ENVIRONMENTAL EMERGENCIES

Heatstroke

Heat Exhaustion

Heatstroke is a medical emergency that can result in significant

morbidity and mortality. It is defined as the combination of
hyperpyrexia (105 F [40.6 C]) and neurologic symptoms. It is
caused by a shutdown or failure of the heat-regulating mechanisms of
the body.

Heat exhaustion is the inadequacy or the collapse of peripheral

circulation due to volume and electrolyte depletion. Heat exhaustion
is one condition in the spectrum of heat-related illnesses, including
heat rash, heat edema, heat cramps, and heat syncope. Untreated heat
exhaustion may progress to heatstroke.

Primary Assessment and Interventions

Expect the patient to be alert without significant

cardiorespiratory or neurologic compromise.

If vital functions are significantly impaired, suspect

secondary condition, such as MI or stroke.

Subsequent Assessment

Obtain history of headache, fatigue, dizziness, muscle

cramping, and nausea.

Inspect skin usually pale, ashen, and moist.

The temperature may be normal, slightly elevated, or as

high as 104 F (40 C).

Measure vital signs for hypotension, orthostatic changes,

tachycardia, and tachypnea.

The patient will be awake but may give a history of syncope

or confusion.

Laboratory analysis will show hemoconcentration and

hyponatremia (if sodium depletion is the primary problem)
or hypernatremia (if water depletion is the primary
problem).

The ECG may show dysrhythmias without evidence of

infarction.

General Interventions

Move the patient to a cool environment, and remove all

clothing.

Position the patient supine with the feet slightly elevated.

If the patient complains of nausea or vomiting, do not give

fluids by mouth.

Start an I.V. line with Ringer's lactate or normal saline until

electrolyte results are confirmed.

Monitor the patient for changes in the cardiac rhythm and

vital signs. Vital signs should be taken at least every 15
minutes until the patient is stable.

Provide fans and cool sponge baths as cooling methods.

Provide patient education.

o

Advise the patient to avoid immediate reexposure

to high temperatures; the patient may remain
hypersensitive to high temperatures for a
considerable length of time.
Emphasize the importance of maintaining an
adequate fluid intake, wearing loose clothing, and
reducing activity in hot weather.
Athletes should monitor fluid losses, replace fluids,
and use a gradual approach to physical
conditioning, allowing sufficient time for
acclimatization.

Primary Assessment and Interventions

Assess airway, breathing, and circulation.

LOC may be altered.

Expect to intervene immediately if cardiovascular collapse

occurs.

Subsequent Assessment

Obtain a history from accompanying person about

environmental conditions, activity, underlying health, and
medications that may have contributed to heatstroke.

Perform a neurologic assessment.

o

Initially, the patient may exhibit bizarre behavior or

irritability. This may progress to confusion,
combativeness, deliriousness, and coma.
Other central nervous system (CNS) disturbances
include tremors, seizures, fixed and dilated pupils,
and decerebrate or decorticate posturing.

Assess vital signs.

o

Temperature greater than 105 F.

Hypotension.

Rapid pulse; may be bounding or weak.

Rapid respirations.

The skin may appear flushed and hot; in early heatstroke,

the skin may be moist, but, as the heatstroke progresses, the
skin will become dry as the body loses its ability to sweat.

ABGs show metabolic acidosis.

General Interventions

Provide cooling measures.

o
o

o
o

o
o

o
o

Reduce the core (internal) temperature to 102 F

(38.9 C) as rapidly as possible.
Evaporative cooling is the most efficient. Spray
tepid water on the skin while electric fans are used
to blow continuously over the patient to augment
heat dissipation.
Apply ice packs to neck, groin, axillae, and scalp
(areas of maximal heat transfer).
Soak sheets/towels in ice water and place on
patient,
using
fans
to
accelerate
evaporation/cooling rate.
Immersion in cold water is contraindicated.
If the temperature fails to decrease, initiate core
cooling: iced saline lavage of stomach, cool fluid
peritoneal dialysis, cool fluid bladder irrigation, or
cool fluid chest irrigations.
Place the patient on a hypothermia blanket.
Discontinue active cooling when the temperature
reaches 102 F. In most cases, this will reduce the
chance of overcooling because the body

temperature will continue to fall after cessation of

cooling.

