Environmental Flashcards
Poor Px factors for Heat Stroke
Delayed Treatment<br></br>CNS: Coma<br></br>Liver: AST > 1000<br></br>Hem: DIC<br></br>Renal: ARF, Lactic acidosis<br></br><br></br>All these leading to shock
Rx of Trench foot
Dry<br></br>Rewarming<br></br>Elevation<br></br>Avoidance of futurue freezing
Long term complications of Immersion/trench foot
Prolonged or permanent numbness<br></br>Hyperhydrosis<br></br>Cold insensitivity<br></br>Chronic pain<br></br>Gangrene
<p><strong>Chilblains/</strong><strong>pernio</strong></p>
<p>Results in painful skin lesions that can sometimes be blue nodules<br></br><br></br>Follows repetitive exposure to dry cold, up to 24 hours after exposure<br></br><br></br>Facial areas, dorsa of hands and feet, pretibial areas<br></br><br></br>Persistent vasospasm and vasculitis à pruritis, erythema and mild edema, blue nodules</p>
<p><strong>Chilblains/</strong><strong>pernio: Rx</strong></p>
<p><strong>Treatment</strong></p>
<ol> <li>Rewarming, bandaging, elevation</li> <li>Nifedipine, prostaglanding E1 (limaprost), topical/systemic steroids</li> </ol>
<p><strong>Long term complications</strong></p>
<ul> <li>Involved body part becomes more susceptible to re-injury</li> </ul>
Frostbite Mx
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When to call to terminate CPR in hypothermic arrest?
“DNR<br></br>Arrest before cooling<br></br>Obvious lethal injury<br></br>Frozen body (can’t do CPR)<br></br>Ice in airway<br></br>T>32 and still no ROSC<br></br>K+ > 10”
Causes of elevated core body temp
<ol> <li>Infection (sepsis, meningitis, encephalitis)</li> <li>Endocrine (Thyrotoxicosis, pheochromocytoma, DKA)</li> <li>Neuro (hypothalamic bleed/stroke, status epilepticus)</li> <li>Drugs (Anticholinergics, sympathomimetics, ASA, SS, NMS,,,Withdrawals)</li> </ol>
Risk factors for any Heat related emergency (hyper or hypo)
Age (very young or very old)<br></br>Envirenmental temp<br></br>Poverty<br></br>Social isolation<br></br>Substance abuse<br></br>Homelessness<br></br>Occupation (outdoors)<br></br>Medications<br></br>Mental illnesses (Dementia, depression, Bipolar)
When to intubate in burn pt
Full thickness burns to face/mouth<br></br>Circumferencial burns to the neck<br></br>Suspected inhalational injury<br></br>ALOC<br></br>Respiratory distress<br></br>Evidence of stridor or hoarsiness/subglottic edema<br></br>When transfer is required<br></br>Associated with other injuries
Indications of burn center referral
Partial thickness burns >10%<br></br>3rd and 4th degree burns in any age grp of any %<br></br>Burns involving h&n, hands, feet, genitalia<br></br>Chemical burns<br></br>Electrical burns<br></br>Inhalational injuries<br></br>Co-morbidities<br></br>Any associated trauma
D/C indications for electrical burns
Low voltage<br></br>Asymptomatic<br></br>No ECG changes<br></br>Normal examination<br></br>No tissue damage<br></br>No associated injuries
Rx of Cyanide toxicity
ABC<br></br>Assess for inhalational inj<br></br>CyanoKit (hydroxycobalamin 70 mg/kg iv over 15 min, may repeated once/max 5 gm)<br></br>Amylnitrate+Na nitrate+Na thiosulphate<br></br>
Indications of CyaniKit
AMS<br></br>Soot<br></br>Lactate level > 10<br></br>Cardiac arrest
Complications of heat stroke
