • Loss of body heat through several methods • Radiation: heat lost to environment from what body gives off (radiates) • Conduction: heat lost by contact with or immersion in cold water or snow • Convection: heat lost by cold water flow or air currents • Evaporation: heat lost through perspiration or wet skin • Respiration: heat lost through expired breaths—warm air to cooler environment Drill of the Month

23. Hypothermia • Description • Abnormally low core body temperature • 95°F or below • Life-threatening at 90°F and below • Core body measurements • Oral measurement: 96.8 to 98.6 °F (affected by liquid and food intake and breathing) • Rectal temperature: 0.9 °F higher than oral • Axillary temperature: 0.9 °F lower than oral • Tympanic temperature: very close to oral measurement Drill of the Month

24. Hypothermia • Classifications: Mild to moderate — 95°F to 90°F core body temperater: Caused by a cold environment • Affects healthy individuals with prolonged exposure • Can quickly affect at-risk individuals • Patients with major trauma and shock, chronic illness, circulatory disorders, infection, burns, and diabetes Drill of the Month

25. Hypothermia • Classifications: Mild to moderate — 95°F to 90°F core body temperature: Caused by a cold environment • Can quickly affect at-risk individuals • Elderly persons in an environment with cool ambient temperature (low thermostat in winter), diet, illnesses, medications, sedentary living Drill of the Month

26. Hypothermia • Classifications: Mild to moderate—95°F to 90°F core body temperature: Caused by a cold environment • Can quickly affect at-risk individuals • Infants and children with their large skin surface to body mass ratio, little fat, and small muscle mass (resulting in no shivering, a typical early warning sign) Drill of the Month

27. Hypothermia • Classifications: Severe, or extreme • Body temperature below 90°F • Presents an unconscious cold patient in a cold environment with no apparent vital signs (heart rate <10 beats per minute) • Patients will not reach biological death for at least 30 minutes: resuscitate • Do not assume death based on body temperature and no vital signs Drill of the Month

28. Hypothermia Signs and Symptoms • General • Vary with patient factors, length of exposure • Shivering, becomes intense; ceases in severe hypothermia • Dizziness and confusion • Numbness, stiffness, rigidity in posture, weakness • Impaired judgment, speech, and vision, glassy stare Drill of the Month

29. Hypothermia Signs and Symptoms • General • Vary with patient factors, length of exposure • Drowsiness, decrease in consciousness to unconsciousness • Cool abdominal skin temperature to your touch (back of your hand) • Reddened skin turning to pale and cyanotic with prolonged exposure (dark skin initially white turning cyanotic) Drill of the Month

30. Hypothermia Signs and Symptoms • Specific • Mild to moderate (core body temperature 90 to 95°F • Shivering, which becomes intense (generates body heat until muscles are fatigued) • Pulse and breathing rates and blood pressure initially increase • Vital signs drop as body temperature drops • Apathy: patient becomes clumsy, apathetic, confused, and has slurred speech (as if drunk) Drill of the Month

31. Hypothermia Signs and Symptoms • Specific • Severe (core body temperature less than 95°F) • Loss of consciousness • Shivering stops • Oxygen intake drops • Heart rhythm becomes irregular • Patient loses consciousness Drill of the Month

32. Hypothermia Signs and Symptoms • Specific • Severe (core body temperature less than 95°F • Continued decrease of pulse and breathing rates • Appearance of death, close to death • No reflexes • Brain activity slows • Pupils dilate • Risk of lethal irregular heart rhythm increases • Patient appears dead at 82°F Drill of the Month

33. HypothermiaAssessment and Emergency Care • Assessment: Perform General Patient Care (Maryland Protocols) • Size up the scene and gather info on approach • Perform initial assessment • Assess mental status: check patient’s orientation to person, place, time • Check airway, breathing, circulation Drill of the Month

34. HypothermiaAssessment and Emergency Care • Assessment: Consider the following • Air temperature, wind chill or water chill • Patient’s age • Clothing worn by patient • Patient’s general health, illnesses and medications, or injuries • Activity at time of incident • Use of alcohol or drugs • Mental status and motor function, which decreases with degree of hypothermia Drill of the Month

35. HypothermiaAssessment and Emergency Care • Assessment • Perform focused history and physical exam • Follow treatment protocols • Communicate with hospital or other response personnel • Disposition: determine priority and mode of transport Drill of the Month

36. HypothermiaAssessment and Emergency Care • Emergency care (adults or peds) • Quickly remove patient from cold environment • Handle gently—rough handling may cause cardiac arrest • Resuscitate as necessary • Assess pulse for 30 – 45 seconds • No pulse, start CPR • Prepare to use AED if indicated Drill of the Month

37. HypothermiaAssessment and Emergency Care • Emergency care (adults or peds) • Use passive rewarming methods to prevent further heat loss • Remove wet or frozen clothing • Wrap patient in thermal blankets and other insulating material • Cover the patient’s head • Administer warmed oxygen, if possible/available Drill of the Month

38. HypothermiaAssessment and Emergency Care • Emergency care (adults or peds) • Maintain a warm environment: do not re-expose to cold environment • Reassess patient • Recheck vital signs • Recheck injuries and treatment • Recheck medical status • Transport/transfer/transition patient and information Drill of the Month

39. Practice • Demonstrate assessment and care of patients exposed to cold environments based on Maryland Medical Protocols • General patient care steps for superficial and deep frostbite patients • General patient care steps for mild to moderate hypothermia patients • General patient care steps for severe hypothermia patients, including resuscitation and AED Drill of the Month

40. Recognizing and Managing Cold Emergencies: Frostbite and Hypothermia Student Performance Objective: Given information, resources, and opportunity for discussion and practice, EMTs will be able to: • Describe types of frostbite and hypothermia • Describe signs and symptoms • Demonstrate patient assessment and care EMTs will follow acceptable Maryland medical practice and Maryland Medical Protocols for Emergency Medical Providers. Drill of the Month

41. Altered Mental Status: Assessing and Managing Seizure Patients Overview • Frostbite description and classifications • Frostbite signs and symptoms • Frostbite assessment and emergency care • Hypothermia description and classifications • Hypothermia signs and symptoms • Hypothermia assessment and emergency care • Practice assessment and care Drill of the Month