Oxygenate patient to supply tissue needs that are

exaggerated by the hypermetabolic condition: 100%
nonrebreather mask or intubate the patient if necessary to
support a failing cardiorespiratory system.

Monitor condition.
o

Replace fluids.
o

o
o

Start I.V. infusion using Ringer's lactate to replace

fluid losses, maintain adequate circulation, and
facilitate cooling.
At least one I.V. line should be a central line.
Fluid replacement is based on the patient's
response and laboratory results.

Other measures:
o

Dialysis for renal failure.

Diuretics, such as mannitol (Osmitrol), to promote

diuresis.
Anticonvulsant agents to control seizures.

o
o

Monitor and record the core temperature

continually during cooling process to avoid
hypothermia; also, hyperthermia may recur
spontaneously within 3 to 4 hours.
Monitor the vital signs continuously, including
ECG, CVP, blood pressure, pulse, and respiratory
rate.
Perform frequent (every 30 minutes) neurologic
assessments.

Potassium for hypokalemia and sodium

bicarbonate to correct metabolic acidosis,
depending on laboratory results.
Antipyretics are not useful in treating heatstroke.
They may contribute to the complications of
coagulopathy and hepatic damage.
Intense shivering may be controlled by diazepam
(Valium). Shivering will generate heat and increase
the metabolic rate.
Patients with depleted clotting factors may be
treated with platelets or fresh frozen plasma.

Insert an indwelling catheter with a urometer, and measure

urine output at least hourly acute tubular necrosis is a
complication of heatstroke.

Perform continuous ECG monitoring and frequent

cardiovascular assessments for possible ischemia,
infarction, and dysrhythmias.

Perform serial laboratory testing (clotting parameters,

electrolytes, glucose, and serum enzymes).

The patient should be admitted to an intensive care unit

(ICU); complications can occur, including heart failure,
cardiovascular collapse, hepatic failure, renal failure,
disseminated
intravascular
coagulation,
and
rhabdomyolysis.

Monitor the patient for the development of seizures, and

provide for a safe environment in case of seizures.

Frostbite
Frostbite is trauma due to exposure to freezing temperatures that
cause actual freezing of the tissue fluids in the cell and intracellular
spaces, resulting in vascular damage. The areas of the body most
likely to develop frostbite are the earlobes, cheeks, nose, hands, and
feet. Frostbite may be classified as frostnip (initial response to cold,
reversible), superficial frostbite, and deep frostbite.

Primary Assessment and Interventions

If not alert, assess airway, breathing, and circulation.

Deficits may indicate coexisting hypothermia or underlying

condition.

Protect frostbitten
interventions.

tissue

while

performing

other

Subsequent Assessment
Frostnip

History of gradual onset.

Skin appears white.

Numb, pain-free.

Superficial Frostbite

Damage is limited to the skin and subcutaneous tissue.

The skin will appear white and waxy.

On palpation, the skin will feel stiff but the underlying

tissue will be pliable, soft, and have its normal bounce.

Sensation is absent.

Deep Frostbite

Skin will appear white, yellow-white, or mottled blue-white.

On palpation, the surface will feel frozen and the underlying

tissue will feel frozen and hard.

The affected part is completely insensitive to touch.

General Interventions

Frostnip may be treated by placing a warm hand over the

chilled area.

Leave the frostbitten area alone until definitive rewarming is

undertaken. Pad the extremity to prevent damage from
trauma.

Handle the part gently to avoid further mechanical injury.

Remove all constricting clothing that can impair circulation,

including watchbands and rings.

Rewarming:
o

Rewarm the extremity by controlled and rapid

rewarming. Rewarm with a temperature of 98.6 F
to 104 F (37 C to 40 C) in a fairly large, tepid
water bath where the part can be fully immersed
without touching the side or bottom. If clothing,
socks, or gloves are frozen to the extremity, they
should be left on and removed after rewarming.
More warm water may be added to the container by
removing some cooled water and adding warm
water.
Slow rewarming is less effective and may increase
tissue damage.

Dry heat is not recommended for rewarming.

