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Emergency Med Exam 4 > Approach to environmental emergencies > Flashcards

Approach to environmental emergencies Flashcards

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1
Q

Frostbite

A
  • Tissue has been frozen
  • Often head, hands, feet
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2
Q

Trench Foot

A

Prolonged exposure to wet cold, but
non-freezing conditions, numbness
and peripheral nerve injury

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3
Q

Once the frostbite area begins to thaw arachidonic acid causes:

A

○ vasoconstriction, platelet aggregation, leukocyte sludging& erythrostasis
● Causes thrombosis & ischemia, necrosis, & dry gangrene
● Areas affected mostly are the heads, hands, feet.
● Clinical diagnosis, and imaging is not typically helpful

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4
Q

1st degree frostbite

A
  • Partial skin freezing
  • Numbness
  • Pale with surrounding erythema
  • Lack of blisters
  • Dysesthesia
  • Prognosis is excellent
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5
Q

2nd degree frostbite

A
  • Full thickness skin freezing
  • Blisters with erythema
  • Numbness
  • Edema
  • Desquamate and forms eschar
  • Prognosis is good
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6
Q

3rd degree frostbite

A
  • Full thickness skin freezing
  • Hemorrhagic blisters 6-24 hrs
  • Later skin necrosis
  • Feels like a “Block of wood”
  • Poor prognosis
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7
Q

4th degree frostbite

A
  • Freezing of the subcutaneous tissue,
    muscle, bone, tendon
  • Skin is mottled, devascularized
  • Later forms a mummified black eschar
  • Results in loss of the tissue
  • Prognosis is very poor
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8
Q

Prehospital frostbite care:

A

● You must not allow the area to refreeze once it is warmed
● Remove wet clothing, cover with dry, protect from wind
● If conscious, give warm drinks & provide analgesia
● Do not heat frozen area, dry heat can cause further injury, careful with fire
● Immobilize & elevate frozen extremity
● Immerse in circulating warm water (102℉)
● Do not rub or rub with snow as it will cause more injury- Oldschool

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9
Q

ER frostbite management:

A

● Place extremity in gentle circulating water heated to 98.6-102.2o F for 20-30 minutes
● Faces can be thawed by warm water compresses
● Pain Management
● Provide Oxygen
● Give Ibuprofen (stops arachidonic acid cascade)
● Removing blisters is still debated
● Apply aloe, separate digits and treat as burn
● Tetanus vaccine if needed
● Pulse deficit after rewarming- evaluated with doppler
● Time sensitive, Some facilities ie burn center may be able to institute thrombolysis,
and restore vascularization

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10
Q

Hypothermia

A

● Drop of core temperature
<35o C or <95o F Accidental or
otherwise
● Impaired Thermogenesis
● ↑ Heat Loss

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11
Q

Hypothermia risk

A
  • Exposure to cold, alcohol, sedatives
  • Metabolic and endocrine
  • Neurologic disorders
  • Sepsis
  • Shock
  • Trauma
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12
Q

How to measure body temperature with hypothermia?

A
  • Esophageal probe
  • Rectal probe
  • Bladder probe
  • DO NOT USE oral or infrared thermometer
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13
Q

Hypothermia stage 1

A
  • Alert, moderate shivering
  • Watch for the Umbles
    – Fumble, Mumble, Stumble
  • Get out of the cold, and limit wind
    and water exposure
  • Rewarm
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14
Q

Hypothermia stage 2

A
  • Impaired or altered, may not be shivering
  • Rewarm, limit exposure
  • Monitor temperature
  • Cardiac monitor
  • Warm saline
  • Full body insulation
  • May see paradoxical undressing
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15
Q

Hypothermia stage 3

A
  • Unconscious, vitals present
  • Rewarm
  • Might need intubation
  • Warm humidified oxygen
  • ECMO
  • Bladder lavage warm saline
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16
Q

Hypothermia stage 4

A
  • Vitals Absent
  • Resuscitation
  • No vitals → CPR
  • Defibrillation
  • Rewarm
  • ECMO
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17
Q

