Ch 16. Environmental

Question 1

Classification of frostbite injuries (first degree – fourth degree, 4)

How do we classify these in the ED (1)?


Answer 1

1. First degree – numbness, pallor, desquamation
2. Second degree – blisters, redness
3. Third degree – full skin thickness loss, hemorrhagic blisters
4. Fourth degree - full tissue loss, deep structures, progresses to black necrosis

5. • Difficult to assess depth initially: classify as superficial or deep

Question 2

Treatment of frostbite (5)


Answer 2

1. Immediate rewarming (37 degree water or warm compresses)

2. Rewarming is very painful. IV opioids PRN
3. Topical aloe vera cream

4. Wound care

5. Tetanus

6. Discuss with plastics: tPA, penicillin

Question 3

ECG finding in hypothermia (1)


Answer 3

1. Osborne J waves

Question 4

Which lab finding indicates death in a hypothermic patient (i.e. stop resuscitation)? (1)


Answer 4

1. Potassium >12mmol/L
* If body frozen solid do not resuscitate


Question 5

You aren’t dead until you are warm and dead (but how warm – 1)?


Answer 5

1. 32 degrees Celsius


Question 6

Signs and symptoms of heat stress (3) and heat stroke (3)


Answer 6

1. Heat stress: temp <40, muscle cramps, NV, headache, malaise, orthostatic hypotension
   
2. Heat stroke: temp >40 and altered mental status! Temp >40, neuro Sx (confusion, delirium, ataxia, coma, seizures), tachy + hypotension


Question 7

Burn rule of 9’s (1)

Answer 7

1. Legs 18 each, arms 9 each, thorax front and back 18 each, head 9, groin 1.

   (Or the patients palm is 1%)

Question 8

Burn classification (4)


Answer 8

1. Superficial burn - like a sunburn. Epidermis only. Red hot and painful. Brisk cap refill. Supportive care.
 Disappears in hours.
2. Superficial partial thickness – involves the epidermis and superficial dermis. Skin is blistered, red and looks wet. Painful. Still has fast cap refill. Takes 2-4 weeks to heal.
3. Deep partial thickness – involves the dermis (cherry red or pale). Painless. Sluggish cap refill or does not blanch. 
“Deep involves the dermis”. Less painful. Healing may take 6 weeks, may require grafting to reduce scarring.
4. Full thickness - All epidermis and dermis destroyed. Skin is charred, painless, leathery. No cap refill. Painless. Requires surgery/grafting.

** Only Partial and Full thickness burns are included in total body surface area calculations.

Question 9

Indications to send to a burn treatment centre (7)


Answer 9

1. Full thickness burn 

2. Burn injury <10 or >50

3. Partial thickness >25%

4. Burns to hands, face, feet, perineum

5. Burns across major joints

6. Circumferential burn

7. Burn with inhalational injury

8. Electrical burn

9. Chemical burn

10. Burns complicated by fracture/other trauma

Question 10

Parkland formula for fluid resuscitation in burns (1)

Answer 10

1. Lactated Ringers at 4mL/kg x KG x % BSA burned
   - Give half in the first 8 hours, and the other half over the next 16 hours
   Goal UO: 0.5-1mL/kg/hour

Question 11

Treatment of ocular burn (2)

Answer 11

1. Irrigation with 1-2L NS or water over 30mins
2. Recheck pH – continue until 7.4
   * If the burn is from a strong base continue irrigation 2-3 hours

Question 12

What is a low risk electrocution injury? (1)

Answer 12

1. <240 volts AC. Normal exam. Normal ECG.

Admit all patients if 600 volts

Question 13

Treatment of acute mountain sickness/high-altitude cerebral edema (4)

Answer 13

Acute mountain sickness – HA, NVD, fatigue, and cerebral edema when acute neuro dysFx

1. Descent
2. Oxygen
3. Acetazolamide
4. Corticosteroids

Question 14

How much carbon monoxide occurs in healthy people? Smokers (1)
Half life of carboxy-hemoglobin? (1)

Answer 14

1. CO 1% in healthy people. CO up to 10% in smokers

1. CO-HGB half life 4-5 hours. But only 1hour on 100% FiO2.

Question 15

Signs/symptoms of carbon monoxide poisoning (5)

Answer 15

1. HA
2. NV
3. Ataxia
4. Chest pain/ischemia
5. Visual changes
6. Confusion
7. Syncope
8. Dyspnea
9. Seizure
10. Focal neuro deficit
    * Keep CO poisoning on the DDx for comatose Pt, altered mental status, unexplained WAGMA
    Dx: Get a VBG to measure carboxy-Hgb %

Question 16

Treatment of carbon monoxide poisoning? (2)

Answer 16

1. 100% FiO2
2. Hyperbaric oxygen IF CO-HGB >25%, CO-HGB + pregnant, cardiac ixchemia, neurological dysfunction (confusion, syncope, seizure, coma)
   * If asymptomatic and CO-HGB <25% observe four hours then D/C