OK, well, thank you. I don't have a disclosure slide, so as you've heard, I'm a past president of the society. I also have been a consultant for Radiometer and a educational speaker for Baxter, but on sepsis, so nothing related to this. And much like Dr. Kaplan, I work for the federal government, but I clearly do not speak for the federal government. Now, like the last lecture, Dr. Efrem tried to cover all of trauma in 15 minutes. I'm going to do the same for environmental emergencies. And I have attempted to cone down and give you the highlights. In the online lecture, there is much more detail. And what I want to focus on in the environment is, first, these are the orphan questions, right? There's only going to be a small percentage, somewhere maybe up to 10% of your board exam will be on these orphan topics. But if you know the answer, that's one less question you have to worry about and one less opportunity that you have to take the test again. But more importantly, in the environment, these are the topics that, while you may not see them in your eyes hue, you may encounter them in your daily life, if you're a runner, at your kid's soccer games, whatever. So this is why I think it's important. Now, my question to the audience is, is there anyone in here who lives in an area that has not had at least one heat wave this summer? Anyone? No, right? The entire country, the entire world, this is the hottest summer on record. And that just shows the importance of heat illness. It is the number one killer of environmental emergencies, probably across the world. We don't have data, but we know, certainly in the United States, heat stroke is the number one killer. Now, since we've all had a heat wave, whose system has stacked ice and cooling tubs in their EDs or their ICUs? Anybody? One, two, right? So we're not prepared. But I'll argue with you that you actually do have a tub. And we do use, especially in a mass casualty situation, anybody can think of what, when I talk about this on the online lectures, body bags, right? Much easier, they fold up. We have lots of them, unfortunately. But you can fill a person in a body bag, fill it with ice water. So keep that in mind when you're during the summer or even other times of year when you have people that have heat stroke. First thing you have to do is identify them. It's pretty easy. You have the marathon runner, like in the earlier question, who collapses halfway through, especially if they're running a marathon in the summer. Or it's a heat wave, and they bring someone who's in who they haven't seen in a couple of days who's been found down at home. Those are the relatively easy ones. One of the first severe heat stroke patients that I saw early on in my career, it was a rainy, drizzly day. It was in the maybe 50 degrees. It was in November. It was one of the lead marathon runners had collapsed on the Philly Marathon. And because they're at mile 22 or 23, they're out by MCP, and they brought them in. She pinned the rectal thermometer when we took her temperature. Pinned it at 106. And unfortunately, whether EMS wasn't aware, I mean, usually at these events, you've got ice and cooling mechanisms. They didn't start cooling her until she got to the emergency department. That is a huge mistake, because these individuals, if you don't cool them rapidly and quickly, significant morbidity, significant mortality. And that's the thing to keep in mind. When we're talking, you want to get them cool within 30 minutes. Now, obviously, there's not any randomized controlled studies on this. The only randomized controlled studies in heat stroke are on healthy volunteers put in hot rooms and made to exercise. And they ethically, obviously, don't take them to the level of being altered. So all the data and information that we have out there is from events, typically case series. There's a great, I don't know if anyone's run the Falmouth run. I think it's a 10K run in Massachusetts. It's going into its 50th year. And they know, based on the temperature and what the humidity is, almost to the exact number, how many patients are going to have to deal with heat stroke during that race. Phenomenal data, but we have very few information like that. So first, you've got to identify these patients. The other ones that are challenging is when it's not the summer and not a heat wave. How many of you have gone to an older friend's house or your elderly relative's house? And you walk in, and it's 85 degrees because they are freezing. And they're bundled in like 10 blankets and 10 sweaters. And you walk in, you're like, oh my god, it is so hot in here. Keep that in mind in people who come in, perhaps with a pneumonia or maybe urosepsis, and they are altered. But they have a very high temperature. They may also have that classic non-exertional heat stroke. Important to keep in mind. The difference, obviously, the exertion like we talked about earlier, they're doing something. But they don't have to be running a marathon. During the heat waves, especially landscapers, those guys that are out there just holding that, when you have road construction going on, those stop signs that they spin, they talk on their radio, they're not really doing anything, those guys also are at risk for heat stroke. So you don't necessarily need to be exerting yourself to have exertional heat stroke, not like a marathon runner. And I talked about the rapid cooling. And then supportive care. In the ICU, what we need to do first is get them cool, get them rapidly cool. One of the risks of cooling, especially if you're using ice water, is you have to worry about frostbite. Keep an eye on where the ice packs are, making sure you're rotating them, changing them, never leaving it on, and direct contact to the skin because these patients will develop frostbites. That is a key thing to look for in your ICU. The other is it causes an environmental risk to your staff. Because if you've ever dealt with this ice, water, and