Hypothermia Complications

A
  • Pulmonary edema and infection
  • Hypotension or arrhythmias
  • Progress to bradycardia, Afib, Vfib to Asystole
  • Seizure disorders, peripheral neuropathy, impaired
    cognitive function, persistent vegetative state
  • Multi-organ failure
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18
Q

Clinical picture of heat exhaustion

A
  • Sweating or may not be if dehydrated
    – Essential for evaporative heat loss
  • Tachycardia, headache, vomiting, malaise, cramps
  • Syncope, hypotension
  • Body temp starts to climb < 40℃ (<104℉)
  • Rehydrate, cool down, rest
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19
Q

Heat Stroke

A

Life threatening
* Hyperthermia > 40℃ (>104℉)
* Uncontrolled rise in body temp
* Red, hot, dry skin
* Cerebellum is heat sensitive
– Ataxia
* Confusion, hallucinations
* Neuro Sx, seizure, coma

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20
Q

Heat Stroke prehospital management

A
  • Remove from heat
  • Rapid cooling
    – Cool water immersion
    – Cool mist- water and airflow
    – Wet towels and sheets
    – Ice packs
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21
Q

Heat Stroke ER management

A
  • IV Fluids
  • Monitor Temperature goal is 39 ℃
  • Evaporative cooling
    – Wet towels with a fan
  • Immersion cooling
  • Gastric and/or urinary lavage
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22
Q

Bee Sting- Hymenoptera workup

A

Bee sting
* Pain
* Swelling
Remove the Stinger
* Ice
* NSAID
* Read a book
* Watch TV

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23
Q

Bee sting anaphylaxis presentation

A
  • Between 15 mins to 6 hrs
  • Hives, pruritus, cutaneous flushing
  • Swollen lips, tongue or uvula
    With at least one of the following
  • Resp compromise, Reduced BP or Organ dysfunction
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24
Q

Bee sting anaphylaxis presentation management

A

EPINEPHRINE 0.3mg SQ (or Peds 0.01mg/kg SQ)
Steroid IV IM PO
Benadryl IV IM PO
H2 Blockers IV PO

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25
Q

Pit Vipers (Crotalinae) sting

A
  • 1-2 fang marks with edema, pain
  • Local tissue injury, lymphadenopathy
  • Venom causes hemolysis
  • Nausea, vomiting, metallic taste
  • Weakness, oral numbness
  • Tachypnea, tachycardia,
    hypotension, alerted
  • 25% are dry bites (wait 8-12 hrs)
26
Q

Pit Vipers (Crotalinae) prehospital care

A
  • Remain calm, limit exertion
  • Immobilize extremity
  • Snake bite kits don’t work, No incisions
  • Ice can worsen the injury
  • Constriction bands OK
    – NO TOURNIQUETS
    – Do not delay transport
27
Q

Pit Vipers (Crotalinae) ER mangement

A
  • IV Access, oxygen
  • Immobilize the limb
  • Leave constriction band in place to antivenom given
  • CBC, Coag studies, blood typing
    – Bleeding with severe coagulopathy may require blood products
  • Measure extremity circumference q 30 mins
  • Watch for compartment syndrome- rare
  • Must observe for 8-12 hrs, cannot rule out serious bite too
    soon. Can appear mild at first
  • Poison control or medical toxicology consultation
  • Antivenom
  • Two options
    – Crotalidae Polyvalent Immune Fab ovine (CroFab; FabAV)
    – Crotalidae Immune F(ab’)2 equine (Anavip; Fab2AV).
  • Admit for severe bites and when antivenom is given
28
Q

Coral snake color rhyme

A

“Red on Yellow, kill a fellow; Red on
Black, venom lack.”

29
Q

Elapid (Coral Snake) bites

A
  • Venom is a potent neurotoxin
  • No significant local injury
  • Nausea, vomiting, HA, abdominal pain
  • Diplopia, muscle weakness, discolored
    urine, seizures
30
Q

Treatment for Coral Snakes

A

● Symptom onset can be delayed
● Treat with antivenom if bite is definitive
● May not be possible to reverse effects once started
● Respiratory Failure, monitor pulmonary function, admit to hospital

31
Q

Jellyfish stings

A

● Hollow sharp threadlike tubes which
penetrate skin & deliver venom
● Mild skin reaction, stinging pain,
erythema or wheal formation.
● Resolve spontaneously over a couple
of days

32
Q

Jellyfish sting treatment

A

● Irrigation with salt water & hot water
immersion (venom is heat labile)
● Topical lidocaine gel
● Remove tentacles- Credit card or
adhesive tape
● Spraying with Vinegar depends on
species
● For Chironex- Antivenom is avail.

