Em today 2014 firefighter down (1)

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Firefighter Down!
Special Consideration for the Resuscitation of the Downed Firefighter
Christopher Watford, Michael Herbert

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License
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Watford, Herbert - Firefighter Resuscitation - EM Today 2014
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Who Are These Guys?
Christopher Watford, BS, NRP
 Lieutenant, Leland Fire/Rescue
 Paramedic, New Hanover EMS
 Senior Editor, EMS 12-Lead Blog
 Lead Software Engineer, GE
Nuclear
Michael Herbert, BA, NREMT-P
 Clinical Educator, Advanced
Circulatory
 FF/Paramedic, Leland
Fire/Rescue
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Conflict of Interest Disclosure
Christopher Watford
 None
Michael Herbert
 Employed by Advanced Circulatory
as a clinical educator.
 Advanced Circulatory is the
manufacturer of the ResQPOD and
ResQGARD.
 Advanced Circulatory has had no
financial or editorial input into this
presentation or its contents.
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Disclaimer
This presentation and our opinions do
not reflect the views or opinions of our
employers.
We’re not speaking for them, we’re
speaking for us.
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Why Listen to Us?
We are not the experts.
We encourage you to question our
assumptions
We encourage you to question our assertions.
We would like you to ask for our references.
We would like your feedback on our proposed
solution to a problem.
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Objectives
 Understand the epidemiology of Firefighter fatalities
 Define physiological changes during stress
 Define physiological changes during firefighting
 Define risks during firefighting
 Understand pathophysiology of HCN exposure
 Define barriers to treatment during Firefighter
resuscitation
 Understand treatment goals during Firefighter
resuscitation
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Captain
David Heath
New Hanover County
Fire Rescue
Watford, Herbert - Firefighter Resuscitation - EM
Today 2014
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Epidemiology
 CDC/NIOSH Fire Fighter
Fatality Investigation and
Prevention Program
“Each year an average of 100 fire
fighters die in the line of duty.
To address this continuing
national occupational fatality
problem, NIOSH conducts
independent investigations of
fire fighter line of duty deaths.
This web page provides access
to NIOSH investigation reports
and other fire fighter safety
resources.”
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Fatality Etiologies
Medical: 1105 (44%)
 Heart Attack: 957
 CVA: 59
 Heat Exhaustion: 9
 Other Medical: 80
Trauma: 1384 (56%)
 Crushed: 390
 MVC: 345
 Struck by Vehicle: 145
 Asphyxiation: 218
 Burns: 118
 Electrocution: 22
 Drowning: 19
 Other Trauma: 108
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Trauma Fatalities
Collapsing structures most common
traumatic etiology
Motor vehicle collisions second most
common
Being struck by a vehicle also common!
Asphyxiation likely if trapped or lost
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Trauma Fatalities (en route)
Rollovers very common
Too fast, high center of gravity,
inexperience, weather
Intersection collisions common
Too fast, driving without due regard
Overuse of lights and sirens?
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Trauma Fatalities (on scene)
Working an MVC is one of the most
dangerous jobs a firefighter or EMS
provider will do.
Spend more time blocking the scene
Backers are even more important on
busy fire scenes
Numerous fatalities from apparatus
repositioning
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Trauma Fatalities (overhaul)
Structure collapse during overhaul is a
real concern
Toxic gasses during overhaul too
Electrocution rare, but happens
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Medical Fatalities
Heart Attacks are the number one cause
of line of duty deaths in fire fighters.
Autopsies of firefighters include findings such
as: cardiomegaly, hypertrophy, severe CAD,
etc.
Heat exhaustion fairly common during
training events
Heat exhaustion coupled with cardiovascular
risks is a dangerous mix!
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Medical Fatalities (cont.)
 CVA’s are comparatively rare
 Cardiomyopathies and channelopathies should be
considered in younger firefighters who collapse
 Do you know what medical problems your crew
has?
 Comorbid factors may play a large role in FF fatalities
 Certain Cancers are now recognized as resulting
from Line of Duty incidents!
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+Physiological Effects
of Firefighting
Watford, Herbert - Firefighter Resuscitation - EM Today 2014 20