cooling, there is water everywhere. I've seen more than one staff member go down. I've had a near miss once or twice myself. But keep in mind, it's a safety risk in the ICU. Now, this is in the CDR that I mentioned earlier today. I want to point out a couple of key things. First is you need to identify them. So we talk about making sure you've identified early and start cooling immediately. And start with what you have. So if you are at your kid's soccer game or you're a coach for your little league, make sure you have a plan. And once you've identified someone with heat stroke, do whatever you have available. That ice tub is great, but it's going to take you time to get it together. Only two people in the room have it already ready to go. Ice packs, cool water, get them out of their clothes, fans, whatever you need to do to start the cooling and start cooling it immediately. In the upcoming heat guideline, we have our patient advocate. His story was he was, I can't remember if it was high school or football player, and they started cooling him. They recognized immediately on scene, they started cooling him. But unfortunately when they put him in the ambulance, they stopped cooling him. And he's had some significant morbidity from that. He started recooling when he got to the emergency department, but don't let them stop. If you were on the sidelines, make sure that continues, key thing. And then once you start their cooling, obviously you're assessing their ABCs to begin with, start the IV fluids. But not everybody's gonna need large volume resuscitation. If you have the option, cool IV fluids are better, but evaluate them by POCUS. Do they need volume resuscitation as well? And if shock is present, they may need vasopressors. And you continually reassess them. You wanna get, if they're very unstable and you've intubated them, esophageal probe, but you need to be monitoring core temperature with the goal of being under 39 in 30 minutes. The literature shows that if up to 60%, depending on which case series you look at, can have significant morbidity where they aren't able to go back to work. I mean, that's a significant problem, right? You take a otherwise young, healthy individual who can no longer function well enough to earn an income. The other key thing to remember is at some point you gotta stop cooling them. Once you get to about 39 degrees, take everything off because you've got CNS dysregulation so that they are not gonna be able to auto-regulate their temperature. So you make sure you don't wanna go to turning them into hypothermic individuals. Once they reach 39 degrees, if they are still altered, you need to look for another process. I mean, they may not be back to their baseline, but they should have significantly improved. So if they haven't significantly improved, you may need to look for cerebral edema or get an EEG. They may have subclinical status or there may be another process going on, just how we talked about the older individual in the winter who's had their temperature at home up to 85 degrees and comes in, they're also Euroseptic. So if they're still altered when you get them down to about 39 degrees, search for another cause. So here we are with the first question. On areas of frostbite, who thinks that you should have immediate debridement to prevent infection? Or how about placing topical antibiotic cream should be applied to blisters? C is initial treatment is with submersion of the affected extremity in warm circulating water. And D, have tissue loss and the underlying tissue is rock hard. Well, that's a little tricky because there are two types of frostbite, so D is not correct because there is superficial frostbite where the tissue is still intact and is still soft underneath. So it is a little bit tricky, so you need to know that there are two levels of frostbite. The classic severe frostbite, and you will see this in the ICU, is that you do have sloughing of skin and the tissue underneath feels like a piece of petrified wood. You don't wanna immediately debride them, keep the surgeons away. I know Dr. Kaplan's walking around, I know. You get blamed for a lot of things, and it's probably true. We've known each other for a very long time. But there's the classic saying, frostbite in January, debride in July. Well, I don't know that you need to wait till July. And there are cases where you do need immediate debridement in those individuals who have obvious infection that needs to be debrided. So if you have a necrotizing soft tissue infection along with your frostbite, that needs surgical steel. So there is the exception to the rule. But in general, leave the tissue intact. And it's somewhere in the six weeks, eight weeks, to three months is where the tissue is gone as far as it's going to go. It's not antibiotic cream, but aloe vera. Yes, that same plant that your grandmother grew in her kitchen window is this thing that you use if you have burn, that can be applied on. In frostbite, if you don't have associated acute kidney injury, if your patient is otherwise able to take nonsteroidals, it's recommended that you give nonsteroidals as well because the antiprostate gland in effect can help prevent worsening of the frostbite. As I mentioned in the hyperthermia section and heat stroke, there is the risk from cooling. So you wanna make sure those ice packs are not spending a significant amount of time on the skin that the ice is not directly on the skin because you can cause frostbite in those individuals. Warm circulating water was the correct answer in the last one, which can be a little bit difficult to do in your ICU. There are adjuncts, I mentioned the aloe vera and the antiprostate glandons with the nonsteroidals. The other thing is splinting these extremities and making sure if fingers or toes are involved that you've put nonstick, nonadherent dressings in between so that they do not stick together. So you wanna splint them and wrap them appropriately and elevate them is