The rewarming procedure may take 20 to 30

minutes.
Rewarming is complete when the area is warm to
the touch and pink or flushed.
Do not rub or massage a frostbitten extremity. The
ice crystals in the tissue will lacerate delicate
tissue.

o
o

Opioids for pain control.

Antibiotics if there is an open wound.

Tetanus prophylaxis.

Protect the thawed part from infection. Large blisters may

develop in 1 hour to a few days after rewarming; these
blisters should not be broken.

Place sterile gauze or cotton between affected fingers/toes to

absorb moisture.

Use strict aseptic technique during dressing changes.

Frostbite injuries make the patient susceptible to infection.
Make sure any dressings are loosely applied.

Elevate the part to help control swelling.

Use a foot cradle to prevent contact with bedding if the feet

are involved prevents further tissue injury.

Perform a physical assessment to look for concomitant

injury (soft-tissue injury, dehydration, alcohol coma, fat
embolism due to fracture, immobility).

Restore electrolyte balance; dehydration and hypovolemia

occur frequently in frostbite victims.

Whirlpool bath for the affected extremity to aid circulation,

debride dead tissue, and help prevent infection.

Escharotomy (incision through the eschar) to prevent further

tissue damage, allow for normal circulation, and permit joint
motion.

Fasciotomy (incision in fascia to release pressure on the

muscles, nerves, blood vessels) to treat compartment
syndrome.

Encourage hourly active motion of the affected digits to

promote maximum restoration of function and to prevent
contractures.

Advise patient not to use tobacco because of the

vasoconstrictive effects of nicotine, which further reduce the
already deficient blood supply to injured tissues.

Perform serial laboratory testing (urinalysis and serum

enzymes) to monitor for the complications of
rhabdomyolysis and subsequent renal failure.

Hypothermia
Hypothermia is a condition in which the core (internal)
temperature of the body is less than 95 F (35 C) as a result
of exposure to cold. In response to a decreased core
temperature, the body will attempt to produce or conserve
more heat by (1) shivering, which produces heat through
muscular activity; (2) peripheral vasoconstriction, to
decrease heat loss; and (3) raising the basal metabolic rate.
Hypothermia may be classified as mild, moderate, or severe.

Assess airway and breathing.

o
o

Pharmacologic interventions:

Primary Assessment and Interventions

Spontaneous respirations may be extremely slow

and imperceptible.
Assist
breathing
and
oxygenation
with
supplemental O2 at 100% or a bag-valve mask
device.
If intubation is necessary, extreme caution should
be used because ventricular fibrillation may be
precipitated.

Assess circulation.
o

If the body temperature falls below 86 F (30 C),

the heart sounds may not be audible even if the
heart is still beating. Tissues conduct sound poorly
at low temperatures.
Blood pressure readings may be extremely difficult
to hear because cold tissue conducts sound waves
poorly.
Pupil reflexes may be blocked by a decrease in
cerebral blood flow, so the pupils may appear fixed
and dilated.
A patient with a heartbeat may present like a
patient in cardiac arrest with fixed dilated pupils,
no pulse, and no blood pressure. Provide CPR until
further evaluation through ECG and hemodynamic
monitoring.

Subsequent Assessment

There is progressive deterioration marked by apathy, poor

judgment, ataxia, dysarthria, drowsiness and, eventually,
coma.

Speech is slow and may be slurred.

Shivering may be suppressed below a temperature of 90 F

(32.2 C).

Cardiac dysrhythmias cold disrupts the conduction system

of the heart, and a variety of dysrhythmias may be seen. A
hypothermic heart is extremely susceptible to ventricular
fibrillation. Very cold hearts do not respond to drugs or
defibrillation.

The heartbeat and the blood pressure may be so weak that

the peripheral pulsations become undetectable.

Urine output may increase in response to peripheral

vasoconstriction cold diuresis.

Initial tachypnea followed by slow and shallow respirations,

possibly two or three per minute in severe hypothermia.

Fruity or acetone odor to the breath because the body may

be metabolizing fat as a result of decreased insulin levels.

General Interventions
Goal: rewarm without precipitating cardiac dysrhythmias.
Supportive Measures

Handle the patient carefully and gently to avoid triggering

ventricular fibrillation.

