Approach to environmental emergencies Flashcards
1
Q
Frostbite
A
- Tissue has been frozen
- Often head, hands, feet
2
Q
Trench Foot
A
Prolonged exposure to wet cold, but
non-freezing conditions, numbness
and peripheral nerve injury
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
4
Q
1st degree frostbite
A
- Partial skin freezing
- Numbness
- Pale with surrounding erythema
- Lack of blisters
- Dysesthesia
- Prognosis is excellent
5
Q
2nd degree frostbite
A
- Full thickness skin freezing
- Blisters with erythema
- Numbness
- Edema
- Desquamate and forms eschar
- Prognosis is good
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
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
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
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
10
Q
Hypothermia
A
● Drop of core temperature
<35o C or <95o F Accidental or
otherwise
● Impaired Thermogenesis
● ↑ Heat Loss
11
Q
Hypothermia risk
A
- Exposure to cold, alcohol, sedatives
- Metabolic and endocrine
- Neurologic disorders
- Sepsis
- Shock
- Trauma
12
Q
How to measure body temperature with hypothermia?
A
- Esophageal probe
- Rectal probe
- Bladder probe
- DO NOT USE oral or infrared thermometer
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
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
15
Q
Hypothermia stage 3
A
- Unconscious, vitals present
- Rewarm
- Might need intubation
- Warm humidified oxygen
- ECMO
- Bladder lavage warm saline
16
Q
Hypothermia stage 4
A
- Vitals Absent
- Resuscitation
- No vitals → CPR
- Defibrillation
- Rewarm
- ECMO
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
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
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
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
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
22
Q
Bee Sting- Hymenoptera workup
A
Bee sting
* Pain
* Swelling
Remove the Stinger
* Ice
* NSAID
* Read a book
* Watch TV
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
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
25
Pit Vipers (Crotalinae) sting
* 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
Pit Vipers (Crotalinae) prehospital care
* 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
Pit Vipers (Crotalinae) ER mangement
* 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
Coral snake color rhyme
“Red on Yellow, kill a fellow; Red on
Black, venom lack.”
29
Elapid (Coral Snake) bites
* Venom is a potent neurotoxin
* No significant local injury
* Nausea, vomiting, HA, abdominal pain
* Diplopia, muscle weakness, discolored
urine, seizures
30
Treatment for Coral Snakes
● 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
Jellyfish stings
● 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
Jellyfish sting treatment
● 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
Barotrauma on Descent - diving emergency
● 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
Sinus Squeeze- Sinus Barotrauma
○ With blocked ostia, cannot equalize pressure
○ Pain and pressure build, possible hemorrhage
○ Caution using decongestants while diving
35
Barotrauma on Ascent
● 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
Pressures exerted on the body - decompression sickness
● 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
Decompression Sickness types
● 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
Prehospital care for near drowning
● Remove from water
● Rapid resuscitation (CPR)
● High flow oxygen by facemask
● Protect the C-spine if indicated
39
Near Drowning ED management
● 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
Acute Mountain Sickness
● 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
Acute hypoxia
Occurs with sudden hypoxic
insult (decompression of aircraft)
●Dizziness, light-headed, dimmed vision,
nausea, vomiting, or unconsciousness
42
Treatment of Acute Mountain Sickness
● Descend & treat immediately
● Acetazolamide: ↓ reabsorption of bicarbonate & metabolic
acidosis. Helps with acclimatization
43
High Altitude Cerebral Edema
● 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
High Altitude Pulmonary Edema
Most lethal altitude illness. Easily reversible if treated quickly
Lack of recognition, misdiagnosis, and inability to descend
45
High Altitude Pulmonary Edema presentation
● 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
Electrical Injury diagnosis
– Commonly based on history
– Presence skin or oral lesions
– Although with AMS and/or no skin injury, may not be obvious
47
Electrical Injury evaluation
– 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
Electrical Injury treatment
* 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
Lightning Injury
* 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
Lightning Injury presentation
– 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
Lightning Injury treatment
– May require prehospital triage
– ACLS/ Trauma/ Spine precautions
– Treat injuries
– Treat seizures
– Tetanus
52
When to admit for a lightning injury
Systemic symptoms. MSK, neuro
symptoms, extensive burns, dysrhythmia.
Pregnancy
53
Carbon Monoxide poisoning symptoms
* 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
Carbon Monoxide poisoning treatment
● 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
Electrical Injuries
* 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
Most lethal altitude illness
High Altitude Pulmonary Edema
57
Lake Louise Score
HA, GI disturbance, dizziness, fatigue, or sleep disturbance.
Occurs more gradually & less severe hypoxic insult.
58
Prevention for acute mountain sickness
Staged ascent
59
Factors Associated with Poor Resusciation
Prognosis in Near-Drowning
* Need for bystander CPR at scene
* Need for CPR in ED
* Asystole at scene or in ED after warming
60
Decompression Sickness treatment
O2, IV fluids, and Recompression