improved. And then we talked about the delayed debridement. Next question. In hypothermic cardiac arrest patients, A, administer ACLS medications per usual protocol. B, CPR should be discontinued with a potassium level of eight. C, should be rewarmed to normothermic temperature prior to pronouncing. Or D, extracorporeal life support is the preferred method for rewarming. Any thoughts? So the answer is actually D. So remember that it's not, you are warm and dead, but you don't need to be all the way to normothermic. So if you work with pre-hospital care and you are involved in either setting up their protocols or are taking the receiving call, if you have a hospital system that has extracorporeal life support available in whatever mode that they can rapidly assess and you have a patient who's hypothermic in cardiac arrest, that is the location that they should go unless it is a prolonged transport time. So depending on where you live, if you're in a city hospital or you have multiple hospital systems around, you want to defer that patient to where they can put them on extracorporeal life support as soon as possible. Otherwise, you want to warm the individuals up to 32 degrees is at that point where you can pronounce them. Now there's the obvious points where the person that you pull them out of the river and they are frozen solid, you can pronounce them. I've seen one or two of those out of the Schuylkill. If they have decapitated, obviously you can pronounce them at time as well. Potassium levels used to be used, but it is at least a level of 10 or 11, depending on the literature. Eight is too low of a level to pronounce. And ACLS medications, keep in mind that the hypothermic heart does not respond well. So you give one round of ACLS medications, one attempt at defibrillation until the core temperature gets to be about 30, 32 degrees, and then you would go into your traditional ACLS medication route. And at that point, at 32 degrees, once you've gotten them to that temperature, you do a couple rounds of resuscitation. If they have not responded, if your bedside ultrasound shows no cardiac activity, at that point you can pronounce. So when you're dealing with a hypothermic patient, the first thing is, do they have vital signs? And what is their mental status? So if they are awake, maybe a little bit sleepy, maybe a little bit confused, but they have good vital signs, you may only need some passive rewarming. Warm blankets or even warm IV fluid, warm humidified oxygen. But if they have abnormal vitals or in shock and altered mental status, then you need to go to more active rewarming. There are some predictors for survival, and I talk more about that in the lecture. There's the five A's, which is age, ADLs, looking at if they're acidotic. I just blanked on the other two. My apologies, it's been a long day, and old and blonde hair. But that looks at all comers of hypothermia. And then the other is the HOPE score, which also looks at age, gender. Then those specifically for cardiac arrest hypothermic patients. Under the cardiac arrest is how long have they been, have they had asphyxia? Have they been under the water for an hour? Have they been in an avalanche and had a snow-packed airway for an hour? So those are not going to do well. And in fact, they recommend if you pull someone out of an avalanche and they've been under the snow and had a packed airway for a significant period of time that you can pronounce them at that point because they're unable to be resuscitated. There's great literature from Europe about that. And then in the cardiac arrest patients, talk about extracorporeal life support, and no one is dead until they're warmed until about 32 degrees. Moving on to burns. Size and depth. You must look at, you must be able to calculate this. Whatever system that you use, I talk more about it in the lecture, what percent are they and how deep are they? And that's going to help you decide if you need to transfer to the burn center. The other thing is fluid replacement. The Parkland formula tends to overestimate fluid replacement and that leads to different issues with volume. However, in fluid replacement, you're going to give the first half of the fluid volume that you need to replace in the first eight hours and the second half in the 16 hours. And these patients are very hypermetabolic. If you have them in your ICU versus the trauma patients that you want to keep warm initially, the burn patients, especially during the time in their ICU, during their care, they are hypermetabolic. You want to cool the room, make sure you have good pain control. You don't want to drive the process. The other thing to remember is if you have a burn patient and they come in altered or they remain, they show up altered in your ICU, it's not from the burn itself. So if they have altered mental status and all you're seeing is burn, not that that's not a significant problem, you must consider carbon monoxide and cyanide. This is key. Carbon monoxide's easy to measure. Most of the blood gases will do it automatically. Cyanide's a different story. Cyanide, most places have to send out, even at the quaternary academic centers, you have to send out a cyanide test and it's going to come back in, maybe if you're lucky, 48 hours, typically a week or more. So you have to treat appropriately. So if they have a burn injury and they are altered, you should consider this. In cyanide, especially if you have a very high lactate, we're talking lactates four or five or higher, and they're altered, treat them for cyanide. Electric injury, there's typically minimal external sign of damage, especially with the DC injury. You may see just a little bit of a wound. And I've seen a couple of lightning strikes over the years. Sometimes you have no idea. You get that random bolt of lightning and if nobody saw what happened, we had a guy brought into the hospital one time who was running down the street naked and there was a call for a crazy person and