Continuously monitor core temperatures with a low reading

rectal thermometer.

Continuously monitor ECG. Because you may be unable to

obtain a pulse due to the hypothermia, rely on the cardiac
monitor to determine the need for CPR.

Monitor the patient's condition through vital signs, CVP,

urine output, ABG values, and blood chemistry
determinations.

Maintain an arterial line for recording blood pressure and to

facilitate blood sampling allows rapid detection of
acidbase disturbances and assessment of adequacy of
ventilation and oxygenation.

Start I.V. therapy with normal saline. Ringer's lactate is not

recommended because the cold liver may not be able to
metabolize the lactate.

Rewarming Techniques
The type of rewarming depends on the degree of hypothermia.
Rewarming should continue until the core temperature is 93.2 F
(34 C). If the patient is in cardiac arrest, rewarming should continue
until a temperature of 89.6 F (32 C) has been reached. Death in
hypothermia is defined as a failure to revive after rewarming.

Passive external rewarming (temperature above 82.4 F [28

C]).
o Remove all the wet or cold clothing, and replace
with warm clothing.
o Provide insulation by wrapping the patient in
several blankets.
o Provide warmed fluids to drink.
o

Toxicology is the study of the harmful effect of various substances on

the body. Poisons are substances that are harmful to the body no
matter how much or in what manner they enter the body. Drugs
become toxic when they are taken in excess quantities or manners
that are not therapeutic. Alcohol is considered a drug. The treatment
goals of toxicologic emergencies are first, supportive; second, to
prevent or minimize absorption; third, to provide an antidote.

Ingested Poisons
Ingested poisons can produce immediate or delayed effects.
Immediate injury is caused when the poison is caustic to the body
tissues (ie, a strong acid or a strong alkali). Other ingested poisons
must be absorbed into the bloodstream before they become harmful.
Ingested poisoning may be accidental or intentional.

Primary Assessment and Interventions

Maintain an open airway some ingested substances may

cause soft tissue swelling of the airway.

Attain control of the airway, ventilation, and oxygenation; in

the absence of cerebral or renal damage, the patient's
prognosis depends largely on successful management and
support of vital functions.

Subsequent Assessment

Disadvantage: slow process.

Provide external heat for the patient warm hot

water bottles to the armpits, neck, or groin. (Do not
apply hot water bottles directly to the skin.)
Warm water immersion.

Disadvantages:

Causes peripheral vasodilation, returning

cool blood to the core, causing an initial
lowering of the core temperature.
Acidosis due to the washing out of lactic
acid from the peripheral tissues.
An increase in the metabolic demands
before the heart is warmed to meet these
needs.

Active core rewarming (temperature below 82.4 F).

Identify the poison.

o

Active external rewarming (temperature above 82.4 F).

o

TOXICOLOGIC EMERGENCIES

Try to determine the product taken: where, when,

why, how much, who witnessed the event, time
since ingestion.
Call the poison control center in the area if an
unknown toxic agent has been taken or if it is
necessary to identify an antidote for a known toxic
agent.

Continue the focused assessment, observing any significant

deviations from normal. Different poisons will affect the
body in different ways.

Obtain blood and urine tests for toxicology screening.

Gastric contents may also be sent for toxicology screening
in serious ingestions.

Monitor neurologic status, including mentation; monitor the

course of vital signs and neurologic status over time.

Monitor for fluid and electrolyte imbalance.

General Interventions
Supportive Care

Initiate large-bore I.V. access.

Administer oxygen for respiratory depression.

Inhalation of warmed, humidified oxygen by mask

or ventilator.
Warmed I.V. fluids.

Warmed gastric lavage.

Monitor and treat shock.

Peritoneal dialysis with warmed standard dialysis

solution.
Mediastinal irrigation through open thoracotomy
has been used successfully but has serious
complications.
Cardiopulmonary bypass.

Prevent aspiration of gastric contents by positioning (on side

with head down), use of oropharyngeal airway, and
suctioning.

Give supportive care to maintain vital organ systems.

Insert an indwelling urinary catheter to monitor renal

function.

Support the patient having seizures; many poisons excite the

CNS, or the patient may convulse from oxygen deprivation.

