In cases of environmental hypothermia, the common sense approach of “Warm them up!” may be the worst thing that you can do for your patient. In this presentation we learn the deadly effects of immersion, after-drop and cold induced vasodilation and how to properly differentiate between mild, moderate and severe hypothermia. We will discuss wilderness EMT and extreme environment treatment algorithms and how they apply to your service area.

1. Ice Rescue & Hypothermia
Training in Ice Rescue and
Treatment of Immersion
Hypothermia
Rommie L. Duckworth, LP
Tuesday, February 21, 2012

2. Introduction
It‟s 10 O‟clock in the morning on a Saturday in
February and the tones go off for a man
through the ice. You arrive as first on scene
with the engine to find a 2 ft. hole in the ice
surrounded by fishing gear. Inside that hole
is a man desperately holding on to the edge
of the ice crying out weakly for help. As a
Police officer on the scene pulls a rescue
suit off the engine and hands it to you and
says „Get out there and save him!‟ you ask
yourself, „Do I know what to do?‟”

3. Introduction
At the end of today, the answer to that
question will be…
YES!

4. Objectives:
 The Rescuer will demonstrate the ability to
initiate appropriate field treatment for
drowning and immersion hypothermia.
 The Rescuer will understand the proper
techniques and equipment to be used to
prevent injury to emergency personnel
operating in cold temperature
environments.
 The Rescuer will demonstrate the ability to
correctly perform ice rescue techniques
under realistic environmental conditions.

6. Course Outline:
4 Introduction
4 Objectives
n Recognition and Treatment: Drowning
& Immersion Hypothermia
n Rescuer Safety
n Incident Size Up
n Ice conditions
n Available resources

7. Course Outline:
n Course Equipment
n Set up and donning
n Hand signals / Tender‟s duties
n Live Rescue
n Extrication Techniques
n Conclusion
n FOOD!!!

8. Recognition & Treatment
In order to understand any rescue techniques,
one must understand the injury to the victim
and the treatment necessary as well as
prevention of the same injury to the rescuer.
In a bad car wreck, why don‟t
we jump in without protective
gear and yank the victim out
by the head?

9. Definition of Hypothermia
Clinically defined as body core temp of
<95 deg. F (<35 deg. C)
Simply defined as the body ‟ s
temperature lowering below the normal
functioning temperature range.

10. Human Environment
Human beings are tropical beings better
designed to shed, not retain heat.

11. Cooling
Types of Cooling (heat loss)
 Conduction
Direct Contact
 Convection
Water / Air Movement
 Radiation
Surface area vs temp.
 Evaporation
Sweating & Breathing

12. Cooling
Environmental Factors Accelerating Cold
 Wind Chill
More convection increases RATE of heat loss.
Objects do NOT cool to Wind Chill Temp.
 Immersion
Heat loss in water is 10-25x loss in air of same
temp.
Cooling rates vary greatly with changes in...

13. Cooling
Cooling rates vary greatly with change in
 Water temperature and circulation
 Time and degree of immersion
 Thermal protection - Clothing
 Muscle Mass vs Body Fat
 Physical Activity
 Age of the victim
 Aerobic fitness vs Illness
 Last oral intake
 ETOH

14. Frostbite
Frostbite, trench foot and
Chilblains: Cold injury
localized to an extremity,
usually associated with
chilled, humid environ-
ment and poor circulation.

15. Frostbite

16. Frostbite
Degrees
 1deg.=numbness and erythemia
 2deg.=blisters / clear or milky fluid
 3deg.=purple or bloody blisters
 4deg.=almost solid ice

17. Frostbite
Prevention for Rescuers!
 Stay dry
 Dress warm but…
 Do NOT overdress
 Do NOT induce sweating (antiperspirant)
(Eskimo Saying:You sweat, you die!)
 No use of ETOH or tobacco
 Proper fitting clothes & equipment
 Be aware of respiratory heat loss
 Beware of touching metals or liquids

18. Frostbite
Signs and Symptoms
 Numbness
 Tingling - Electric shock feeling
 Decreased motor function
 Pain
 Necrosis
 Burning Sensation

19. Frostbite
Treatment
 Remove from cold
 Stabilize temperature
 Protect the skin
 DO NOT RUB
 DO NOT initiate rewarming if there is any
likelihood of re-freezing.
 Leave blisters intact
 NO ETOH ingestion!

