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1. Fellowship Written - SAQ > Environmental > Flashcards

Environmental Flashcards

1
Q

What are predictors of a poor outcome in drowning?

A

immersion over 10 minutes
delay to CPR
come on arrival to ED
time to first breath
cardiac arrest on scene
temp of water -cold is neuroprotective

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2
Q

Post drowning what is of relevance here?
What ventilation strategies would you use?

A

bilateral coalescing pulmonary infiltrates - ARDS
low volume ventilation

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3
Q

What are the post intubation priorities in drowning

A
  1. protective lung ventilation and oxygenation - VQ mismatch likely, prevetion of secondary brain injury from hypoxia or hypercarbia
  2. cardiovascular support and fluid as likely cold diuresis and arthymias
  3. rewarm to 34 and prevent shivering to prevent organ dysfunction from hypothermia
  4. disposition planning or retrieval
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4
Q

what is the pathophysiology of acute mountain sickness/high altitude cerebal oedema?

A

vasogenic cerebral oedema as hypoxia causes cerebral vasodilation and increased blood flow
Leaky BBB due to loss of autoregulation and increased permiability

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5
Q

What is the pathophysiology of acute pulmonary oedema?

What are the risk factors?

What is the treatment?

A

non cardiogenic, hydrostatic oedema
pulmonary vasoconstriction which is widepsread but patchy. this heterogeneity causes diversion to less constricted areas and therefore leaky

Risk factors:
* rapid ascent
* genetics
* exertion
* cold
* pre existing pulmonary hypertension
* sleeping medication

Treatment
* immediate descent
* oxygen
* minimise exertion
* CPAP
* nifidine

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6
Q

What are the clinical features of acute mountain sickness?

A
  • headache worse on bending over
  • anorexia/nausea/vomiting
  • weakness and irritability
  • fluid retention
  • retinal haemorrhages
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7
Q

what is the toxin and mechanism of action of the blue ringed octopus?

What are the early and late signs of toxidrome?

What is the definitive management?

A

**Tetrodotoxin **- Sodium channel blockade causing neurotoxicity

Toxidrome signs

Early
* peri oral parasthesia
* ptosis, blurred vision, doplopia

Late
* progressive descending flaccid paralysis
* respiratory failure and arrest

management
intubation and mechanical ventilation for 24 hours - no antivenom

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8
Q

list three marine creatures and mechanism of collapse

A
  • blue ringed octopus - descendingflaccid paralysis
  • box jellyfish - sudden collapse and death from dysryhtmia
  • sea snake - descending flaccid paralysis
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9
Q

What is parklands formula?

A

estimates fluids to be given over first 24 hours in burns in ml

%TBSA x 4 x kg

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10
Q

What is the rule of 9 for burns

A
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11
Q

what are the key features of an examination post drowning

A
  • evidence of other injuries eg c spine
  • temp
  • signs of lung injury/aspiration
  • neurological deficit
  • signs of poor perfusion
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12
Q

how would you prepare the department for a paeds drowing?

A
  • assemble adequate staff, give handover/what is known to team
  • prepare resus bay with paeds equipment including wamer, IO, paeds cannulas etc
  • clearly defined team roles
  • notify anesthetics/paeds
  • prepare drugs eg 20ml/kg fluid, adrenaline 0.1ml kg of 1:10000
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13
Q

when should resus caese following drowning?

A

serum K over 11
one hour of asystole/apnoe most becoming normothermic

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14
Q

What are the phases of drowning?

A
  • voluntary breath holding then involunary laryngospasm due to liquid in oropharynx and may swallow large volumes of water
  • hypoxia, hypercarbia and acidosis
  • active respiratory movements but no gas exchange
  • worsening hypoxia stops laryngospasm and active water ingestion
  • electrolyte imbalance, acid base disturbance
  • washout of surfactant, pulmonary htn and worse hypoxia
  • multi organ failure and death
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15
Q

what is the conn and modell classification for neurological dysfunction in drowning?

A

A- Awake
B - conscious but obtunded
C - Comatose and can be C1-C3 flex to pain/extend to pain/flaccid

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16
Q

list three diving related causes of confusion at depth

A

nitrogen narcosis
hypoxia eg breathe holding
oxygen toxicity
contaminated gas

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17
Q

what are the differentials and signs of vomiting and ataxia after a rapid diving ascent?

