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This information covers various water-related emergencies and altitude-related injuries. It emphasizes the importance of assessing and treating patients with drowning, decompression sickness, and air embolism. It also highlights the risks of alcohol and drug use in water-related incidents. Additionally, it discusses the effects of high altitude on the body, including acute mountain sickness, high altitude pulmonary edema, and high altitude cerebral edema. The treatment for altitude-related injuries is descending to a lower altitude. Lastly, it provides information on lightning strikes and the importance of immediate CPR and AED use in cardiac arrest cases. that can cause the floating double vision. Check the level of consciousness, be suspicious of drugs or alcohol because 90% of water-related injuries. And open the airway and assess in an unresponsive patient. Obviously, they're going to do resuscitation if it's cardiac arrest. Provide BVM on the patient, have suction available, listen to lung sounds. If the most mechanism of injury suggests trauma, assess for bleeding and treat appropriately. Transport all near-drowning patients to the hospital. Any patient with any water-related emergency should be transported to the hospital. Remember that if they've inhaled water the potential for pulmonary edema can be there. They need to be assessed. For patients with decompression sickness or air embolism, they need a recompression chamber or hyperbaric chamber. They can be taken to a hospital with that. When you call medical control or you call C-Med, they can advise you of what hospital to go to if you're not sure. Get your sample history. You want to know the depth of the dive, the length of the time the patient was underwater, the onset of symptoms and any previous diving activity. Bring the equipment with you. They'll have what they call a dive computer or a dive log and they'll have their O2 tank and everything. Bring it with you to the hospital because the hospital will look at it and make sure it's not a faulty equipment that caused it. Look for life threats and trauma. They might be hidden. You might not realize. Could be spinal cord injury. You don't know. Do a detailed complete physical examination of the body head to toe because the patient is going to be a poised historian at that point. Assess all your vital signs to include skin color or discoloration, itching, pain and paresthesia which is numbness and tingling. That's common in the bends because the blood vessels are blocked by those bubbles and so it causes poor circulation. Check all your vital signs. Oxygen saturation readings may be inaccurate because of the poor circulation due to the blockages. Drowning patients may deteriorate rapidly due to pulmonary injury. Again, that fluid can shift and fill up in their lungs very quickly. Cerebral hypoxia and hypothermia. Pneumothorax, aneurysms and decompression sickness patients may decompensate very quickly. Call ALS, rapid transport for any water related emergency. Document the circumstances of the drowning and extrication. What you found and what you did to get them out. The time submerged. The temperature and clarity of water. It's one thing to drown in a pool. Most people don't drown in pools. They drown in standing water that might be full of bacteria. Imagine a flood. Imagine the floods that just happened in Florida. People exposed to that water. That's not clear water. That's full of oil and bacteria and dirt. Everything from the ground is churned up in that to include the possibility of dead bodies and everything. Now they're breathing that liquid in. They're not only going to be exposed to the fluid in their lungs but the bacteria as well. Possible spinal cord injuries and again bring all diving equipment to the hospital to include their diving computer and or log. If the patient is not breathing bag them. If there's no pulse chest compressions and AED treat for hypothermia. Keep them warm. Cardiac arrest is cardiac arrest whether they're hypothermic or not. We're going to do the same thing. For air embolism and decompression sickness Remove the patient from the water. Keep the patient calm. Administer oxygen. Consider pneumothorax. Monitor vital signs and breath sounds and transport promptly. And again, air embolism happened right after they ascended. Decompression sickness is going to take 30 minutes or more. It's not going to be immediate. Other water hazards take close attention to body temperature of persons rescued from the cold water because of hypothermia. Breath holding syncope. A person swimming in shallow water may experience a loss of consciousness from a decreased stimulus to breathe. Most of the time it's caused by that cold water that cold water laryngeal spasm. Treat the same as any drowning patient. Prevention. Appropriate precautions can prevent most immersion incidents. That's why in Massachusetts if you have a pool you either have to have a minimum 4 foot high pool wall with a locked ladder gate or you have to have a 4 foot high fence around your house so that kids can't get in your pool and drown in your pool. Half of all teenage and adult drownings are associated with the use of alcohol. Actually 90% of water related injuries or fatalities in the adult population