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Physiological Effects of Firefighting
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The Stress of Firefighting
Firefighters:
perform strenuous physical work
while wearing heavy personal
protective equipment (PPE)
often in hot environments and under
physiologically stressful conditions
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The Stress of Firefighting
Firefighting results in
significant cardiovascular
and thermal strain as a result
of:
strenuous work
heavy and insulating PPE
psychological stress
environmental extremes
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Physiology of Stress in Firefighting
Strenuous firefighting activities can
lead to:
Attainment of maximal HR
Elevated core temperature
Dehydration
Decreased stroke volume
Increased arterial stiffness
Alterations of myocardial function
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Other Stress of Fire/EMS Response
Alarm Response
 “Noxious Arousal” from pager
T-wave inversion seen even in healthy
subjects
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Cardiovascular Effects of Note
 At the Attainment of Maximal Heart Rate…
Subendocardial viability ratio (SEVR):
Decreases
 Index of myocardial oxygen supply and demand
 Decrease in myocardial perfusion relative to cardiac
workload.
 Rate Pressure Product: Increases
 Determines the myocardial workload
 Increases significantly during firefighting activity due to
the increase in myocardial oxygen consumption.
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Question
Is a reduced SEVR and increased RPP
related to sudden cardiac events during
firefighting?
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Answer
We don’t know…
More research into the effects of
firefighting is needed!
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Hematological and Blood Chemistry
Changes
 Hemoconcentration
 ~15% reduction in plasma volume
 Release of platelets from the spleen and lymph tissue
 Platelet count increased significantly (18%)
 H&H increases
 Hemoglobin (Hgb) and hematocrit (Hct) revealed small but
significant increases (P<0.001)
 Platelet closure time decreased significantly (15%
ADP, 20% EPI)
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Hematological and Blood Chemistry
Changes
*Decreased Platelet closure time == Quicker Clotting
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Smith et al. 2013 - Clotting and fibrinolytic changes after firefighting activities

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Fibrinolytic changes
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Smith et al. 2013 - Clotting and fibrinolytic changes after firefighting activities

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Coagulatory changes
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Smith et al. 2013 - Clotting and fibrinolytic changes
after firefighting activities

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Coagulation
1.45
1.22
1.38
1.09
200%
175%
150%
125%
100%
75%
50%
25%
0%
FVIII TF
Pre Post 120Post
450%
400%
350%
300%
250%
200%
150%
100%
50%
0%
Fibrinolytic
Tpa act Tpa agn
Pre Post 120Post
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Horn et al 2010: Effects of Fire Fighting and On Scene Rehab on Hemostasis

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Risks of SCA during Firefighting
 2007 study by Kales
and coworkers clearly
demonstrated that the
relative risk of
suffering from a fatal
cardiac event was 10–
100 times greater
following fire-suppression
activities
than during non-fire
duties.
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Summary
 Studies suggest there is an
increased risk of
thrombosis due to a
procoagulatory state,
hours after firefighting.
 In effect an increased
vulnerability to myocardial
infarction after fighting fire.
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How do we address this?
 NIOSH and NFPA stress Prevention and Detection
as the key!
 Reduce modifiable risk factors
 Fitness and Nutrition Programs
 Smoking Cessation Programs
 Screening and Detection
 Annual Physicals
 Assessment of Cardiovascular Risks
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+Chemical Exposures
during Firefighting

Used with permission from Capt. Steve Jones – Burlington Fire
Dept
Ammonia Methane
Dioxin
Benzene
Chloromethane
Bromomethane
Oxides of Nitrogen
Carbonyl Fluoride
Furfural
Sulfur Dioxide
Formaldehyde
Phosgene
Ethylene
Carbon Dioxide
Hydrogen Sulfide PCB’s
Acrolein
Carbon Monoxide
Hydrogen Cyanide
Benzopyrine
Alcohols Acetic Acid