20. General Hypothermia
The body‟s reaction to heat loss
and the cold environment.

21. THE BODY‟S REACTION
Heat senses (primarily through the skin)
are connected to the hypothalamus.
The body attempts to increase heat
production and decrease heat loss.
The body primarily increases heat
production by increasing two things:
 Activity (metabolism)
 Food digestion (chemical reaction)

22. THE BODY‟S REACTION
The body reduces heat loss by...
 Peripheral Vasoconstriction
Blood shunting from extremities to core
 Reducing Respirations.
For protection the body also uses...
 Cold Induced VasoDilation (C.I.V.D.)
Due to vascular smooth muscle paralysis
Constriction relaxes momentarily
Cycles in 5-10 minute cycles
Theory as to amount of protection is in doubt

23. Assessment
Reading temperatures in the field are
usually NOT practical.
 Field temp. instruments must be both
calibrated and capable of reading to <20C,
68F.
 Preferred rectal or esophageal NOT
tympanic or oral!
What do we use for assessment?
 Physical Observations
 Signs and Symptoms
 BRAINS!

24. Assessment
Mild Hypothermia (98.6-96 f)
 Feeling Cold
 Piloerection
 Involuntary Shivering
 Unable to perform complex functions
Skiing
Climbing
 “Normal” Vitals
 Peripherally Cold
 Peripheral Cyanosis

25. Assessment
Moderate Hypothermia (95-90 f)
 Dazed & Confused
 Violent Shivering
 Difficulty performing simple functions
Walking
Undressing
 Slurred Speech
 Centrally Cold
 “Umbles”
Mumbles, Stumbles, Grumbles, Fumbles

26. Assessment
Severe Hypothermia (Below 90 f)
 Intermittent or No Shivering
 Inability to move
 Unconsciousness
 Muscle Rigidity
 Internally Cold
 Depressed Vitals

27. The Body‟s Reaction
Nervous System
 Depression
 Impaired memory
 Impaired Judgment
 Excessive Radio Use
 Loss of reflexes
 Sluggish to Fixed Pupils

28. The Body‟s Reaction
Metabolism
 Increased Catecholamine Production
 Major Muscle Groups increase rate 2-5X
 Increased digestion
 Changes in O2 Consumption
 Disseminated Intravascular Coagulation
Systemic blood coagulation
Initiated by blood chemicals
Process poorly understood

29. The Body‟s Reaction
Renal System
 Decreased ADH
 Increase in urinary output 200-350%
 Increased pressure on system (Immersion)
Relative hypotension after hydrostatic squeeze
is like rapid deflation of MAST
 Further increase in blood viscosity
 Change in blood pH-acidosis

30. The Body‟s Reaction
Cardiac
 Initial Tachycardia
 Progressive Bradycardia
 Conduction irregularities due to many
mechanisms
Acidosis
Electrolyte imbalance
Hypoxia
 More on this in the ACLS section

31. The Body‟s Reaction
Respiratory System
 Increased viscosity of surfactant
 Decreased elasticity
 Decreased muscle energy (reserves)

32. Afterdrop
BEFORE we start to treat, understand…
How the watermelon freezes, or
PATHOPHYSIOLOGY OF AFTER DROP
 Shivering
 Peripheral Vasoconstriction
 Extremities numb and useless
 Wastes build up in extremities
 Core remains warm (for now)
 Influx of fluid causes more diuresis

33. Afterdrop continued
 Blood begins to “sludge”
 Skin senses warming resulting in
peripheral vasodilation
 Pressure Drops (relative hypotension)
 Frigid Wastes flush back to warm core
 Pt. Feels warmer but core organs
temperature drop.
 Cardiac complications, renal failure, etc.

34. Treatment - Mild - Mod.
Stop the cooling!
Stabilize temperature
Application of Blankets / Coverings
Application of heat to heat points
Tx of signs / symptoms as they present
Tx of other illness / injuries as needed
ACLS Hypothermia Algorithm

35. Treatment - Severe
Stop the cooling!
Stabilize temperature
Heat from inside out
 Heated humidified O2
 Warmed IV fluids
Direct skin application of heat to skin is
discouraged (possible burns)
May need to check pulse >1 minute
Tx of signs / symptoms as they present
ACLS Hypothermia Algorithm

36. INTERMISSION

37. Drowning

38. Drowning Definitions
DROWNING: Death by asphyxiation
following submersion.
NEAR-DROWNING: NEAR-death by
asphyxiation following submersion.
SUBMERSION INCIDENT: Refers to any
in-water drowning-type event,
regardless of eventual outcome.