have some component of alcohol and drug related. High altitude disparities in injuries caused by the difference between the surrounding atmospheric pressure and the total gases in the body which can cause fluid shifts. When I go up to altitude if I go up above 10,000 feet I might say 12, 13,000 feet. It's the same amount of oxygen. It's 21% oxygen. But as I go up the air dissipates because it's more area so the air dissipates so there's less pressure. When I get up above 13,000, 14,000 feet it's the same amount of oxygen but there's only a half atmosphere of pressure. At sea level right now my intercostal muscles contract, pull my ribcage up, diaphragm contracts, pulls down and I have approximately one half atmosphere inside. So one half atmosphere inside, one atmosphere outside that natural vacuum sucks air in. When I get up above 14,000 feet I have a half atmosphere outside and a half atmosphere inside. I'm not sucking any air in so I'm taking a breath but nothing's coming in. I have to breathe harder and faster to get the same amount of oxygenation. That's why mountain climbers when they climb like Everest and Gate 2 they have these special oxygen tanks. It's not just a tank with a mask on it. They actually put it on their face, they force it on and they push a button and it forces air and they take a breath and it forces the air in. It's almost like CPAP on the face. And that's how they get the oxygen. They usually do that every 5th breath or 6th breath. When you get up above Mount Everest, when you get up above 20,000 feet, you really need permanent oxygen. That permanent, that diminished oxygen, it's not diminished oxygen here, it's diminished diminished concentrations of air. Which makes it less, more difficult to get the oxygen into the blood. It affects central nervous system and pulmonary system. Acute mountain sickness. Diminished oxygen in the air, it is not it is diminished air pressure reducing the amount of oxygen you get in. Caused by ascending too high, too fast or not being acclimatized to the height. Headache, lightheadedness, fatigue, you'll get facial swelling, you'll get severe like migraine headaches, confusion, dizziness, you'll get double vision, dyplopia, difficulty sleeping, loss of appetite. So, all of these, we're going to talk about that, which is the acute mountain sickness. We're going to talk about HAPE. HAPE is high altitude pulmonary edema that loss of pressure causes fluid to shift out of the pulmonary, out of the vascular system into the lungs. And you get this development of this pulmonary edema. Shortness of breath, pit, carotid sputum, cyanosis, and rapid pulse. It's basically like CHF. It's basically it's basically cardiogenic shock but it's just that the heart, the lungs can't maintain that pressure. HAPE can lead to HACE, which is high altitude cerebral edema. This is life threatening. HAPE much more than HAPE is because this is intercerebral pressure. This is intracranial pressure. Severe constant throbbing headache from the intracranial pressure. Ataxia, that difficulty walking, that uncontrolled gait, ataxic gait. Extreme fatigue, vomiting, and possibly loss of consciousness. The treatment for all of these is to get down. So, if I respond to a patient with an altitude injury and they're up 20,000 feet, I'm going to be at the base camp and I'm going to say bring them to me. I'm not going to go up and treat them. I'm going to have them brought down to me. When they come down, that's going to treat 90% of the condition because descending is what fixes it. Now, they might still have some pulmonary edema. They might have to put them on CPAP when I get them down. They might have to go to the hospital for diuretic treatments but as a general rule, coming down is going to fix most of that problem. Lightning. Lightning is the fifth most common cause of death from isolated environmental phenomena. It targets people engaged in outdoor activities and anyone in a large open area. There are two types. There's the direct and indirect. Most people have an indirect strike, like it hit something like me. It hit the porch and I was next to it. So, I got an indirect strike, as it were. Many people do not survive direct strikes. Most people that get indirect strikes usually do survive. Cardiac arrest is what kills patients. Cardiac and respiratory arrest. So, we use, for anybody with electrical exposure to include lightning, we use what we call reverse triage. Triage is a word meaning to sort. We do the greatest good for the greatest number of people. And we treat the sickest patient first and we work them on down, right? And if the patient is dead, we move them off. We leave them and go back to them after everybody else is treated. In a lightning strike, if you're conscious and moving around, you're going to be okay. The cardiac arrest, we work. We'll work them first. In regular triage, we don't. But in a lightning strike, electricity, we do because we can get them back. Lightning stopped their heart. Lightning acted like an AED and stopped their heart. An AED will start it again. So, immediately start CPR and put the AED on them. We'll generally get them back. So, in lightning strikes, CPR, AED, absolutely all day. This is one of the reasons why you need to stay away from, if you're in the woods, that's one thing, but