33
Q

Barotrauma on Descent - diving emergency

A

● Ear Squeeze
○ Pressure exerted on the ear from change in depth- “Clear the ears”
○ TM at risk for rupture → vertigo → panic
○ ENT referral, antibiotics, can’t dive till healed
● Inner Ear Barotrauma
○ Rupture can occur with too much force with valsalva causing rupture of
the oval or round window of the inner ear
○ Urgent ENT referral, rest, elevate head of bed, possible surgery
● Sinus Squeeze- Sinus Barotrauma
● Face (or Mask squeeze)- increase pressure on mask
● Tooth - fillings or dental abscess
● Dry Suit Squeeze- must equalize pressure in the suit

34
Q

Sinus Squeeze- Sinus Barotrauma

A

○ With blocked ostia, cannot equalize pressure
○ Pain and pressure build, possible hemorrhage
○ Caution using decongestants while diving

35
Q

Barotrauma on Ascent

A

● Upon ascent, therefore opposite of descent and the air expands
● Alternobaric vertigo- If air trapped in middle ear, results in vertigo
● Pulmonary Barotrauma- Air trapped in lungs holding breath on ascent
○ Rapid, panicked ascent
○ Maybe called “burst lung syndrome”
○ Mild ↔ Pneumothorax

36
Q

Pressures exerted on the body - decompression sickness

A

● As a diver descends the amount of inert gases dissolved in blood
increases, based on depth/time
● As they ascend, those bubbles are freed from solution and lodge in
various tissues or circulation
○ Leads to ischemic and/or inflammatory activation
● Prevention requires a “decompression stop”
● Required to follow dive tables or a dive computer

37
Q

Decompression Sickness types

A

● Type I - Pain only
● Type II - Involves CNS eg. spinal cord, Cardio, Pulmonary, Vestibular
○ Ascending paralysis, vertigo, etc
● Type III - Type II but with stroke symptoms
○ Derived from arterial gas embolism on cerebral vasculature- stroke, death
● Minutes to hours after resurfacing
● Could occur in an airline flight after a dive
● Tx- O2, IV fluids, and Recompression

38
Q

Prehospital care for near drowning

A

● Remove from water
● Rapid resuscitation (CPR)
● High flow oxygen by facemask
● Protect the C-spine if indicated

39
Q

Near Drowning ED management

A

● Assess & secure airway, provide oxygen, determine core
temperature. Treat hypothermia
● Spinal injury is rare if no history of diving so routine c-spine
immobilization or brain CT not needed
● Sea water associated with increased pulmonary edema leading
to hypoxia. – Why?
● Neurologic recovery after asystole is very unlikely
● GCS>13 & SpO2
>95% at lower risk
- Observe for 4-6 hours
● GCS <13 maintained on oxygen & ventilatory support, prn
●Xray, cardiac monitoring, SpO2
, temp. monitoring
● Prophylactic antibiotic not found to be needed

40
Q

Acute Mountain Sickness

A

● Elevation >8000 ft is a hypoxic environment
● Provo is 4551 ft. Could you be affected by altitude?
● At this level decreased exercise performance & increased
alveolar ventilation occurs without major impairment in
arterial oxygen transport
● Acute Mountain Sickness (AMS) can occur at 7000-8000 ft
● “Snow Blindness”- Ultraviolet Keratitis

41
Q

Acute hypoxia

A

Occurs with sudden hypoxic
insult (decompression of aircraft)
●Dizziness, light-headed, dimmed vision,
nausea, vomiting, or unconsciousness

42
Q

Treatment of Acute Mountain Sickness

A

● Descend & treat immediately
● Acetazolamide: ↓ reabsorption of bicarbonate & metabolic
acidosis. Helps with acclimatization