A

**DCI **- delayed onset after exiting water, joint and skin symptoms
Aterial gas emboli - immediate onset, stroke sx. pneumothorax/mediastinum
vestibular dysfunction - nystamus, signs of peripheral vertigo

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18
Q

what are three relatie contraindications to air retrieval post dive injury?

A

DCI or CAGE due to boyles law
intra cranial or spinal air
combative patient
other air if not decompressed eg bowel perf

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19
Q
A
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20
Q

what are two differentials for rash post diving?

A

contact dermatitis from wetsuit
Cutis marmorata - cutaneous decompression illness

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21
Q

what are some risk factors for decompression illness

A
  • increased dive duration
  • multiple dives
  • dehydration
  • strenuous exercise post dive
  • ascent to altitude post dive
  • smoking
  • obesity
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22
Q

what are the advantages or disadvantages for flying to hyperbaric chamber?

What are the key things needed to be done for helicopter transport?

A

advantages
* quick
* direct transfer between hospitals
* less turbu;ence if fixed wing

disadvantages
* helicopters cant be pressurised and requies ascent
* vibration and cold may worsen DCI
* cant fly at night and in certain conditions if helicopter

key things
* fly at sea level
* high flow o2
* lay flat
* go to decompression chamber
* delay leads poorer outcomes

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23
Q

list 5 body systems affected by DCI

A
  1. neuro - confusion, memory loss, LOC
  2. cardioresp- chest pain, hypoxia, APO
  3. MSK - myalgia, arthralgia
  4. skin - rash
  5. vestibular - ataxia
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24
Q
A
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25
Q

list some diving related pathologies that may occur shortly after ascent

A

Pneumothorax/mediastinum
Middle ear pathologies
Sinus pain
Arterial gas embolism esp cerebral
Tooth pain
Abdominal cramps

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26
Q

describe wound

A

deep full thickness burn to plantar aspect of foot
depressed central area
darkened skin

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27
Q
A
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28
Q

electric shock

A
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29
Q
A
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30
Q

what are the types of lightening strike

A

direct - direct strike to victim
contact - from object holding to victim
side flash - hits nearby object and transfers to person

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31
Q

what features are pathognominic with lightening strike?

Other features

A

Lichtenberg flowers - feathery cutaneous burns
keraunoparylysis - lower limb paralysis with vascular spasm. flaccid, loss of sensation, mottled with no pulses

Other
delayed cataracts
tympanic membrane rupture
asystole due to massive depolarisation
neuro deficits - flaccid paralysis, confusion, amnesia

32
Q

what are the indications for use of telemetry in electrical injury?

A

LOC
over 100 volts
seizures
ECG changes
previous cardiac disease
burns

33
Q
A
  1. safe approach - scene safety
  2. trauma assessment
  3. humanitarian - analgesia/anaesthesia
  4. plan the destination eg burns centre
  5. fluid and temp management
34
Q

What are the limb and systemic complications of electric shock?

A

Limb
* vasospasm/thtombus
* compartment syndrome
* avulsion fractures and pain at entry site
* trauma from being thrown

Systemic
* cardiac arrhymias
* rhabdo
* traumatic injury
* seizures/loc/coma
* skin burns

35
Q

What are some clinical complications associated with drowning

A

Pulmonary: Chemical Pneumonitis, Atelectasis from surfactant loss, ARDS
Hypothermia
Hyponatremia
Hypoglycaemia
Cerebral: Seizures, Hypoxia, Persistent coma

36
Q

what is the management for box jellyfish sting?

A

apply vinegar and remove tentacles
titrate iv opiates for pain plus mag
cardiac monitoring to assess for arryhtmias
antivenom

37
Q

what is this and why?

A

box jellyfish
classic pattern of linear welts
NB sudden collapse

38
Q

name four groups at risk from high temperature

A

elderly - co-morbid, polypharmacy eg diuretics
young - cant phyisically escape hear eg in car, rely on others
obese - poor thermoregulation, cant access services
crazy - lots of meds with impact on cooling and may not actively cool eg on meth
poor - no air con, cant access services

39
Q

what is the triad needed for heatstroke?