if you're in an open field with one tree or two trees, don't stand next to the tree because the lightning will strike the tree. It'll travel down to about your height and it'll jump through the air to you and go to ground because you have a much lower resistance than the tree does. You're actually a walking conductor. You've got these nerves in you and these electrolytes flowing through your blood. You're a really good conductor of electricity, unlike a tree, which is not. Best thing to do is get as close to the ground as you can. One of the safest places to be is inside a vehicle because the electricity will go around the vehicle, around the outside of the vehicle. Just don't touch anything metal inside. Myocategories, loss of consciousness, amnesia, confusion, tingling, superficial burns, that was me. Moderate, seizures, respiratory arrest, dysrhythmias and superficial burns, and then severe is cardiopulmonary arrest. And again, CPR, AED will bring them back. Protect yourself, move the patient to a sheltered environment. Lightning will strike in the same place twice. I know the old saying, lightning won't strike twice in the same place. It absolutely will. It all has to do with resistance. And you can see it. You'll have, before lightning strikes, you'll see these shoots of static electricity coming off the ground. And if one of those static electricities make connection with the static electricity in the air, that's the path the electricity is going to travel. You can see them. These little micro streaks of static on the ground right before a lightning strike. So we use reverse triage, stabilize the spine, bag them, AED, control bleeding and transport. Spider bites. Spiders are numerous and widespread in the United States. Many species of spiders. The only two to worry about is the female black widow and the brown recluse spider. And they don't necessarily, for a small child or an elderly patient, they might kill them for you. They're just going to make you very uncomfortable. So this is a black widow, approximately two inches long, about the size of my thumb. Ow! It has the hourglass shape on its belly. God bless you. The male also is smaller and it also has the hourglass shape. Its bite is not as dangerous as the female. These are everywhere in the United States. I had one in my garage in Worcester. I was cleaning out my garage and I put my hand in between a brick to move it and I just saw something black and I looked at it. Sure enough, it was a black widow. So I didn't go back in that garage for long. They usually very standoffish. They usually like warm, they like cool shaded places where they can stay protected and they can get food. They will only attack when they're when they are What's that? What about dogs? What do they do to dogs? They can jump off. A small dog, if a black widow bites a small dog, it'll kill it. Gradually what happens is the black widow has these small fangs. You might not even notice that you've been bitten until you develop the signs and symptoms. Most fangs will cause localized pain but then it starts with these agonizing muscle spasms. You get these agonizing spasms and this cramping and it can last for up to 48 hours. The beauty is we have an anti-venom for it and they actually have it at Mass General. So if you have a black widow bite and you identify it and you tell the hospital, they'll have it either flown by life flight out to UMass or they'll fly the patient out to Mass General to give you the anti-venom. And usually within 20 minutes you're better. It's poisonous to nervous tissue so you want to treat it as quickly as possible. If you guys got bit by a black widow, probably just be very uncomfortable for about 48 hours and you get over it. Dizziness, sweating, nausea, vomiting, rashes, tightness in the chest, severe cramping and again they'll last, subside in about 48 hours. Treatment is DLS for respiratory distress transport as soon as possible. The brown rectum spider the black widow has a neurotoxic venom. The black brown recluse has a cytotoxic venom. It is actually smaller, it's about half the size, it's only about an inch long and it has this violin shape. You see it looks like a violin right here? It's kind of see-through black and it's brown and it's got the violin shape. When the black widow, when a brown recluse bites you, you might not even notice it bites you but it will produce a swollen cyanotic blister like pustule and that's the tissue necrosis and it can actually get infected and it can be really bad you can lose tissue and everything. I got bit let me see if I still have it maybe not anymore. I got bit like 20 years ago by one and I had a red spot maybe that's the one right there but it was a cyanotic blister like this big on my arm and it was like that for like 6 months before it finally healed. It's a nasty bite and you might not even feel it. We have brown recluse up here. Penicillin in dark areas of venom is cytotoxic which damages tissue. The bite is not painful but becomes so with hours and it develops a pale mottled cyanotic center like a big open blister. Hymenopterus stings, bees, wasps, yellow jackets and ants. Stings are painful but not medical emergencies. Unless you get stung by 50 bees it's generally not going to kill you. What does kill people is the anaphylaxis and again