43
Q

High Altitude Cerebral Edema

A

● Defined as progressive altered mental status, ataxia, stupor,
& progression to coma
● Due to raised intracranial pressure secondary to edema
● High microvascular pressure & pulmonary hypertension
● Often associated with Pulmonary Edema

44
Q

High Altitude Pulmonary Edema

A

Most lethal altitude illness. Easily reversible if treated quickly
Lack of recognition, misdiagnosis, and inability to descend

45
Q

High Altitude Pulmonary Edema presentation

A

● Starts as dry cough, decreased exercise performance, dyspnea on exertion.
● Localized ralesLate in course: tachycardia, tachypnea, dyspnea at rest, marked weakness, productive cough, cyanosis, rales
● Hypoxemia worsens, altered mental status, & eventually coma

46
Q

Electrical Injury diagnosis

A

– Commonly based on history
– Presence skin or oral lesions
– Although with AMS and/or no skin injury, may not be obvious

47
Q

Electrical Injury evaluation

A

– EKG and cardiac monitoring- Arrhythmias?
– Serum CK, myoglobin, urine myoglobin- Rhabdomyolysis?
– Head CT if AMS present
– Skin, MSK, vascular, lungs, GI, eye/ hearing exam

48
Q

Electrical Injury treatment

A
  • ACLS protocol, Spinal precautions
  • Treat as a trauma patient
  • Monitor electrolytes, urine output
  • Treat burns and bony injuries
  • Minor injuries can be discharged home
49
Q

Lightning Injury

A
  • Different type of injury then an
    electrical AC voltage injury
    – High voltage electrical Injury
  • Typically travels over the skin
    (Called a “Flashover”)
    – Heat and shockwave
50
Q

Lightning Injury presentation

A

– Cardiac arrest is common
– Seizure, AMS
– Burns
– May show fern-like burn- rare
– Transient weakness and paralysis
– Tympanic membrane/hearing loss/ vertigo
– Eye injury, cataracts, corneal lesions
– Blunt trauma/Compartment Syndrome

51
Q

Lightning Injury treatment

A

– May require prehospital triage
– ACLS/ Trauma/ Spine precautions
– Treat injuries
– Treat seizures
– Tetanus

52
Q

When to admit for a lightning injury

A

Systemic symptoms. MSK, neuro
symptoms, extensive burns, dysrhythmia.
Pregnancy

53
Q

Carbon Monoxide poisoning symptoms

A
  • Headache, nausea, dizziness
  • Tachypnea, tachycardia,
  • Seizures, AMS, coma
  • Chronic exposures do ocur
  • “Classic” findings of cherry red nail beds and cherry mucosa
    are not classic, and typically only seen post-mortem
  • Standard O2 oximetry does not pick up on carbon
    monoxide
  • Smokers may show higher levels of carboxyhemoglobin
  • Half life of carboxyhemoglobin is 5 hours
  • Give consideration to self harm and/or suicide attempts
54
Q

Carbon Monoxide poisoning treatment

A

● Highest concentration of oxygen available
● May send home with minimal exposure
● Observe 6 hours release if symptoms resolve on 100% O2
● Hyperbaric chamber use to supersaturate with oxygen
● Watch for neurologic sequelae appropriate follow-up

55
Q

Electrical Injuries

A
  • Everything from skin burns to multisystem injury
    – Direct tissue
    – Thermal burns
    – Mechanical injury from fall or muscle contraction
  • Can cause numerous life threatening and serious injuries
    – Loss of consciousness, coma, respiratory, renal, GI, etc
    – Seizures
    – Cardiac arrest
  • Skin injuries may not reflect internal damage
56
Q

Most lethal altitude illness

A

High Altitude Pulmonary Edema

57
Q

Lake Louise Score

A

HA, GI disturbance, dizziness, fatigue, or sleep disturbance.
Occurs more gradually & less severe hypoxic insult.

58
Q

Prevention for acute mountain sickness

A

Staged ascent

59
Q

Factors Associated with Poor Resusciation
Prognosis in Near-Drowning

A
  • Need for bystander CPR at scene
  • Need for CPR in ED
  • Asystole at scene or in ED after warming
60
Q

Decompression Sickness treatment

A

O2, IV fluids, and Recompression

Emergency Med Exam 4 (5 decks)

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