Environmental

2-3-a. Allergic Reactions Minor

Administer diphenhydramine 25 – 50 mg PO/IV/IM

Major / Anaphylaxis

1) Administer O2 [see 1-4. Oxygen Administration]

2) Administer epinephrine 1:1,000 (1 mg/1 ml) dose 0.3 mg IM

3) Establish IV NS and give 250 ml rapid infusion as needed to maintain BP > 90 mmHg systolic.

4) Administer diphenhydramine 25 mg IV. Repeat if needed in 10 minutes. If IV is unavailable administer diphenhydramine 50 mg IM.

5) In case of wheezing or respiratory distress administer aerosolized albuterol 5 mg (2 vials) with ipratroprium 0.5 mg (1 vial) and repeat nebulizer treatment if needed.

6) If patient persistently hypotensive continue IV NS bolus. If unable to establish IV the establish IO access.

7) If patient remains in critical condition, administer epinephrine IV or IO at 0.1 mg increments titrated up to 0.5 mg. For more accurate dosing, use the dilute form 1:10,000 which is 0.1 mg/ml. Have the IV running briskly, and give the IV epinephrine dose slowly, over 1-2 minutes.

8) Monitor cardiac monitor and VS.

9) If no IV or IO access available repeat epinephrine 1:1,000 0.3 mg IM 5 minutes after 1st dose, if still in shock.

2-3-b. Burns Types: thermal, electrical, chemical, and radiation

1) General considerations: Monitor airway and support as needed. If there is no indication for intubation, administer oxygen [see 1-4. Oxygen Administration]. Use high flow at 15 liters for suspected cyanide or carbon monoxide.

2) Establish IV with Normal Saline. If the burn is second or third degree and involves more than 15% of the patient’s total body surface area, administer a 500 ml NS fluid bolus.

3) Remove rings, bracelets, and other constricting items.

4) Treat the patient’s pain per the pain reduction [see 1-5 Pain Reduction].

5) Cover the burn with dry sheet or dressing. If the burn surface area is less than 15 %, then a wet or cold water-soaked dressing may be used for pain relief. Avoid direct contact of ice with burned area. Burns:

*Special Considerations:

6) Chemical Burn:

• a) Dust off chemical, remove clothing, irrigate wound with NS.

• b) For Eye exposure irrigate with NS for 15 minutes.

7) Electrical Burn:

• a) Do not contact patient until source of electrical shock is safely removed.

• b) Monitor cardiac rhythm

• c) Obtain history of the nature of electrical source (AC/DC), voltage, and amperage.

8) Radiation Burns – are possible from industrial or medical radiation sources.

• a) Consider scene safety, and involving the County HazMat Team

• b) The person harmed by radiation is not likely be an ongoing source of radiation dangerous to others.

2-3-c. Drowning

1) Administer oxygen per [see 1-4. Oxygen Administration]. Early, optimized and continuous respiratory support is our most important action in this diagnosis.

2) Start an IV.

3) For wheezing, [see 2-8-b. Bronchospasm].

4) If indicated, apply Continuous Positive Airway Pressure (CPAP) [see 1-1. Continuous Positive Airway Pressure]

2-3-d. Heat Illness

1) HEAT EXHAUSTION (= NO mental status change)

• a) Remove patient from hot environment and remove outer layers of clothing

• b) Check VS / Temperature (core Temp if possible)

• c) Cool body with ice packs (to groin, axilla, and neck), wet cool towels, evaporative cooling with air conditioning and fans, but avoid making patient shiver.

• d) Cardiac monitor

• e) Check Glucose and treat as needed

• f) IV NS (250 ml boluses, repeat as needed up to 2L for rehydration if indicated.)

2) HEAT STROKE (= with mental status change)

• a) Heat stroke is a time sensitive, life threatening condition involving hyperthermia.

• b) Measure Temp – a core temp is preferable

• c) COOL the patient as quickly as possible to <102°F. (This may require staying at the scene to achieve rapid cooling).

  • i. If patient is in ice water bath immersion, let patient remain there for a few minutes until AMS improves and/or core temp is <102°F (avoid causing hypothermia). This will likely take approx. 5-8 minutes total time in ice bath immersion. Ice bath immersion is the fastest, most efficient way to rapidly cool a pt.

  • ii. If no ice water bath immersion is available, cool patient with ice packs, and also use wet towels to head, torso, arms, legs with evaporative cooling methods [see 2-3-d. Heat Illness].

  • iii. IV NS giving NS 250 ml boluses up to 2 L, if not contraindicated

  • iv. Apply cardiac monitor—watch for arrhythmias

  • v. Check Glucose and treat as needed

  • vi. Watch for seizures and if needed [see 2-2-c. Seizures and Status Epilepticus]

  • vii. Notify receiving hospital early

2-3-e. SCUBA Diving Injuries / Decompression Sickness + Barotrauma

If the patient breathed underwater, and may have a diving injury (air embolism / barotrauma / decompression sickness) then:

1) Put the patient on high flow 15 LPM NRB mask oxygen and start an IV TKO

2) Manage the airway, examine the patient and look for other serious illnesses (aspiration, STEMI, trauma, etc.)

3) To get a reliable dive history, if possible bring along with the patient their dive computer (with regulator, if connected) and their dive buddy, or dive master (or their cell phone numbers).

4) Early communication with the receiving Emergency Department to discuss the case, including a possible IV fluid challenge.

5) All patient transfers done by aircraft should be done at low altitude / sea level cabin pressure.