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Last updated June 26, 1999
The Cascade Hospital is a resource website designed specifically to help FANFIC and other FICTION WRITERS who want to make their stories more medically authentic. It is NOT for people seeking answers to personal medical questions -- that is a job for your private physician.
~ Unnatural causes of injury and death ~
Please read the Sentinel and Medical Disclaimers.
Hypothermia - treatment
Frostbite - symptoms and treatment
Effects of almost drowning
Short-term electrical shock; Lightning
Smoke inhalation
Burns -- classification ("degrees")
Heat stroke
According to my internal medicine book, patients should first be put on an EKG monitor and a continuous blood pressure monitor. A foley catheter should be placed to monitor urine output. Normal saline should be started (and hooked up to a warming device that warms the normal saline before it goes into the patient). CPR should be avoided if possible because a cold heart is very irritable and can easily go into a fatal arrythmia because of chest compressions. Also, warmed oxygen should be given by mask.
If the person has mild hypothermia (not sure what the exact temperature cutoff is), an insulated blanket is used to rewarm them (not a heated blanket or sticking them in hot water, because these things warm them up too fast).
If they have severe hypothermia, you can do more aggressive things like warm peritoneal lavage (that's where you poke a hole in their abdomen and stick a catheter -- small plastic tube -- into the abdominal cavity and run warmed normal saline into them. Then you drain the fluid out and do it again.) If you really want to be drastic, in bad cases you can also do things like a partial cardiopulmonary bypass or hemodialysis with a heat exchanger (basically you run the patient's blood out of their body into a machine which warms up the blood and then pumps it back into their body).
Frostbite is freezing of the skin or underlying tissues that occurs as a result of prolonged exposure to cold. Frostbite looks like a serious heat burn, but it's actually body tissue that's frozen and, in severe cases, dead. Most often, frostbite affects the toes, fingers, earlobes, chin, and tip of the nose. These body parts are often left uncovered and can freeze quickly. Danger signs are pain (initially), swelling, white skin, then numbness and eventually loss of function and absence of pain. Blisters may also develop.
Frostbite can happen when temperatures drop below freezing, but wind chill speeds up heat loss and can add to the risk. Frostbite can set in very slowly, or very quickly. This will depend on how long the skin is exposed to the cold and how cold and windy it is.
Frostbitten skin is pale or blue, stiff or rubbery to touch, and feels cold and numb. The severity is divided into three degrees:
First degree: Frostnip. Numbness and whitening of the skin with little likelihood of blistering if rewarmed promptly.
Second degree: Superficial frostbite. Outer skin feels hard and frozen but tissue underneath has normal resilience. Blistering is likely.
Third degree: Deep frostbite. Skin is white or blotchy and blue. Skin and tissue underneath is hard and very cold.
Prevention: Layer your clothing. Many layers of thin clothing are warmer than one bulky layer. Air spaces trap body warmth close to the skin, insulating the body against the cold. Wear two or three pairs of socks instead of one heavy pair, for example, and wear roomy shoes. Wool and polypropylene are good insulators. Wear wind- and waterproof outer layers. Wear wool socks and well-fitting, waterproof boots. Wear a hat to prevent heat loss from your head. Wear mittens rather than gloves. Don't drink alcohol or smoke cigarettes. Alcohol causes blood to lose heat quickly. Smoking slows down blood circulation to the extremities. Stay indoors as much as possible when it is very cold and windy. When you are out of doors, shield your face, etc... from the wind.
What to do:
Check for signs of hypothermia (see above) and treat it before treating frostbite. This is very important. Hypothermia is much more worrisome and fatal than frostbite is. Of course, if the person is talking and shivering, you wouldn't be *as* worried about hypothermia, but you want to be sure and take steps to warming up the entire person, not just the "frostbitten" parts.
Protect the frozen body part from further exposure. Don't rewarm the area if refreezing is possible. Wait until you reach shelter.
Warm small areas (ears, face, nose, fingers, toes) with warm breath or by tucking hands or feet inside warm clothing next to bare skin.
Don't rub or massage the frozen area, because doing so will further damage tissues. The old wives' tale that says you should treat frostbite by rubbing the area with snow or soaking it in cold water is wrong. This treatment is ineffective and dangerous. Instead: Warm the affected area by soaking in a tub of warm water (101 F to 104 F) and an antiseptic solution. Stop when the affected area becomes red, not when sensation returns. (This should take about 45 minutes. If done too rapidly, thawing can be painful and blisters may develop.)
