14 CEN: Enviro and Toxicology Emergencies, and communicable dz

Question 1

With burns, what would be concerning for airway?

Answer 1

Airway patency: edema, hoarse voice, carbonaceous sputum, and stridor indicates oral burns (not just singed nasal hairs) - intubate immediately.

Question 2

What is needed for circumferencial burns?

Answer 2

Escharotomy if circumferential chest burn, and you cannot ventilate.

Question 3

Fluid resuscitation for burns- which isotonic fluid?
How much (ml/kg) for adults, peds, electrical?

Answer 3

LR fluid of choice
American Burn Association Recommendations (2 adult, 3 peds, 4 electrical)
Begin LR at 2 ml/kg X TBSA for thermal burns,
3 ml/kg x TBSA for pediatrics,
4 ml/kg x TBSA for electrical burns.

Calculate based on partial and full thickness, not superficial.

Question 4

TBSA “rule of 9s”

Answer 4

9% - head
9% - chest
9% - back
9% - abdomen
9% - lower back
9% - Right whole arm (4.5% front, 4.5% back)
9% - Left whole arm (4.5% front, 4.5% back)
9% - Right front leg (thigh and calf)
9% - Left front leg (thigh and calf)
9% - Right posterior leg (thigh and calf)
9% - Left posterior leg (thigh and calf)
1% - private (penis or vagina)
_________
100%

Question 5

What is the Parkland Formula?

Answer 5

Parkland Formula - 4 ml/kg instead of 2 ml/kg for adult thermal burn.

1s half of the total volume of fluid over the 1st 8 hours from time of burn injury; remaining half over the next 16 hours.

Monitor urine output to get 0.5-1.0 ml/kg/hour (1-2 ml/kg/hour for pediatrics), at least 75-100 ml/hour for electrical burns.

Question 6

What are the 2 main risks of Electrical burns?

Answer 6

Risk of rhabdomyolysis, so increase IVF’s.
ECG monitoring for 24 hours for electrical burns, risk of ventricular fibrillation.

Question 7

Lightning burn s/s?

Answer 7

Lichtenberg feathering, ruptured tympanic membrane, cataracts long-term.

Question 8

Chemical exposure

Answer 8

Brush off dry chemicals first (lime powder).
Decontaminate outside of facility if fumes. Consider inhalation injury and support oxygenation and ventilation.


Question 9

Asphalt burn tx?

Answer 9

Asphalt - cool and apply emollient to loosen if ordered by burn professional.


Question 10

Phenol (carbolic acid) burns tx?

Answer 10

Phenol (carbolic acid) burns - copious irrigation with 50% PEG (MiraLAX) and water.


Question 11

Hydrofluoric acid (rust remover) burn tx?

Answer 11

Hydrofluoric acid (rust remover) - irrigate for at least 30 min, until pain relief, then apply 2.5% calcium gluconate gel.


Question 12

Alkalis (lye, cement, ammonia) burn tx?

Answer 12

Alkalis (lye, cement, ammonia) cause liquefaction or saponification (destroy tissue) so require large volumes of irrigation.

Question 13

How does Carbon monoxide poisoning occur?
S/s?

Answer 13

Carbon monoxide poisoning

1. Carbon monoxide (CO) poisoning can develop with exposure to smoke. When you breathe CO in, it attaches to and replaces the oxygen on the hemoglobin molecule, resulting in carboxyhemoglobin and reducing the oxygen content of the blood “silent killer”.

S/S: headache, nausea, vomiting at 10-20%; confusion and lethargy at 20-40%; ST segment depression from hypoxia, arrhythmias, seizures at 40-60%; death > 60%, cherry red skin.



Question 14

Carbon monoxide poisoning Dx? Tx?

Answer 14

DX: serum Carboxyhemoglobin, do not trust SpOz.
TX: Treat with 100% high-flow 02 via tight-fitting mask until level < 10%, consider hyperbaric oxygenation HBO for pregnant patient (fetus most vulnerable).