I think 200 people a year die from snake bites 200 people a year die from these things and it's mostly due to anaphylaxis and it's the delay in seeking care. Of the approximate 115 different species of snakes in the United States, only 19 are venomous. Sprattlesnakes, copper snakes copperheads, cottonmouths, water moccasins. Water moccasins we have here in Massachusetts. If you go swimming in a small pond and you see the snake that's swimming up after you that's a water moccasin. Get the hell out of the water. They're extremely territorial and very aggressive. I thought they didn't come up past Virginia. No, no, we got them here. Oh, we got them here. Water moccasins oh yeah, well I know because I've had them go after me. Their bite is not necessarily dangerous like deadly, but it does produce severe cytotoxic damage. You can lose fingers and have serious injuries. So there is your rattlesnake in A, B is the copperhead, C is the cottonmouth or the water moccasin and D is the coral snake. Now the difference with the coral snake these are all like vipers, pit vipers because they have the pit in the back of their head. They all have cytotoxic poison. It damages and causes tissue necrosis, doesn't necessarily kill. You know the movie where the guy gets bit on the leg by the rattlesnake and falls over and dies, doesn't happen. People get bit by rattlesnakes and walk out of the desert and people don't die from that. They can, but generally they don't. The coral snake is different. The coral snake has a neurotoxic, this will kill you. We used to have these down in Fort Jackson, South Carolina and we had these. You had to be very careful, especially when you were in the jungles and woods and things. They're aggressive but you don't see it. You might not even feel it. They don't bite you once and retract. They bite and they kind of chew on you and they insert their venom in you. And they're small snakes and they usually like ankle or toe biters. If you were in a good boot you're generally okay. But their toxin is neurotoxic. You have to be careful with those. The old saying is red on yellow will kill a fellow, red on black, venom lacked. So red, see how the red touches the yellow? That means that it is a coral snake. It is toxic. If the red touches the black, if it goes red, black, yellow then that's what they call a milk snake. A milk snake is non-venomous. But it's designed to look that way to scare predators. So remember that. Red on black, red on black, venom lacked, red on yellow, kills yellow. But if you're not sure, just stay away from it. If you have a spider bite or you have a snake bite, do not search for the snake or the spider. Grab it and bring it to the hospital. They'll be very angry at you. Take a picture of it. Snakes usually don't bite unless provoked, angered or accidentally injured. Most people are bitten by snakes because they inadvertently step on them and they don't realize that they're there. So if you watch where you walk, you're generally okay. Protect yourself from getting bit. Use extreme caution and wear PPE. Classic appearance of a snake bite, you have the puncture wounds with discoloration, swelling and pain. What we usually do is if I go to a snake bite, I'll take a pen or marker and I'll circle it. And then I can tell how the swelling advances because I can tell where I do the circle versus where I'll circle the bite and the swelling and then watch as it expands. Rattlesnakes, copperheads and cottonmouths are all pit vipers with a triangle snake flat head. They've got that pit in the back that they can actually bite their nostrils and they can sense and smell. Although most of them are smelling with their tongue. They taste the air literally. Rattlesnakes are the most common pit viper. They can go up to six feet long and have that telltale rattle sign. They rattle when they get irritated or they get scared. They won't bite before they rattle. So if you hear the rattle, you've got a chance to get the hell away from it. Copperheads are usually two to three feet long. They have the red copper color with brown and red bands. And again, they're a smaller snake, less powerful toxin and usually if you're wearing a good set of boots, they won't bite through it. A rattlesnake can bite through boots. No. Rattlesnakes and copperheads are not. Cottonmouths and water moccasins are. Olive brown water snakes are very aggressive. Tissue destruction can be severe. Signs of envenomation. Severe burning, pain at the site, swelling and blue discoloration as the tissues become cyanotic. Weakness. You might get nausea, vomiting, sweating. Seizures can develop and faint. Vision problems, changes in level of consciousness and shock. So mark with a pen the edges of the skin. Do not have a patient walk. Pick the patient up on a stretcher or on a backboard and individually carry the patient out. We do not want to put tourniquets or restrictive bands on the wound. We want to let that toxin spread through the body so the body can break it down. But we want to do it slowly. Keep the patient calm. Keep their heart rate down. Oxygenation and transport. Do not keep anything by mouth and be alert for vomiting and also be alert for anaphylaxis. That's what's going to kill the patient more than anything is the anaphylactic reaction. If the bite occurs in