Keep the frostbitten part warm and elevated. Protect exposed area from the cold. It is more sensitive to re-injury. Wrap with blankets or soft material to prevent bruising. If possible, immerse it in warm water (104° to 108°) for 15 to 30 minutes. Avoid walking on frostbitten feet if possible.
Blisters may appear as the skin warms. Do not break them. The skin may turn red, burn, tingle, or be very painful. Aspirin or acetaminophen may help.
When to Call a Health Professional: After being in cold temperature, if you have any of these problems, you may have frostbite or hypothermia and should get medical attention.
You have two major problems with drowning or near drowning: asphyxia (lack of oxygen) and damage done to the lungs from the water/sediment/whatever else the victim inhales. If they don't die from lack of oxygen, they can die from the damage to the lungs.
The major possible result from asphxia (assuming the person doesn't die) is brain damage. In children, there is something called the "diving reflex" that sometimes kicks in and allows the child to survive without permanent injury. The diving reflex is activated in very cold water and it somehow triggers a slowing of the heartbeat with a decreased demand for oxygen. Since the body then requires less oxygen, the person doesn't suffer damage from not having enough. For this reason, paramedics and other rescuers are very aggressive in attempting CPR on children especially when they have "drowned"; it is still possible to resuscitate someone up to 45 minutes after drowning. The sad thing is that the paramedics have no way of knowing if the victim will recover with or without brain damage. Sometimes they do, sometimes they don't. But you can't tell until they've been resuscitated.
Damage done to the lungs from inhaling water/sediment: this situation would be more likely to happen in an adult that (nearly) drowned. The excess water and sediment can set up an inflammatory reaction in the lungs which impairs air exchange (actual inflammatory membranes develop around the tiny sacs in the lungs). The person often will require intubation with mechanical ventilation. A condition called ARDS (Adult Respiratory Distress Syndrome) means that the person gets these nasty membranes and they simply can't breathe through their lungs and get enough air. They end up requiring very high amounts of oxygen and pressure to get the oxygen into their lungs, which in itself can further damage the lungs ("barotrauma"). Once a person gets ARDS, the mortality or death rate is upwards of 50%. ARDS can be caused by many things besides drowning (such as smoke inhalation, other serious infections, etc.); it is a final common pathway for damaged lungs. Anyone who actually recovers from ARDS can easily be considered a miracle.
Other things that can happen during drowning include a reflexive slowing of the heart (called reflex bradycardia), electrolyte imbalances that can happen when you inhale and absorb the water through your lungs and dilute your blood, and arrhythmias (irregularities of the heart beat). You can also get spasm of your upper airway (laryngospasm and bronchospasm). This last one is thought to also lead to the asphyxia problem.
Short term electric shock, for example a car battery
I think the number one problem would be pain! Real bad pain. You also have the mental torture of anticipating the shocks, and a lot of people wouldn't think too kindly about that either.
As for other medical problems, the next one would probably be the possibility of burns, both from heat and from the electrical current. There may be no external evidence at all from a shock, or the person may be badly burned. Electrical shock is worse than other kinds of burns (like thermal burns from a fire) because it tends to travel along the path of least resistance, which in the body is the nerves and blood vessels (the nerves after all are designed to conduct electrical signals rapidly). This gives you the possibility of having more internal injury. Low voltage burns from electrocution (i.e. car battery) may be evidenced by small pale or dark pits with raised edges. High voltage burns (telephone poles, lightning) may have little external injury or massive burns. The worst burns come from alternating current (AC) rather than direct current (DC) (a car battery is DC), with AC of 60 cycles being very dangerous. High voltage (>1000 volts) is also lethal (not a car battery, obviously).
Another more serious problem would be related to the heart, because electrical current can induce arrhythmias (irregular heartbeat). Shock is used for a person whose heart stops beating, but shock also goes the other way too, and it can cause arrhythmias as well as stop them. Arrhythmias would be more likely to happen in an older person who already had a bad heart or a predisposition to arrhythmias, if the voltage and current were higher, and if the electrical current is applied such that the path travels through the heart. Arrhythmias can be insignificant, or they can be fatal. I don't know how common this would be either -- not terribly common but certainly not unheard of.
Also, if the shock is massive enough, it can fry the nerves that run your respiratory muscles, thereby killing the person because they stop breathing.