Monitor and treat for complications: hypotension, coma,

cardiac dysrhythmias, and seizures.

o
o

Disadvantage of active core rewarming is the

invasiveness of the procedures.

Minimizing Absorption

The primary method for preventing or minimizing

absorption is to administer activated charcoal with a
cathartic to hasten excretion. Newer superactivated
charcoals can reduce absorption of a toxic substance by as
much as 50%. Administering activated charcoal plus a
cathartic is just as effective or more effective than gastric
lavage.
o Administration of oral-activated charcoal absorbs
the poison on the surface of its particles and allows
it to pass with the stool. Multiple doses may be
administered.
o Activated charcoal is usually mixed tap water to
make a slurry.

If the carbon monoxide poisoning is due to smoke

inhalation, stridor (indicative of laryngeal edema
due to thermal injury) may be present.

Primary Interventions

Provide 100% oxygen by tight-fitting mask. (The

elimination half-life of carboxyhemoglobin, in serum, for a
person breathing room air is 5 hours 20 minutes. If the
patient breathes 100% oxygen, the half-life is reduced to 80
minutes; 100% oxygen in a hyperbaric chamber will reduce
the half-life to 23 minutes [treatment of choice].)

Intubate if necessary to protect the airway.

Subsequent Assessment

A thorough history is important: determine the type and

length of exposure as well as possible other fumes inhaled.
An underlying anemia, cardiac disease, or pulmonary
disease may place a person at higher risk.

Gastric lavage for the obtunded patient (see Procedure

Guidelines 35-5, pages 1164 and 1165). Save gastric
aspirate for toxicology screens. This procedure is
controversial.

Determine LOC the patient may appear intoxicated from

cerebral hypoxia; confusion may progress rapidly to coma.

Assess complaints of headache, muscular weakness,

palpitation, dizziness.

Procedures to enhance the removal of the ingested substance

if the patient is deteriorating.
o Forced diuresis with urine pH alteration to enhance
renal clearance.
o Hemoperfusion (process of passing blood through
an extracorporeal circuit and a cartridge containing
an adsorbent, such as charcoal, after which the
detoxified blood is returned to patient).
o Hemodialysis used in selected patients to purify
blood and accelerate the elimination of circulating
toxins.
o Repeated doses of charcoal for binding
nonabsorbed drugs/toxins.
o Gastric lavage may be used in conjunction with
activated charcoal and a cathartic to maximize
elimination of the substance.

Inspect skin: may be pink, cherry red, or cyanotic and pale

skin color is not a reliable sign.

Monitor vital signs: increased respiratory and pulse rates are

generally present. Be alert for altered breathing patterns and
respiratory failure.

Listen for rales or wheezes in the lungs (with smoke

inhalation, indicates acute respiratory distress syndrome).

Obtain arterial blood samples for carboxyhemoglobin

levels.
o Normal is less than 12%.

Providing an Antidote

An antidote is a chemical or physiologic antagonist that will

neutralize the poison.

Administer the specific antidote as early as possible to

reverse or diminish effects of the toxin.

Carbon Monoxide Poisoning

Carbon monoxide poisoning is an example of an inhaled poison and
is the result of the inhalation of the products of incomplete
hydrocarbon combustion. It may occur as an industrial or household
accident or as an attempted suicide. Carbon monoxide exerts its toxic
effect by binding to circulating hemoglobin to reduce the oxygencarrying capacity of the blood. The affinity between carbon
monoxide and hemoglobin is 200 to 300 times that between oxygen
and hemoglobin. (Carbon monoxide combines with hemoglobin to
form carboxyhemoglobin.) As a result, tissue anoxia occurs.

Primary Assessment

Psychiatric evaluations may be done after the patient is

stabilized.

Assess airway and breathing.

o

Respiratory depression may be present.

Severe carbon monoxide poisoning is present when

levels are greater than 30% to 40%.

General Interventions

History of exposure to carbon monoxide justifies immediate

treatment.

Goals are to reverse cerebral and myocardial hypoxia and

hasten carbon monoxide elimination.

Give 100% oxygen at atmospheric or hyperbaric pressures

to reverse hypoxia and accelerate elimination of carbon
monoxide. Patients should receive hyperbaric oxygen for
CNS or cardiovascular system dysfunction.