Question 15

What happens with Cyanide poisoning? Signs? Tx?

Answer 15

Burning of plastics or carpets, interferes with cellular respiration (shifts oxyhemoglobin curve to left - hemoglobin holds onto 02).

Signs: smell of bitter almonds on breath, headache, dizziness, seizures.

Treatment: Cyanide Kit - inhaled amyl nitrite (causes methemoglobinemia), IV sodium nitrite, IV sodium thiosulfate or Cyanokit: Hydroxocobalamin (vitamin B12) - turns urine pink.

Question 16

What does Black Widow look like?
S/S? TX?

Answer 16

Black Widow - red hourglass on abdomen of female.

S/S: Immediate sting, dull ache in 20 minutes, then abdominal cramping, muscle spasms,
HTN, tachycardia, nausea & vomiting, weakness.
TX: Ice, elevate, analgesics and benzodiazepines to control muscle spasms, antivenin cautiously.

Question 17

What does Brown Recluse look like?
S/S? TX?

Answer 17

Brown Recluse (Fiddle-Back) - “violin-shape”

S/S: - Painless bite; pruritus, redness, blister in 1-3 hours, bluish ring

-Fever, chills, nausea, vomiting, malaise within 24 hours of bite.
-Necrotizing ulcerating wound (tissue sloughing) over time.

TX: Wound care, removal of necrotic tissue, hyperbaric oxygen therapy, antibiotics, steroids.

Question 18

Pit viper (Crotalid)

Answer 18

Venomous: diamond-shaped (triangular) heads; vertical, elliptical pupils; fang(s); single row of caudal plates. Hemotoxic (bleed)

Rattlesnakes, copperheads, & water moccasins (cotton mouth).


Question 19

Signs of envenomation? Tx?
When is antivenin needed?

Answer 19

Signs of envenomation: pain, redness, swelling to site, progressive edema, blood-filled vesicles (candidates for antidote).

TX: 2 large-bore IV’s, remove constrictive clothing and jewelry, immobilize limb in neutral position, antivenom (antivenin) if severe hemorrhagic swelling, repeated until swelling subsides;
NO ICE.

Question 20

What do Coral snakes look like? S/s of bite?

Answer 20

Coral snakes (Elapidae) “Red on yellow, kill a Fellow. Red on black, venom lack.”
-Neurotoxic venom causing respiratory paralysis.

S/S: respiratory distress, local paresthesia, diplopia, ptosis, difficulty swallowing, increased salivation. TX: Supportive care, possible antivenom.

Question 21

Tx for stingrays with venom coated barbed stingers?

Answer 21

Stingrays - Venom-coated barbed stingers create severe pain and swelling at site.
TX: Immerse in warm water (110 degrees F) for up to 2 hours until relief of pain, removal of barbs with hemostats.

Question 22

Tx for jellyfish?

Answer 22

Nematocysts are stinging darts that fire producing severe pain and reddened welts.
TX: Rinse in normal saline and remove tentacles using forceps. Water stimulates venom.

Question 23

What is in cat bites that causes highest rate of infection?

Answer 23

highest rate of infection of animal bites because long fangs penetrate deep into tissue, saliva contains Pasteurella which can cause cellulitis or osteomyelitis; leave wound open unless on face, prophylactic antibiotics. (Excrement toxoplasmosis)

Question 24

Decompression Sickness/Arterial Gas Embolism S/s? Tx?

Answer 24

Inadequate decompression after exposure to increased pressure resulting in bubbles growing in tissue that causes local damage known as “the bends;”
body absorbs nitrogen during ascent, if ascent is too quick the nitrogen forms bubbles - arterial gas embolism.

S/S: SOB, creptitus, numbless, tingling, diplopia, petechial rash, seizures, joint discomfort, pain.