39. Drowning Statistics
 As of 1986 drowning was second only to
motor vehicle accidents as a cause of
accidental death in America for ages < 44.
 It ranks third for all age groups, just
behind automobile accidents and falls, but
well above alien abductions.
 Many experts suggest that the numbers of
drownings are actually much higher due to
the fact that many incidents (as with alien
abductions) go unreported.

40. Ice Rescue Victims
Typical Victims of Ice Related Accidents
-Animals
-Children
-Ice fishermen
-Ice Skaters
-Snomobilers (4-wheelers, etc)

41. Common Factors:
Unprepared for immersion: Two thirds of
all drowning victims could not swim
and did not intend to be in the water.
Non Use Of A PFD (life jacket)
Alcohol / Drug Use: Several studies have
shown that as many as fifty percent of
drowning victims were legally drunk.

42. Common Factors:
Underlying Disease: Hypoglycemia, MI,
cardiac arrythmias, syncope, seizures,
stroke and many other disease states
Trauma: As previously discussed.
Hypothermia: As previously discussed.

43. Pathophysiology
Wet Drownings. In 85% of all drownings
the victim immediately aspirates water
upon submersion. This is termed a “Wet”
drowning.
Dry Drownings. In the remaining cases,
cold water stimulates laryngospasm, an
uncontrolled shutting off of the trachea by
the epiglottis. Because of this
laryngospasm, no water enters the lungs.

44. PATHOPHYSIOLOGY
Salt vs. Fresh: Regardless of submersion
in Salt or any variation of fresh water,
the end result is the washing out
surfactant and causing atelectasis,
decreased ventilatory compliance and
again inducing massive shunting.

45. PATHOPHYSIOLOGY
Contaminants, whether they be from
sand, vomit, chemicals, bacteria or
suspended particles, are also of
concern. While there are no direct
treatments in the field for contaminants
in the lungs of a drowning other than
suctioning it is important to notify the
hospital of what contaminates are
suspected.

46. Cold Water Reflex:
This is an involuntary reflex of the
diaphragm stimulated by cold water. When
the victim is splashed in the face with cold
water the diaphragm spasms causing a
sharp inhalation gasp. Unfortunately,
because the victim’s airway is often
partially or fully submerged during this
gasp, the victim will simply suck in water
leading to increased panic. RESCUERS…
-COVER YOUR MOUTH!!!

47. Mammalian Diving Reflex:
Marine mammals’ physiological response
when stimulated by cold water submersion
is the shunting blood from their peripheral
tissues to their body’s core. The increased
blood volume in the core then stimulates a
vagal response which produces profound
bradycardia. This shunting of blood from
non-essential organs and lowered oxygen
demand allows the diving mammal to
remain underwater for a prolonged period.

48. Mammalian Diving Reflex:
Mammalian Dive Reflex theory purports that
some humans, notably children under 5,
may also use this reflex to survive
prolonged submersion. The mammalian
diving reflex theory was developed in the
1960’s as an explanation for the well
publicized survival of exceptional
submersion times of some near drowning
victims.

49. Post Immersion Synd.
This term describes the occurrence of Adult
Respiratory Distress Syndrome (ARDS) in
near drowning victims after an
asymptomatic post submersion interval
from several hours to several days. This
syndrome occurs through different means
depending on what type of fluid the victim
was immersed in (salt vs. fresh water)
although the end result is the same.

50. Treatment for Drowning
Asymptomatic: The asymptomatic
patient will most often wish to go home
and forget the incident. Because of the
threat of Post Immersion Syndrome it is
important that all patients be observed
in a hospital for four to six hours. At a
minimum, patients should be
convinced to have a follow up visit with
a physician within twenty four hours.