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Let’s concentrate on the “toxic
twins”…
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Toxic Twins
Hydrogen Cyanide Carbon Monoxide
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Cyanide
 Extremely poisonous,
colorless chemical, with faint
almond* smell.
 24 times more toxic then CO
 Synergistic toxicity with CO
 IDLH – 50ppm
 NIOSH REL – 5ppm
 OSHA PEL – 10ppm
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Pathophysiology of Cyanide
Histotoxic hypoxia
 Inability of cells to take up or
utilize oxygen from the
bloodstream
 Despite physiologically
normal delivery of oxygen to
such cells.
Inhibits cytochrome
C-oxidase
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Signs & Symptoms of CN toxicity
 Headache
 Confusion
 Anxiety
 Blurred vision
 Loss of judgment
 Increased respiratory
rate
 Dyspnea
 Cardiac arrhythmias
 Seizures
 Coma
 Death
MODERATE
EXPOSURE
SERIOUS EXPOSURE
Dept

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Cyanide Poisoning
Cyanide exposure:
Expected in those exposed to smoke in
closed-space fires
Important cause of incapacitation and death
in smoke-inhalation victims
Cyanide can act independently of, and
perhaps synergistically with, carbon
monoxide to cause morbidity and mortality
(“Toxic Twins”)
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Columbia Fire Department Study
 Eight month study
monitoring CO and
HCN at fires.
 Found extremely high
HCN levels at calls
 Found no correlation
between CO and HCN
production
Dept

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Food for thought…
Air monitoring of
these firefighters at
this moment found
HCN levels to be:
38 ppm
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Dept

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Treatment
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Suggested Literature Review
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Report of the Investigation Committee into the Cyanide Poisonings of
Providence Firefighters. J. Curtis Varone, Thomas N. Warren, Kevin Jutras,
Joseph Molis, Joseph Dorsey. May 30, 2006.

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Considerations during
Resuscitation

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RIT
If the downed firefighter is inside a
structure, you’ll need to effect rescue.
MAYDAY incidents are chaotic and
communication will be poor.
Frequent training for RIT will improve
chance of a rescue.
Consider that it may take upwards of 15
minutes to rescue a downed firefighter.
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Determining the Etiology
RIT has just rescued a downed firefighter.
Does not appear to be breathing.
Is it trauma?
 Blunt? Penetrating?
Asphyxiation?
Is it medical?
Does it matter initially?
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Getting them out of their gear!
Extrication.
We’re at an impasse until we get these
guys out of their turnout gear.
Their gear is going to be hot, wet,
maybe even contaminated.
Their gear is in the way of what we
need to be doing: Chest Compressions!
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FD-CPR
Concept began with Hilton Head Island Fire &
Rescue
 Video showing the time delay to get firefighter out
of gear
 Thanks to Capt. Tom Bouthillet for sharing their
experience on Youtube
Revised with the help of input from numerous
firefighters and EMS providers.
Proposed Process: FD-CPR
 10 Steps to Doff Gear and perform CPR
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+FD-CPR
Video