TX: oxygen administration, fluids, analgesia, position patient on left side in trendelenberg, hyperbaric oxygen therapy, heliox.

Question 25

Heat cramps s/s? Tx?

Answer 25

Heat cramps - sweat-induced electrolyte depletion causes muscle cramps.

TX: with rest in a cool environment and fluid/electrolyte replacement.



Question 26

Heat exhaustion s/s? Tx?

Answer 26

Heat exhaustion - prolonged exposure to heat leads to heat cramps, anorexia and vomiting, headache, syncope.

TX: with rest in a cool environment and fluid/electrolyte replacement.

Heat Stroke - young and elderly more vulnerable, decreased LOC.

Question 27

Heat Stroke s/s?

Answer 27

Heat Stroke - young and elderly more vulnerable, decreased LOC.

Medication risk: Thyroid meds, Haldol, antihistamines, anticholinergics.

S/S: Core body temperature above 41 C (105.8 F) affects CNS and cardiac.
Tachycardia, tachypnea, hypotension, hot dry skin, decreased level of consciousness.
Rhabdomyolysis from muscle breakdown - dark brown urine.


Question 28

Heat stroke tx?

Answer 28

TX: - Cool patient quickly to 102 F
a. Remove clothing, evaporation, not immersion. Cover with wet sheets & blow fans on patient.
b. Cool IV fluids, and correct electrolyte (sodium) imbalances. Prevent shivering with benzodiazepines.

Question 29

Hypothermia Core body temp levels
S/s? Tx?

Answer 29

Hypothermia Core body temp < 95F (35.3C) is mild; 33-35 is moderate; < 33 severe.

a. S/S: hypoventilation, altered mental status, shivering (mild), hypotension, cardiac dysrhythmias (Osborn or J wave), bradycardia (< 90 F) to V Fib with severe hypothermia).
TX: Severe (< 33) - active core rewarming (warmed IVF’s, heated humidified oxygen, warm peritoneal, gastric, or colonic lavage, hemodialysis). Rewarm core prior to periphery to prevent rewarming shock - may cause ventricular fibrillation.

c. Passive external like warmed blankets for mild (< 36); active external with warming devices for moderate hypothermia.

Question 30

Frostbite Tx?

Answer 30

TX: Pain medication and quickly rewarm the affected part for 15 to 30 minutes in 40-42 °C
(104-107 °F) water; avoid any friction or rubbing; NSAIDS to limit damage, administer narcotics.

Question 31

Lyme disease (Borreliosis) S/s? Tx?

Answer 31

S/S: non-pruritic, target-like, circular bulls-eye rash; flu-like symptoms (malaise and headache).
TX: antibiotics (doxycycline), risk if untreated: facial paralysis, arthritis, and myocarditis.

Question 32

Rocky Mountain Spotted Fever (Rickettsia) S/s? Tx?

Answer 32

• S/S: non-pruritic, non-blanching macules on the palms, wrists, forearms, soles, and ankles; nausea & vomiting; fever and chills.

TX: antibiotics (doxycycline).

Question 33

Measles (Rubeola) incubation period?
S/s? Tx?

Answer 33

highly contagious; incubation period of 8-12 days.

S/S: 3 C’s - conjunctivitis, coryza (rhinitis), cough; fever, eyelid edema; Koplik spots rash first- small specks on buccal mucosa (near molars “grains of salt”); maculopapular rash from head to trunk to lower extremities.

TX: supportive care, immunizations for patient’s family/contacts.

Question 34

How long is Mumps (Parotitis) contagious?

Answer 34

• contagious 16-18 days, swollen salivary glands leads to puffy cheeks and swollen jaw.

Question 35

How long is Rubella (German or 3-day Measles) contagious?

Answer 35

• contagious up to a week prior to symptoms and a week after rash Rash starts on face. Complication is birth defects and arthritis.

Question 36

Pertussis (Whooping cough) effects on lungs? Stages of symtoms?
Dx? Tx?