<b>Cardiorespiratory:</b><br></br><i>Hypotension<br></br>Myocardial injury<br></br>Pulmonary edema<br></br>ARDS</i><br></br><br></br><b>CNS:</b><br></br><i>Cerebral edema<br></br>Persistent Neuro deficit</i><br></br><br></br><b>Renal:</b><br></br><i>Rhabdomyolysis<br></br>ARF<br></br>Electrolytes dist (K, Na, Ca)</i><br></br><br></br><b>Hematology:</b><br></br><i>TCP<br></br>DIC</i>
ECG findings in hypothermia
<b>Think of an ECG complex:</b><br></br>Bradycardia<br></br>AF/flutter<br></br>PR prolongation<br></br>AV block<br></br>Wide QRS<br></br><i>Osborne Wave</i><br></br>QT prolongation<br></br>T inversion<br></br>Dysrrhythmia:<br></br><i>PVCs<br></br>VT<br></br>VF<br></br>Asystole</i>
“<span>If this patient were to arrest, how would his resuscitation differ from a normothermic patient?</span>”
Longer pulse check (up to 30-45 seconds, secondary to severe bradycardia)<br></br>Invasive rewarming<br></br>Consider less frequent epi, until temp >30C<br></br>Consider less frequent defibrillation, until temp >30C<br></br>Continue resus until patient rewarmed, at least > 32C<br></br>RSI meds may need dose adjustment
High voltage electrical injury (power line)
<b>CNS</b>:<br></br><i>Direct brain inj<br></br>Seizure</i><br></br><b><br></br>CVS</b>:<br></br><i>Arrhythmia<br></br>AV block<br></br>Myocardial damage</i><br></br><b><br></br>Localized limb complications:</b><br></br><i>Burns<br></br>Compartment syndrome<br></br>Myonecrosis/rhabdomyolysis leading to AKI<br></br></i>
“Contamination/exposure to toxins,<br></br><span>What four pieces of information do you want from the paramedics before the patient arrives at your emergency department?</span>”
Number of exposed<br></br>Type of exposure (ocular/skin/etc.)<br></br>Concentration of Hydrofluoric acid<br></br>How long before arrival<br></br>Initial vitals/arrhythmias<br></br>If decontamination strategies have been started/completed
<p>Definition and Treatment of High Altitude Pulmonary Edema</p>
<ul> <li>Recent gain in altitude</li> <li>2 of the following (<strong>symptoms</strong>):</li> </ul>
<p>–Dyspnea at rest, Cough, Weakness or decreased exercise performance, Chest tightness or congestion</p>
<ul> <li>2 of the following (<strong>signs</strong>):</li> </ul>
<p>–Central cyanosis, Audible rales in at least one lung field, Tachypnea, Tachycardia</p>
<ul> <li><strong>On X-Ray</strong> – patchy edema of the lungs (often RML)</li> <li><strong>Prevention</strong>:</li> </ul>
<p>–Gradual Ascent, Nifedipine 20mg po tid (CCB that causes pulmonary vasodilation</p>
<ul> <li><strong>Treatment</strong>:</li> </ul>
<p>–DESCEND, O2, Nifedipine 10mg sl then 20mg tid, Hyperbaric Chamber, PEEP</p>
<p>Definition & Treatment of High Altitude Cerebral Edema</p>
<ul> <li>Recent gain in altitude</li> <li>In a person with AMS:</li> </ul>
<p>–Mental status changes <u>or</u></p>
<p>–Ataxia (tandem gait)</p>
<ul> <li>In a person without AMS:</li> </ul>
<p>–Mental status changes <u>and</u></p>
<p>–Ataxia</p>
<ul> <li>Mortality in untreated patients is 13%</li> <li>If progresses to coma, mortality is 60%</li> <li>Recovery to completely normal neurological function usually takes weeks</li> <li>Prevention – same as AMS</li> <li>Treatment:</li> </ul>
<p>–DESCEND</p>
<p>–Oxygen at 2-4 LPM</p>
<p>–Dexamethasone 4mg PO/IM/IV q6h</p>
<p>–Hyperbaric therapy</p>
What constitute active rewarming?
Techniques that warm the core of the body directly.<br></br>Heated iv fluids<br></br>Heated NG lavage<br></br>Bladder irrigation<br></br>Heated inhaled gases<br></br>Pleural lavage<br></br>Peritoneal lavage <br></br>ECMO