What does a person feel like following being shocked? I'm not sure, not having experienced a big shock myself. However, I have a friend who accidentally touched an electric fence when she was little (yikes) and she says she felt "twitchy" afterwards. I think mostly you'd feel like you had a huge adrenaline rush (too huge to be pleasant, though). That would mean fast breathing, maybe shaking, sweaty, that type of thing. I don't think it would give you the chills or make you weak or have trouble breathing in particular. It shouldn't make you unconscious.
Lightning
A few extra facts on getting struck by lightning: it's a specialized form of electrical injury. Surprisingly, most victims survive. External injuries can vary from nothing to massive burns. One interesting characteristic finding is that the victim may have an arborescent (leaf-like) pattern of redness at the point of entrance or exit of the lightning bolt. This redness isn't a real burn, but a localized area of increased blood flow.
You have several problems to deal with in smoke inhalation. 1) lack of oxygen (hypoxia), 2) direct damage to the lungs from soot, carbon monoxide and other noxious gases, 3) thermal injury (the sheer heat damaging the lungs). All of these can kill you, and often it's the combination that does the person in.
Lack of oxygen will kill you most quickly. Oxygen is consumed by a fire, so in a closed area the person may simply run out of air to breathe. Hypoxia will also happen with carbon monoxide poisoning (a product from burning gases and other materials), because the carbon monoxide displaces the oxygen from the blood cells. For more info on carbon monoxide poisoning, see the toxicology page. Either way, a person who dies at the site of the fire will often have died from lack of oxygen. If they are rescued in time but have experienced a partial lack of oxygen, there can be brain damage and other organ damage from the lack of oxygen.
The soot and noxious gases and the heat from the fire can damage the lining of the lungs, causing bronchospasm (where the air passageways constrict and the person can't get enough air through the narrowed passageways) and later an intense inflammatory reaction can occur with a lot of white blood cells and fluid collecting in the lungs and impairing air exchange. The worst type is called ARDS (Adult Respiratory Distress Syndrome). ARDS can be caused by a lot of different things, but smoke inhalation is one of them. 50% of all people who develop ARDS will die. These people's lungs have been damaged so badly and the inflammatory reaction has been so severe that even very high concentrations of oxygen and high pressures from a mechanical ventilator cannot get enough oxygen into the person's blood to survive. ARDS usually takes days to set in, and the person may not die for days or weeks. If they survive, they usually take days or weeks or even months to recover, and usually spend a lot of that time on a respirator.
If the person went unconscious (which hypoxia can do to you), they often aspirate their secretions (saliva, stomach contents) into their lungs. This sets up a nasty aspiration pneumonia, which requires antibiotics and more oxygen and respiratory support. Definitely doesn't help matters.
Treatment for someone with smoke inhalation follows the regular trauma sequence of ABC's: airway, breathing, and circulation. People with burns and smoke inhalation are often intubated early before they "crash", if the doctor thinks they might eventually need to be on a respirator to help with breathing. The airway spasm can happen in the upper airway as well as the lungs, i.e. the trachea and larynx/pharynx, and these areas can swell up from being burned, which is why it is important to get them intubated before they swell up too much. The person might be hoarse from the vocal cords being burned. Anyway, the person will be given oxygen and their oxygen saturation watched very closely. In the immediate situation, oxygen and intubation are really the main things you do for a smoke inhalation victim. Later, you can give bronchodilator treatments (inhaled medicine similar to what you give people with asthma and emphysema) to open up the lungs -- stuff like albuterol and atrovent. These can be given whether a person is intubated or not, usually every 4 hours and more often if needed. You have to watch their fluid balance carefully to make sure they don't get too much fluid and end up with fluid in the lungs (pulmonary edema) which makes it even harder to breathe. If they develop aspiration pneumonia, you can give antibiotics. Doctors will get chest x-rays often if the patient isn't doing well, just to monitor how the lungs look. Other than this supportive care, you just have to wait and see if the patient will get better, keep giving them oxygen and keep them on a respirator as long as they need help breathing. There are dangers in having a person on a respirator at high oxygen concentrations for too long; barotrauma from the high pressures can damage the lungs, and too much oxygen can cause oxygen toxicity (has to do with free radicals being formed from the oxygen which damages cells).
Another thing to think of is that people with bad smoke inhalation often have burns on the outside of their bodies, which also contributes to whether they survive or not and how long it takes for them to recover.