Answer 36

• highly contagious, attaches to the respiratory tract and limits the child’s ability to clear secretions. Incubation period of 7-10 days. Pertussis Stages

Catarrhal - coryza, sneezing, low-grade fever.
Paroxysmal - unremitting paroxysmal bursts of coughing “whoop”, petechial rash above nipple line from burst blood vessels.
Convalescent - gradual recovery.

DX: Dacron swab in posterior nasopharynx.
TX: Supportive care, erythromycin, antitussives, antipyretics, treat family with antibiotics, pertussis vaccination.

Question 37

Chickenpox (Varicella)
S/s? Tx?

Answer 37

• virus becomes latent after primary infection (may become shingles).
  Infectious for 48 hours before rash appears, contagious until all skin lesions are crusted over. Airborne precautions.

S/S: purulent vesicular rash starts on trunk, fever, pruritus, urticaria.
TX: symptomatic care, antiviral agents, antihistamines, antipyretics

NO aspirin containing products should be administered since associated with Reye’s syndrome (liver dysfunction - increased ammonia).
Prevention: varicella zoster vaccine

Question 38

Shingles s/s? Tx?

Answer 38

• reactivation of dormant varicella virus, lesions follow path of nerve dermatomes.
  S/S: pain develops first, followed by vesicular lesions (typically does not cross the body’s midline), severe nerve pain.

TX: Antivirals, pain control with analgesics, xylocaine patches, and nerve blocks. Prevention: varicella zoster vaccine.

Question 39

Diphtheria incubation?
S/s? Dx? Tx?

Answer 39

• Incubation 1-8 days.
  S/S: Sore throat; low-grade fever; thick, gray, membranous (pseudo membrane) covering on tonsils and pharynx. Complications: airway obstruction.
  DX: throat culture and gram stain.
  TX: Erythromycin STAT, diphtheria antitoxin counteracts toxin produced by bacteria.

Question 40

Mononucleosis - Epstein-Barr virus
How is it spread? S/s? Dx? Tx?

Answer 40

• spread by body fluids, especially saliva (Kissing Disease, college students).

S/S: fatigue, myalgia, lymphadenopathy, abdominal pain.
Complications: splenomegaly - so watch for splenic rupture (avoid strenuous activities and return for LUQ and left shoulder pain), hepatomegaly.
DX: Monospot (+ 2nd week of illness), CBC, LFTs.
TX: Analgesics; corticosteroids; warm salt gargles.

Question 41

What is C. difficile? S/s? Tx?

Answer 41

• gram +, anaerobic, bacillus; antibiotic-associated diarrhea.

S/S: profuse, frequent diarrhea; abdominal cramping and pain; fever; loss of appetite; dehydration.
Standard and contact isolation.
TX: stop antibiotics, IVFs, antiemetics, Metronidazole (Flagyl), fecal transplant for chronic infection.

Question 42

Multidrug-Resistant Organisms

Answer 42

(contact isolation)

MRSA “spider bite” - incision and drainage (I&D), treat with mycins or tetracycline.
VRE - remove source of infection. Consult infection control and wound care.

Question 43

Active Pulmonary Tuberculosis (TB)
S/s? Dx? Tx? D/c teaching?

Answer 43

• most TB infections are latent, 10% progress to active disease, pulmonary TB 90% of time, but sometimes spreads outside lungs.

S/S: chronic cough, night sweats, fever, chills, hemoptysis, weight loss, anorexia, fatigue.
DX: Chest x-ray, sputum culture for acid-fast bacilli.
Isolation: standard and airborne precautions (Negative pressure room)
TX: 6 months of combination antibiotic therapy - rifampin, isoniazid.

DC teaching: importance of medication compliance, containment of respiratory secretions (zip lock bags), avoidance of close contact with others until medically cleared (work), rifampin stains body fluids bright orange (no contacts). Prevention: TB vaccine