51. Treatment for Drowning
Symptomatic: “No one is dead until they
are warm and dead”
Always consider C-Spine Precautions
Airway:Tube and suction
Breathing: Ventilate
Circulation: CPR (in water, like on stairs
do it if you can, if not, MOVE!)
Disability

52. Treatment for Drowning
History to note for drowning victims
 Age
 PMHx
 Medications
 Trauma
 H2O temp
 Depth of submersion
 Length of time in water vs. submerged
 Breathing off compressed air source
 Contaminates aspirated

53. ACLS Interventions

54. ACLS Interventions

55. Rewarming Methods
34°C to 36°C:
Passive rewarming (remove wet clothing; warm
blankets)
Active external rewarming (most convenient: IV
solution bags heated in microwave; convective
heating methods [eg, Bair blankets], radiant heat
shield, convective heat, heating pads)
30°C to 34°C:
Passive rewarming (completely dried off; warm
blankets)
Active external rewarming to truncal areas only
<30°C:
Activeinternal rewarming under controlled
circumstances (ED or OR).

56. Active Internal Rewarming
 Warm, humidified O2 (42°C to 46°C)
 Warmed IV fluids (42°C to 44°C)
 Warm lavage: gastric, pleural (through chest
tubes), bladder
 Peritoneal dialysis
 Esophageal rewarming tubes
 Extracorporeal rewarming (cardiopulmonary
bypass)
 Continuous arterial / venous rewarming
(CAVR)

57. Active Internal Rewarming
Patient Warming Devices

58. BREAK TIME!
Rest your…
Butts
Books
Brains

59. Ice Rescue & Safety
“Well its about freakin‟ time!”

60. Ice Rescue Safety:
 According to national statistics, more rescuers
die each year trying to perform water rescues
than victims are saved from the water. Most of
these victims are firefighters.
 We are part of the problem, not the solution.
 Like everything else we do, “If you don’t know,
don’t go!”
 You must be properly trained, equipped and
prepared.
 Don’t do anything uncomfortable.

61. Safety for the Rescuer
 Dangers are Drowning, Hypothermia and other
bodily injury.
 Take a break when you need it so you can go
out again.
 Stay warm and dry!
 Ambulance standing by for rehab. and Tx.
 Always wear a PFD
 H.E.L.P. & Huddle
 Self-Rescue / Elbow Crawl

62. Safety for the Rescuer
 The turn out gear vapor barrier will trap air.
DEMO

63. Safety for the Rescuer
HAZARDS:
 Physical Hazards
 Rocky approach
 Steep Approach
Hazardous Materials
 Chemicals
 Biologicals
 Vehicles in the water
 Swift / moving water
 Large Moving Ice Blocks

65. Size Up:
Begins while enroute
Weather
Time of Day / Day of week
Light Conditions (Glare / Dark)
Available Resources
Ice Conditions
Type of incident

66. Size Up:
On Scene
 Spotters (For point-last-seen) Binoculars
 911 Caller
Reliability
Point & Time Last Seen
 Number of Victims
 Access to Victims
 Risk vs. Benefit
 Strategy & Tactics

67. Types of Ice Rescue
-Animal rescue
Risk vs. benefit
NEVER risk human life for an animal
rescue
Civilians may go to retrieve animal
-Vehicle through the ice
Occupants in vehicle
Extrication of occupants
Haz-Mat release
Associated Trauma

68. Ice Conditions
Quality: much more important than thickness for
weight bearing
Thickness and quality can vary greatly in different
areas at different times.

69. Available Resources
General rules
Call early, can always send back
Keep it close, but not too close
Boats
Different boats for different jobs
Useful trailers & sleds
Can be deceptive hindrance
DO NOT bother trying to break ice
Either paddle or slide flat bottom
boat through H20

70. Available Resources
Dispatch : Coordinate multiple resources
Fire Engine
Personnel
Lighting
Equipment
Special Rescue Equipment

71. Available Resources
Equipment NOT to call or use
 Any person not wearing PFD
 Untrained persons
 Human chains
If 1 fell through will 10 people?
 Anything that SINKS!