the police brought him in and we figured out he'd been hit by lightning because he had that classic figures on his body and where his clothes had literally been vaporized off him, he had a metal chain that had caused a burn. So it does happen. If you're worried about it, take a look in their ears. This is just like a blast injury. They're gonna have ruptured tympanic membranes. And if you happen to be at scene of a mass lightning strike where a couple people are down, this is an exception to the rule of going to the dead person first. Typically, mass casualty, if they're dead, you leave them be. But in a lightning strike, it's a DC shock. They get asystolic and for whatever reason, after a lightning strike, the heart will suddenly restart, maybe a minute or two or three, and so support them, give them CPR. They may very well survive. So go to the dead people first. Last question. In patients with pulmonary findings after a drowning event, A, intubated patients have an equal risk of developing pneumonia as those that do not require intubation. B, intubated patients require increasing PEEP for oxygenation, should have weaning trials held for 48 hours. C, administer 100% oxygen by non-rebreather mask, or D, fresh versus saltwater drowning patients require different therapy. Any thoughts, any ideas? B, absolutely correct. Study came out about three years ago in CHESS that reviewed in patients who had drowning, and you required increasing PEEP to oxygenate them, they did much better. You have to allow the surfactant to regenerate, so do not put them in your weaning protocol. Make sure that people are aware of that. Obviously, intubated patients are gonna have a higher risk of developing pneumonia, and not all patients require 100% non-rebreather, so it's the way the question is worded. So if they were hypoxic, absolutely, but in drowning patients, as long as you're maintaining their SAT 92 to 94%, you may only need, excuse me, a little bit, two liters of nasal cannula. So not every drowning patient needs 100% FiO2. And in the past, fresh versus saltwater drowning was felt to be very important, but in reality, the injury is the same. You have alveolar damage, you have surfactant washout, and you develop acute lung injury. What you drown in, however, can be important for sequelae. So if you, toddlers who drown in a five-gallon bucket, if that had chemicals in it, they can develop a chemical pneumonitis. If you are thrown from a car and have a drowning episode in a ditch, in addition to being injected out of the car, you have whatever organisms were growing in that ditch. So it is important to know what type of fluid they drowned in because that may be pertinent to what complications they are going to develop. Drowning is also another exception to the rule of the ABCs. We now focus in cardiac arrest typically on C first. Drowning is a pulmonary event. It's traditional CPR. So if you are on scene, it's airway breathing circulation, traditional CPR. In the ICU, if you have a drowning victim who comes in, and there's not a great reason for why they drowned. They were in a three-foot of water and all they needed to do was stand up, and yet they've had a drowning event. You must look for a different etiology. Did they have a seizure? Do they have some type of prolonged QT syndrome or something that made them have an event that drowned? So you must investigate. We talked about the weaning, and unfortunately there's no proven predictors. You cannot prognosticate. I mean, obviously people who've come in with CPR in progress who've been in the water for an extended period of time, most likely are not going to do well, but there's plenty of case reports and case series that people who've been cooled, especially in cool water drowning, survive completely intact, especially in the young. And the last thing to focus on is diving injury. Now there's a couple additional questions on top of that ample history that you want to ask. When was the last dive? How long, how many dives have they done? How deep was the dive? Did they fly after their dive? And was there some type of event, you know, they saw a shark and rapidly went to the top? So there are additional questions to ask about diving. This is the group that if you have someone who comes up with a diving injury, it doesn't really matter. Everybody gets 100% FiO2. So whether they had an acute gas embolism or whether they have too much nitrogen in their tissues, everybody gets 100% FiO2. And if you have the ability, and these people who are significantly injured, they've had a stroke from a gas air embolism, they've got significant, the bends, they've got terrible pain, you want to get them to hyperbarics. And the way to do it, and you can look this up, the number's here for you, or you can look it up online, the Dan Network, the Diver's Alert Network, there's someone always manning the phone. So wherever you are, I think in the world, but certainly in the US, you can call the number and they will help you decide whether A, your person does need hyperbarics, and if they do need hyperbarics, figure out where you can get them to a chamber. And with that, just to sum up, heat stroke, rapidly cool them within 30 minutes to about 39 degrees, and remember to stop the cooling. Hypothermia, especially in cardiac arrest, you need to warm them until they're at least 32 degrees before you should pronounce. Burn a significant injury, more than 20%, face, genital area, other significant areas, consider transferring them. Don't forget about that inhalation injury, specifically the carbon monoxide and the cyanide if they are altered. ABCs of drowning and delay their weaning, do not put them on the weaning protocol. And everybody who has a diving injury, if they have any significant problem, even if their pulse ox is okay, put them on 100% FiO2 and take them to dive chamber.

environmental emergencies

heat stroke

frostbite treatment

hypothermic cardiac arrest

burn management

diving injuries