the trunk, keep the patient supine and quiet. If there's any signs of shock, treat it. If the snake has been killed, bring it with you. Just take a picture of it. Notify the hospital that you had a snake bite. Coral snakes, again, these are tiny fangs with a chewing motion that leave punctured wounds. If you have a good thick pair of shoes or a set of boots, they won't come up above your calves. So if you've got a good high pair of boots that are thick, you're not going to be able to bite through them. Many times people are bitten because they sit down and they put their arm down and they reach down and that's when they get bitten. They have a potent neurotoxin that can cause paralysis, cause respiratory paralysis, exhibit bizarre behavior, paralysis of eye movement and respirations. There is an antivenom. Most hospitals do not stock it. They do in Boston. So they will get it from Boston to out here. Emergency care is the same. Scorpions. There's only one type of scorpion out of the hundred or so species of scorpion. There's only one type that actually is dangerous, that has a neurotoxin. Most scorpions are no more than a bee sting. You know those big, big black ones that people see? People eat those. They sting you, it's no more than a bee sting. It's this other one that's dangerous. And you only see the one that's dangerous in like Arizona, New Mexico, Texas. It's not up here in Ann Arbor, Colorado. That's true. It's this guy right here. They call it Centroides Sculptoratus. That's the one right there. And it's not very big. It's maybe this big. It's not that big. It usually causes the bite is more painful than it's dangerous in the standard scorpion, but this one actually can be dangerous. Circuits or collapse, severe muscle contraction, excessive salivation, hypertension, convulsions and cardiac failure. You don't want to get stung by this sucker here. Tick bites? Well, we live in New England, so we know all about ticks, right? Ticks can carry a number of different diseases from Rocky Mountains Body Fever. They carry Lyme disease. So you have to be very careful. They're found everywhere around here. By the way, don't bother opossums. Don't hit them with your car. Opossums eat ticks. So if you've got opossums in your yard, that's good stuff. And it's not the big, and the ones you've got to worry about are not the big deer ticks. The big ones you don't have to worry about is the ones you can barely see. Those are the small ones, right? The infection spreads through the ticks' saliva. And it's this little guy right here. 40% of people do not develop the bull's-eye rash, but 60% do. If you see a patient with this with flu-like symptoms, that is a classic Lyme disease. I had Lyme disease. I was not aware of it. A lot of people don't have it. I was just sleepy for a week or so. A lot of people don't know they have it. Lyme disease, it was coined from Lyme, Connecticut, where it was first identified. And if you get bit by a tick, and you pull a tick off within 24 hours, you won't get it. It has to be on you for more than 24 hours, they say. And it's in the tick's saliva. It's a bacteria. And it can cause, some people don't have bad reactions, but some people can get really bad problems like rheumatoid arthritis, autoimmune disorders. They can get organ failure. Some of it's really serious. There are three stages. You have the incubation phase, the infectious phase, and then the and it can't be spread, by the way. I can't give it to somebody who's not contagious. And then the latent phase. So once you hit the latent phase, if it's not treated, that's where you get all the long term effects from it. So what they do is they treat it with tetracycline. Some patients are on tetracycline their whole life. Because it's the only way they can treat the symptoms of it. And yeah. Rocky Mountain spotted fever is another one. It occurs 7 to 10 days after the bite. It can cause very severe, almost like a pneumonia, with paralysis and cardiorespiratory collapse. It's not common around here. It's more common out in the western United States. We talked about Lyme disease, painful joints and swelling of the joints, rheumatoid arthritis. It's most common in the spring and summer months. Be careful. If you're going to remove a tick, make sure you get the head out. You've got to pull the whole thing out. And that idea that you can burn it out or you can smother it with petroleum jelly and all that, those are all wives' tales. The only way to get a tick out is to pull it out. We do it all the time. When I take the tick with the dog pan roller, they're really strong. You put it all over your body. Salarander apes are responsible for more venominations than any other marine animal. Things like fire, coal, Portuguese man o' war, sea wasps, sea nettles, two jellyfish, sea anemones, two coral and soft coral. And there's some of them there. This is the Portuguese man o' war. Its tentacles can stretch as much as 100 feet. And those tentacles get on you. The tentacles have what they call the mastocysts. They're little stinging organs. And even after they sting you and they get ripped off, they continue to pulsate. And these can actually be life-threatening. Portuguese man o' war can be life-threatening. So can't the sea coral. There's a lot of things in the ocean that can kill you.