A

core temp over 40
CNS dysfunction
anhydrosis

40
Q

what are some differentials for heatstroke?

A

infections - meningitis, encephalitis

41
Q

what are the pros and cons of three cooling methods?

A
42
Q

what are the important history and examination features of someone collapsing in heat from sport?

A

history
* normal health - meds, allergies etc
* events around collapse - did people see, sudden CP etc
* current symptoms - headache/confusion

Examination
* Vitals, esp temp
* neuro exam - ?bleed or sign of UMN dysfunction
* CV - arrhtymia or dysryhtmia
* other injuries

43
Q

collapse post run

A

Midazolam - 5mg IV
hypertonic saline - IV 2-3ml/kg over 10 minutes

44
Q

what are the complications of exertional heat stroke?

A
  • confusion, seizures, cerebral oedema
  • Rhabdo
  • pulmonary oedema and shock
  • AKI from rhabdo
  • ARDS
  • DIC
  • electrolyte derangement
45
Q

initial treatment with endpoints

A

rehydration - cool fluids 20ml/kg to maintain adequare circulating blood volume
**urgent cooling **- various methods
**support airway **- consider adjuncts
monitoring - bsl, rectal probe, ecg
consider other causes eg sepsis, ich, snakebbite

46
Q

collapse after marathon - most important abnormalities and significance

A

High Ur/Creatinine - acute renal impairment
High CK - rhabdomyolysis
High K+ - ARF/muscle breakdown
Elevated Hb - Dehydration
Elevated WBC - Dehydration/infection
Low plt - tcp/DIC/coagulopathy

47
Q

name four complications of heat stroke from separate organ systems

A

**muscular **- shivering
renal rhabdo and aki
cardiac - heart failure and arrhtymias
**resp **- ARDS
**metabolic **- high K low NA
haem - DIC

48
Q

list the four types of heat related illnesses and their criteria

A

**Heat stroke **- temp over 40, CNS dysfunction and anhydrosis
Heat exhaustion - any heat related illness with volume depletion but normal mental state
heat cramps - painful involuntary skeletal muscle cramps
prickly heat - pruritic, erythematous, maculopapular rash

49
Q
A

remove from heat
cooling
cautious hydration (pulmonary odema)
check metabolic function
seek and treat complications
consider intubation

50
Q

what investigations would you perform?

A

x EUC – Low Na, High K, Impaired renal function
x CK – High risk muscle damage and rhabdo
x Coags/LFTs – Risk of DIC
x BSL – Metabolic derangement
x UA – Myoglobinuria
x ECG – Cardiac arrhythmias
x Ongoing core rectal temp

51
Q

how do you define a heat wave?

A

3 days or more or high maximum or mininum temperatures that is unusual for that location

52
Q

what drug classes increase chance of heat related illness?

A

**interference with sweating **- beta blockers, anti cholinergics, anti histamines
interference with thermoregulation - antipsychotincs, cocaine, meth
decreased thirst - ACEI
dehydration and electrolyte imbalance - diuretics, alcohol
reduced renal function - ACEI, NSAIDS

53
Q

list the important initial investigations for heat stroke

A

Glucose (significant changes with heat stroke)
Coags (INR correlated to outcome)
VBG/ABG (electrolytes in particular + glu)
FBE (thrombocytopaenia/leukocytosis)
LFTs (significantorgandysfunction)
Urinalysis (with myoglobin)
U&Es (hyperkalaemia, renalfailure)
ECG (arrhythmias)
CTB (exclude intracranial cause)

54
Q

What are the ECG changes for hypothermia

A

bradycardia
osborne/j waves
very long QT
shivering artefact
slow af

55
Q

What are the rewarming methods in hypothermia

A
  • bair hugger
  • warm IV fluids
  • Passive - remove wet clothes, warm blankets, space blankets
  • warm humidified air if tubed
  • warm lavage
  • ECMO
56
Q

what are the supportive care measures in hypothermia

A
  • core temp measurement
  • pressure areas if on floor for a long time
  • treat underlying cause eg sepsis, ICH
  • airway mangement
  • careful handling due to risk of VF
57
Q

VF arrest in hypothermia - what are the deviations away from standard ALS protocol?