72. Specialty Ice Rescue Devices
Many different rescue devices are available.

73. Specialty Ice Rescue Devices
Start on shore

74. Specialty Ice Rescue Devices
Ice Rescue and Immersion Suits

75. Specialty Ice Rescue Devices
For the perfect ensemble: Accessorize!!!

76. Specialty Ice Rescue Devices
Getting to the victim fast.

77. Specialty Ice Rescue Devices
Grabbing the victim

78. Specialty Ice Rescue Devices
Grabbing the victim

79. Specialty Ice Rescue Devices
Let them see you!

80. Specialty Ice Rescue Devices
Rescue sleds
and small boats

81. Specialty Ice Rescue Devices

82. Specialty Ice Rescue Devices
Slide across ice or paddle across water.

83. Specialty Ice Rescue Devices
Pull the victim onto the sled and signal
your crew to pull you both in smoothly.

84. Specialty Ice Rescue Devices

85. Specialty Ice Rescue Devices

86. Specialty Ice Rescue Devices

87. TODAY’S EQUIPMENT
1) Suit:
a) 16 lbs. buoyant.
b) NOT Water proof
c) Secure seals as best you can
d) Be careful of zipper (bees wax)
e) Do NOT wear shoes if possible
f) Watch where you walk
2) Harness:
a) Chest Harness to keep upright & disperse weight
b) Carries additional. Equip.
c) DO NOT substitute waist harness or looped rope

88. TODAY’S EQUIPMENT FOR
NFVFD
3) Rope: Reeled or bagged. Poly preferred!
4) Rescue Tube: To reach and/or secure victim
5) Knife: Used on rope, not on Victim! Disposable!
6) Drop Marker Buoy: One hand release to mark
location
7) Cyalume: increase rescuer vis. & hand signals
8) Sled, SKED, Backboard or Boat: For sliding Victim
9) Pole: Huh, huh, he said “pole”. Reach & Grab victim
& ice
10) ICE PICKS:Home-made or Commercial
11) Whistle

89. Ice Rescue Techniques
Tender Duties
 Prep Equipment
 Assist dressing Rescuer
 Check Rescuer Signals
 Assist Rescuer Mobility
 Standby with Rescuer
 Coordinate Line Manipulation

90. Ice Rescue Techniques
Rescuer Duties
 Prep Equipment
 Get Dressed
 Check Tender Signals
 Move into position
 Standby with Tender

91. Ice Rescue Techniques
In any form of water rescue
 Reach
 Throw
 Row
 GO!

92. Ice Rescue Techniques
REACH!
 Pike Pole
 Ladder
 Specialized Rescue Devices
 Inflated Hose (less than 50‟ away)
NO!
 HUMAN CHAIN
 LADDER

93. Ice Rescue Techniques
THROW!
 Throw Bag
 Flotation Devices
 Specialized Rescue Devices
NO!
 SPARE TIRE
 PFD

94. Ice Rescue Techniques
ROW!
 Sled
 Boat
 Specialized Rescue Devices
NO!
 OPEN PROP
 ICE CHUNKS

95. Ice Rescue Techniques
GO!
 Coordinate w/ IC
 Use spotters
 Prep equipment
NO!
 NOT EQUIPPED
 NOT READY

96. Ice Rescue Techniques
Move to Patient
 Swim
 Slide
 Crawl
 Tap
 Talk

97. Ice Rescue Techniques
Reach to Patient
 Pole
 Flotation Device
 Harness

98. Ice Rescue Techniques
Contact Patient
 Grab them from behind
 If not already done, connect harness
 Remember to talk & reassure

99. Ice Rescue Techniques
Lift / Push Patient
 If possible use floatation device,
harness, special rescue device, etc.
 Use spec rescue devices as directed
 Communicate w/tender to pull pull
 Pull must be smooth and gentle
 No Jostling of the patient, remember.

100. Ice Rescue Techniques
Lift / Push Patient
 If necessary make direct pt. Contact
 Use YOUR buoyancy to lift pt.
 Use bobbing technique to lift pt.
 You must get the patient UP AND
OUT OF THE HOLE!
 If needed, immobilize the patient‟s
spine prior to moving to shore.

101. Ice Rescue Techniques

102. Ice Rescue Techniques

103. Ice Rescue Techniques

104. Ice Rescue Techniques
Don‟t forget the water / land interface!
IC should coordinate RESCUE re-
sources with EMS resources.
The ambulance should be at the
extrication point, ready to receive the
pattient (s).

105. What’s wrong with this picture?

106. Questions?