How much is life-threatening? That's hard to say as far as how many minutes. It only takes about 6 to 8 minutes without oxygen to get brain damage. As for the lung damage, it really depends how much junk and smoke the person ended up inhaling. You'll have some damage with several minutes (say 5 to 10 minutes) of smoke inhalation, and the more you inhale the worse it will be. The amount it takes to get ARDS really varies on the person. It could take a little or a lot, depending on the person.
Burns -- classification ("degrees")
Burns are categorized by severity into "degrees". Most people use 1st, 2nd, and 3rd (though some also use a "4th"). The numbers refer to the depth of tissue that is burned. Therefore, 1st degree is the least bad ("1st layer of skin") and 4th would be the worst or deepest. You can't really say that a certain thing (like a cigarette burn or fire) would always cause a certain degree of burn. It all depends on the temperature of the heat/flame, the length of time in contact with skin, whether the person had any kind of protection (for example, clothing), etc. The way you tell which "degree" of burn is by the physical findings on the skin itself after the burn. A 1st degree burn is just red, sensitive skin. Mild sunburn is a good example of a 1st degree burn. A 2nd degree burn is indicated by blistering, and the epidermis (outer layer of skin) is the only layer damaged. A 3rd degree burn is where the epidermis and dermis (the top 2 layers of skin) have been killed -- basically anything worse than a 2nd degree burn. For people who use the term 4th degree burn, that usually refers to visible charring (blackening) of the tissues.
While most burns are not life-threatening, if a person is burned over 70% of their body, that is *very* serious and life-threatening. These people must be transported quickly to a specialized "burn unit" which only certain hospitals have. The person loses a significant amount of fluid through their tissues because the skin is not there to hold it in, and they often go into shock and kidney failure. For those who survive, they are very susceptible to infection (very common) because they do not have the protective barrier of the skin to keep germs out. 1st and 2nd degree burns heal without leaving a scar. 3rd or 4th degree burns can have problems healing, particularly if an infection occurs, and may require skin grafting. Contractures (dense scar tissue that limits motion) are common with severe burns that heal.
You can die much more easily from excessive heat than excessive cold.
Heat exhaustion is a different and less severe problem than heat stroke, and it is not fatal. Heat exhaustion is caused by insufficient water intake, insufficient salt intake and a deficiency in the production of sweat. (Sweat evaporation is what helps to cool the body.) Symptoms of heat exhaustion include 1) Dizziness, fatigue, faintness, headache 2) Skin that is pale and clammy (the person is sweating) 3) Pulse rapid and weak 4) Breathing is fast and shallow 5) Muscle cramps 6) Intense thirst
Heat stroke is caused by overexposure to extreme heat and a breakdown in the body's heat-regulating mechanisms. The body becomes overheated to a dangerous degree. This is an emergency and can be fatal!
Symptoms of heat stroke
1) Often preceded by heat exhaustion and its symptoms.
2) Skin that is hot, dry and flushed
3) *NO* sweating!
4) High body temperature (105 F or more)
5) Rapid heartbeat (100/minute or more)
6) Rapid and shallow breathing
7) Elevated or lowered blood pressure
8) Nausea
9) Confusion -- disorientation is a key symptom and often the first noticeable
sign. This may include bizarre behavior, irritability, combativeness, and
hallucinations.
10) Loss of consciousness
Treatment for heat stroke involves removal from exposure and aggressive hydration and cooling.
1) Remove the person from the area to a cool sheltered place.
2) Encourage them to drink cool water or a sports beverage slowly but constantly
if they are able. Do not give coffee, tea, or alcohol since that worsens
the dehydration.
3) Cool the person by removing their clothes and covering them with damp
sheets, spraying with water, fanning them. Some people also recommend using
ice packs on the person's neck, armpits, and groin. Lay the person down
and elevate their legs.
4) Call for medical help immediately -- this is an emergency. The paramedics
will put an IV in immediately and give them as much cool normal saline
as possible via the IV ("normal saline wide open" is how they
would say it).
Prevention of heat exhaustion and heat stroke
1) Drink plenty of fluids (water and/or sports drinks) to replenish
fluids and electrolytes.
2) Dress in lightweight, tightly woven, loose-fitting clothes preferably
of a lighter color
3) Schedule vigorous outdoor activities for cooler times of the day
4) Protect yourself from the sun by using a hat, umbrella and sunglasses
5) Increase the time spent outdoors gradually so that your body can get
acclimatized to the hot conditions.
6) During outdoor activities take frequent drink breaks in the shade and
take precautions to ensure that you don't overstrain yourself.
7) Try to spend as much time as possible indoors or in the shade.