A
  • withold defibrillation until over 30 degress
  • withhold drugs until over 30 degress and then double interval between doses
  • extend CRP until patient warm then one hour after
  • hero measures - early ECMO

NB
aggressive rewarming
likely resistance to shocks and drugs
high chance of electrolyte dysfunction

58
Q

list the organ complications of hypothermia

A

Resp - aspiration, resp depression
Cardiac - bradyarrtyhmias, VF
CNS - decreased LOC
Renal - AKI/rhabdo
Haem - DIC
metabolic acidosis
pancreatitis

59
Q

what are the pros and cons of intubation with hypothermia eg for CT

A

Pros
* protects airway from aspiration
* facilitates rapid rewarming
* correction of resp component of acidosis
* optimeses oxygenation
* optimal conditions for good CT images - still patient

Cons
* high risk of arrhtymia with manipulation of airway
* modified drug therapy - slow onset, prolonged action
* resource heavy
* could avoid if correct temp in short term

60
Q

differentials for low temp and low GCS

A

hypothermia
hypoglycaemia
seizure
ICH
cold sepsis
drug overdose

61
Q

list the clinical triggers for each warming method:

passive warming
warm fluids
warm bladder lavage
warm gastric lavage
pleural lavage
ECMO

A
  • passive warming - below 35
  • warm fluids - below 35
  • warm bladder lavage - where idc is indicated mand hypothermic
  • warm gastric lavage - intubated
  • pleural lavage - cardiac arrest
  • ECMO - cardiac arrest
62
Q

list the specific features of a suspected snakebite envenomation

A
  • bite site assesment
  • ?lymphadenopathy
  • evidence of coagulopathy eg bleeding gums
  • evidence of neurotoxicity eg descending paralysis, cranial nerves
  • respiratory assessment eg peak flow
63
Q

what are the two most relevat lab tests for ?snake bite

A

coagulation profile
CK

64
Q

what is the discharge criteria post snake bite with no signs of envenomation?

A
  • 12 hours observation
  • normal neuro exam
  • normal 12 hour coags
  • normal 12 hour CK
  • parental considerations eg distance from hospital
65
Q

which australian snakes cause coagulopathy?

A

brown
tiger
taipan
mulga

66
Q

which pathological effects of snakebite are relieved by anti venom?

A

established pre synaptic paralysis
post synaptic paralysis
anticoagulant coagulopathy
rhabdo

67
Q

how do you administer snake anti venom?

what do you do if allergy occurs?

What are the other considerations

A

monitored area and dilute 1 ampoule in 500ml NaCal over 15-30 mins

Allergy:
* stop infusion
* IM adrenaline 0.5mg lateral thigh
* cautiously restart ?with adrenaline infusion

NB
monitored area
risk of hypotension and allergy
slow IV push in cardiac arrest
1 vial for adults and children but children on 100ml

68
Q

what are the clinical features of brown snake envemonation?

A
  • **neurotoxicity **- progressive descending paralysis, facial and bulbar, resp depression
    * myotoxcity - pain, raised CK and rhabdo
  • **systemic **- nausea, vomiting, headache, abdo pain
  • **CV **- sudden collapse, cardiac arrest, hypotension
  • c**oagulopathy **- local bleeding, IC/GU bleeding
69
Q

what does VICC (venom induced consumptive coagulopathy) look like?

What snakes can cause it?

A

high INR and D dimer
low fibrinogen

Snakes
Brown
Tiger
Taipan

70
Q

what are the options for venom detection kits?

A

swab
urine
blood - not reliable

71
Q

what are the absolute and relative indications for snake anti vemon

A

Absolute
* sudden collapse/cardiac arrest
* Abnormal INR
* evidence of paralysis with ptosis

Relative
* CK >1000
* systemic symptoms
* abnormal aptt
* leucocytosis/lymphopenia

72
Q

What are the immediate priorites in ?snake bite

A

ABCDE
pressure bandage
analgesia
bloods

73
Q
A
74
Q

how does being pregnant affect administration of snake antivenom?

A

dose/indication/volume all unchanged

because whats best for mum is whats best for baby

75
Q

what medical criteria for the destination must be net for transferring snakebite patient?

A

staff able and willing and able to manage complications
lab facilities at site
antivenom at site

1. Fellowship Written - SAQ (27 decks)

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