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Treatment
CPR, CPR, and more CPR.
Consider the etiology
Was their air cylinder empty? Early adv airway.
Was their mask off? Early adv airway and
consider HCN.
 Did they simply collapse suddenly? Std pit
crew.
 Structure collapse? Check rhythm, transport
decision?
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Your Plan?
What is your plan for:
EMS response to structure fires?
Rehab?
RIT?
Downed firefighters?
Cyanide exposure?
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FD-CPR References
 Us:
 Christopher.Watford@lelandfirerescue.com
 Mike.Herbert@lelandfirerescue.com
 Leland Volunteer Fire/Rescue Department
 http://www.lelandfirerescue.com
 http://www.facebook.com/lelandfirerescue
 http://www.facebook.com/LelandFireRescueTraining
FD-CPR
 http://www.fd-cpr.com (Coming Soon!)
 http://www.facebook.com/fd-cpr (Coming Soon!)
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References
 NIOSH Fire Fighter Fatality Investigation and Prevention Program.
 http://www.cdc.gov/niosh/fire/
 Brandt-Rauf PW, et al. Health hazards of fire fighters: exposure assessment. Br J
Indust Med. 1988; 45:606-612.
 Smith DL, et al. Effect of strenuous live-fire fire fighting drills on hematological blood
chemistry and psychological measures. J Therm Biol. 2001; 26:375-379.
 CDC. Fatalities Among Volunteer and Career Firefighters: United States, 1994-2004.
Morbidity and Mortality Weekly Report. 2006; 55(16):453-455.
 Dweck MR, et al. Noxious arousal induces T-wave changes in healthy subjects. J
Electrocardiol. 2006; 39:324-330.
 NIOSH. Preventing Fire Fighter Fatalities Due to Heart Attacks and Other Sudden
Cardiovascular Events. Publication Number 2007-133. June 2007.
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References
 Geibe JR, et al. Predictors of On-Duty Coronary Events in Male Firefighters in the
United States. Am J Cardiol. 2008; 101:585-589.
 Fahs CA, et al. Impact of Excess Body Weight on Arterial Structure, Function, and
Blood Pressure in Firefighters. Am J Cardiol. 2009; 104:1441-1445.
 Horn GP, et al. The Effects of Fire Fighting and On-Scene Rehabilitation on
Hemostatis. University of Illinois Fire Service Institute. November 2010.
 Estes CR, Marsh SM, Castillo DN. Surveillance of Traumatic Firefighter Fatalities: An
Assessment of Four Systems. Pub Health Rep. 2011; 126:540-551.
 Kunadharaju K, Smith TD, DeJoy DM. Line-of-duty deaths among U.S. firefighters:
An analysis of fatality investigations. Acc Anal and Prev. 2011; 43:1171-1180.
 Smith DL, et al. Effect of Live-Fire Training Drills on Firefighters’ Platelet Number
and Function. Prehosp Emerg Care. 2011; 15:233-239.
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References
 Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment stragies.
Scand J Trauma Resus Emerg Med. 2013; 21(31):1-15.
 IAFF. Heart Disease in the Fire Service. 2013.
 http://www.iaff.org/hs/index.htm
 Smith DL, Barr DA, Kales SN. Extreme sacrifice: sudden cardiac death in the US
Fire Service. Extr Phys Med. 2013; 2(6):1-9.
 Mbanu I, et al. Seasonality and Coronary Heart Disease Deaths in United States
Firefighters. Chronobiol Int. 2007; 24(4):715-726.
 Poston WSC, et al. An examination of the benefits of health promotion programs for
the national fire service. BMC Pub Health. 2013; 13(805):1-14.
 Yang J, et al. Sudden Cardiac Death Among Firefighters ≤45 Years of Age in the
United States. Am J Cardiol. 2013; 112:1962-1967.
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References
 Fent KW, et al. Systemic Exposure to PAHs and Benzene in Firefighters
Suppressing Controlled Structure Fires. Ann Ccup Hyg. 2014; 58(7):830-845.
 Hostler D, et al. A Randomized Controlled Trial of Aspirin and Exertional Heat Stress
Activation of Platelets in Firefighters during Exertion in Thermal Protective Clothing.
Prehosp Emerg Care. 2014; 18:359-367.
 Hunter A, et al. Abstract 27: Fire simulation exposure causes impairment of
endothelial function and increased thrombogenicity in healthy firefighters. Heart.
2014; 100(Suppl 3):A14-A15.
 Kales SN, Smith DL. Sudden cardiac death in the fire service. Occup Med. 2014;
64:228-232.
 Perroni F, et al. Psychophysiological Responses of Firefighters to Emergencies: A
Review. Open Sport Sci J. 2014; 7(Suppl-1, M3):8-15.
 Smith DL, et al. Clotting and Fibrinolytic Changes after Firefighting Activities. Med
Sci Sports Exerc. 2014; 46(3):448-454.
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