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1. Fellowship Written - SAQ > Environmental > Flashcards

Environmental Flashcards

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1
Q

What are predictors of a poor outcome in drowning?

A

immersion over 10 minutes
delay to CPR
coma on arrival to ED
time to first breath
cardiac arrest on scene

temp of water -cold is neuroprotective

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2
Q

What ventilation strategies would you use for ARDS post drowning

A

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 high altitude 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 and sea snake - descending flaccid paralysis
  • box jellyfish - sudden collapse and death from dysryhtmia
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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

Children 3-4

Half in 8 hours

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10
Q

What is the wallace 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/lactate I compatible with life
one hour of asystole/apnoe
No cardiac output on echo
One hour post 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
list some diving related pathologies that may occur shortly after ascent
Pneumothorax/mediastinum Middle ear pathologies Sinus pain Arterial gas embolism esp cerebral Tooth pain Abdominal cramps
26
describe wound
deep full thickness burn to plantar aspect of foot depressed central area darkened skin
27
AC more dangerous than DC we can’t detach
28
electric shock
29
30
what are the types of lightening strike
direct - direct strike to victim contact - from object holding to victim side flash - hits nearby object and transfers to person
31
what features are pathognominic with lightening strike? Other features
**Lichtenberg figues** - feathery cutaneous burns **keraunoparylysis** - temp 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
what are the indications for use of telemetry in electrical injury?
LOC seizures ECG changes previous cardiac disease burns
33
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
What are the limb and systemic complications of electric shock?
**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
What are some clinical complications associated with drowning
Pulmonary: Chemical Pneumonitis, Atelectasis from surfactant loss, ARDS Hypothermia Hyponatremia Hypoglycaemia Cerebral: Seizures, Hypoxia, Persistent coma
36
what is the management for box jellyfish sting?
apply vinegar and remove tentacles titrate iv opiates for pain plus mag cardiac monitoring to assess for arryhtmias antivenom
37
name four groups at risk from high temperature
**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
38
what is the triad needed for heatstroke?
core temp over 40 CNS dysfunction anhydrosis
39
what are the pros and cons of three cooling methods?
40
what are the important history and examination features of someone collapsing in heat from sport?
**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
41
collapse post run
Midazolam - 5mg IV hypertonic saline - IV 2-3ml/kg over 10 minutes
42
what are the complications of heat stroke?
* confusion, seizures, cerebral oedema * Rhabdo * pulmonary oedema and shock * AKI from rhabdo * ARDS * DIC * electrolyte derangement
43
initial treatment with endpoints
**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
44
collapse after marathon - most important abnormalities and significance
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
45
name four complications of heat stroke from separate organ systems
Seizures **renal** rhabdo and and renal failure **cardiac** - heart failure and tachyarrhtymias **resp **- ARDS **haem** - DIC Liver failure
46
list the four types of heat related illnesses and their criteria
**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
47
remove from heat cooling cautious hydration (pulmonary odema) check metabolic function seek and treat complications consider intubation
48
what investigations would you perform?
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
49
how do you define a heat wave?
3 days or more or high maximum and mininum temperatures that is unusual for that location
50
what drug classes increase chance of heat related illness?
**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
51
What are the ECG changes for hypothermia
bradycardia osborne/j waves very long QT shivering artefact slow af
52
what are the supportive care measures in hypothermia
* 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
53
VF arrest in hypothermia - what are the deviations away from standard ALS protocol?
* 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
54
list the organ complications of hypothermia
Resp - aspiration, resp depression Cardiac - bradyarrtyhmias, VF CNS - decreased LOC Renal - AKI/rhabdo Haem - DIC metabolic acidosis pancreatitis
55
what are the pros and cons of intubation with hypothermia eg for CT
**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
56
differentials for low temp and low GCS
hypothermia hypoglycaemia seizure ICH cold sepsis drug overdose
57
list the clinical triggers for each warming method: passive warming warm fluids warm bladder lavage warm gastric lavage pleural lavage ECMO
* 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
58
list the specific features of a suspected snakebite envenomation
* bite site assesment * ?lymphadenopathy * evidence of coagulopathy eg bleeding gums * evidence of neurotoxicity eg descending paralysis, cranial nerves * respiratory assessment eg peak flow
59
what are the two most relevat lab tests for ?snake bite
coagulation profile CK
60
what is the discharge criteria post snake bite with no signs of envenomation?
* **12 hours observation** * normal neuro exam * normal 12 hour coags * normal 12 hour CK * parental considerations eg distance from hospital
61
which australian snakes cause coagulopathy?
brown tiger taipan mulga
62
which pathological effects of snakebite are relieved by anti venom?
established pre synaptic paralysis post synaptic paralysis anticoagulant coagulopathy rhabdo
63
how do you administer snake anti venom? what do you do if allergy occurs? What are the other considerations
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
64
what does VICC (venom induced consumptive coagulopathy) look like?
high INR and D dimer low fibrinogen
65
what are the absolute and relative indications for snake anti vemon
**Absolute** * sudden collapse/cardiac arrest * Abnormal INR * evidence of paralysis with ptosis **Relative** * CK >1000 * systemic symptoms * abnormal aptt * leucocytosis/lymphopenia
66
What are the immediate priorites in ?snake bite
ABCDE pressure bandage analgesia bloods
67
Snake bite characteristics
68
how does being pregnant affect administration of snake antivenom?
Doesn’t
69
what medical criteria for the destination must be net for transferring snakebite patient?
staff able and willing and able to manage complications lab facilities at site antivenom at site
70
what do you get with acute radiation sickness?
**1 - Haematopoetic bone marrow suppresion -** bleeding fatgiue and immune suppresion. treat with stem cell transplant and GCSF - good prognosis **2 GI **- vomiting, fever, diarrhoea - treat as normal - 50% mortality **3 Cerebral/vascular** - capillary leakage, CV collapse, coma and cerebral oedema - death
71
what are the burn patterns with lightening?
Linear skin folds Lichtenberg Thermal injury eg heat
72
alterations for rescue with lightening
reverse disaser triage dont use pupils unreliable motor response
73
what are the types of rewarming?
* Passive external warming - remove wet clothes, blankets, warm room * Active external warming - heating fans, warm baths * Active Internal - warm fluids, endovascular rewarming, ECMO
74
compliations of rewarming
hypoglycaemia ventricular arrthymias hyperthermia thermal burns electrolyte disturbance
75
What are the three types of altitude sickness?
**Acute mountain sickness **- headache, nausea, vomiting fatigue - usually occues in first day and resolves within 1-3 days if not ascending **High altitude cerebral oedema **- severe hedaches, ataxia, confusion, coma, death - ascend, oxygen, CPAP, nifidipine **High altitude pulmonary oedema** -SOB, chest pain, frothy cough. need to descent and oxygen
76
Thoracic lavage methid
Place two 32-36 F intercostal catheters: one anterior and one posterior lateral Use 3L bags of 40-42 C saline Use a Level 1 Fluid Warmer to pump warm fluids into the anterior chest tube (e.g. 180 mL/min) attach auto-transfuser or pleur-evac to posterior-lat chest tube to allow continuous emptying

1. Fellowship Written - SAQ (30 decks)

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