Use continuous ECG monitoring, treat dysrhythmias, and

correct acidbase and electrolyte abnormalities.

Observe the patient constantly psychoses, spastic paralysis,

visual disturbances, and deterioration of personality may
persist after resuscitation and may be symptoms of
permanent CNS damage.

Insect Stings
Insect stings or bites are injected poisons that can produce either
local or systemic reactions. Local reactions are characterized by pain,
erythema, and edema at the site of injury. Systemic reactions usually
begin within minutes and produce mild to severe and life-threatening
reactions.

Primary Assessment and Interventions

Assess airway, breathing, and circulation.

Anaphylactic reactions may produce unconsciousness,

laryngeal edema, and cardiovascular collapse.

Epinephrine is the drug of choice the amount and route

depend on the severity of the reaction.

Administer a
bronchospasm.

Initiate an I.V. with Ringer's lactate.

Prepare for CPR.

bronchodilator

to

help

relieve

the

Subsequent Assessment

Obtain history of insect sting, previous exposure, and

allergies.

Inspect skin for local reaction erythema, edema, pain at site

of injury as well as generalized pruritus, urticaria, and
angioedema.

Continue to monitor blood pressure and respiratory status

for dyspnea, wheezing, and stridor.

General Interventions

Apply ice packs to site to relieve pain.

Elevate extremity with large edematous local reaction.

Administer oral antihistamine for local reactions.

Clean the wound thoroughly with soap and water or an

antiseptic solution.

Administer tetanus prophylaxis if not up to date.

Provide patient education.

Spray garbage cans with rapid-acting

insecticide, and keep areas meticulously
clean.

Snakebites
The majority of snakes in the United States are not poisonous. The
poisonous varieties are pit vipers (rattlesnakes and copperheads) and
coral snakes. Bites by these snakes may result in envenomation, an
injected poisoning.

Primary Assessment and Interventions

Assess airway, breathing, and circulation if patient is not

alert.

Severe envenomation may lead to neurotoxicity with

respiratory paralysis, shock, coma, and death.

Be prepared to resuscitate and provide advanced life

support.

Subsequent Assessment

Get a description of the snake, the time of the snakebite, and

the location of the bite. Bites to the head and trunk may
progress more rapidly and be more severe.
o Pit vipers have triangular heads, vertical pupils,
indentations between the eyes and nostrils, and
long fangs.
o Coral snakes are small, brightly colored, with short
fangs and teeth behind them, and with a series of
bands of yellow, red, yellow, and black (in that
order).

Always have epinephrine on hand (EpiPen).

Wear medical emergency bracelets indicating

hypersensitivity.
Instructions when sting occurs:

Assess for local reactions burning, pain, swelling, and

numbness at the site. Local reactions to coral snakebites
may be delayed several hours and may be very mild.

A few hours after the bite, hemorrhagic blisters may occur

at the site, and the entire extremity may become edematous.

Watch for signs of systemic reactions, including nausea,

sweating, weakness, lightheadedness, initial euphoria
followed by drowsiness, difficulty in swallowing, paralysis
of various muscle groups, signs of shock, seizures, and
coma.

Monitor vital signs closely because tachycardia or

bradycardia may develop.

Take epinephrine immediately if stung.

Remove stinger with one quick scrape of

fingernail.
Do not squeeze venom sac because this
may cause additional venom to be
injected.
Report to nearest health care facility for
observation.
Avoid exposure.

Avoid locales with stinging insects (camp

and picnic sites).
Stay away from insect feeding areas
flower beds, ripe fruit orchards, garbage,
fields of clover.
Avoid going barefoot outdoors yellow
jackets may nest on ground.
Avoid perfumes, scented soaps, bright
colors attract bees.
Keep car windows closed.

General Interventions

Keep the patient calm and at rest in a recumbent position

with the affected extremity immobilized.

Administer oxygen.

Start an I.V. line with normal saline or Ringer's lactate.

Administer antivenin and be alert to allergic reaction

(antivenin is horse serum-based).

Administer vasopressors in the treatment of shock.

Monitor for bleeding, and administer blood products for

coagulopathy.