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Rosh Review > Environmental Disorders > Flashcards

Environmental Disorders Flashcards

1
Q

Pathophysiology of decompression sickness

A

Metabolically inert gas dissolved in body tissue under pressure precipitating out of solution (joints, lungs, vessels) and forming bubbles during decompression

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2
Q

Risk factors for decompression sickness

A
  • Increasing depth of dive
  • Rapidity of ascent
  • Multiple dives in same day
  • Air flight soon after dive
  • Obesity (nitrogen is fat soluble)
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3
Q

Clinical picture of decompression illness

A
  • Onset usually within 6 hours, but may occur only after air travel, particularly if within 24 hours of last dive
    MSK: arthralgias and myalgias “the bends”
    PULM: dyspnea, chest pain, cough “the chokes”
    NEURO: vertigo, tinnitus, nausea “the staggers”
    SPINE: paresthesias, paralysis
    DERM: pruritus, burning, mottling (purpura marmorata), erysipelas-like rash over fatty areas
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4
Q

Tx for decompression sickness

A

If only msk or derm manifestations can treat with IVF, 100% O2, and ASA

If pulm, neuro, or vestibular manifestations - hyperbarics

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5
Q

Clinical picture of arterial gas embolism

A
  • Sudden onset (within 10-20 mins of ascent)
  • Affects brain but spares spinal cord
  • Can occur with short and shallow dives
  • Dyspnea, hemoptysis, chest pain
  • MI
  • Stroke
    Sx may resolve spontaneously as air bubbles are forced into venous system by spike in cerebral blood pressure - but still require tx as there is a high risk of recurrence!
  • Requires immediate hyperbaric therapy
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6
Q

Which congenital defect increases prevalence of decompression sickness?

A

Patent foramen ovale

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7
Q

Symptoms from dysbarism of descent

A

Ear pain - air is trapped in enclosed spaces and causes local trauma due to increased pressure at depth and “squeeze” - Eustachian tube dysfunction causing pain, hematoma, TM rupture, vertigo in middle ear or possible rupture of round window in inner ear causing hearing loss, vertigo, tinnitus
Epistaxis - if sinus ostia are obstructed and air is trapped
Petechial rash - air between skin and diver’s dry suit
Dental pain - trapped air in cavity fillings may cause severe dental pain
Hemoptysis from rapid descent (rare); PTX, pneumomediastinum from rapid ascent

NOT part of decompression sickness

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8
Q

How can you differentiate joint pain from decompression sickness from other MSK pain?

A

Joint pain of decompression sickness is typically unrelieved but not worsened with movement

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9
Q

What is the most commonly used method of estimating dose exposure and prognosis in acute radiation syndrome?

A

Andrews lymphocyte depletion curves - level of lymphocytes over 48 hours

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10
Q

Which body system is most sensitive to effects of radiation?

A

Hematopoietic system followed by GI system

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11
Q

What medication may be administered to prevent absorption of radioactive material by thyroid gland?

A

Potassium iodide

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12
Q

Black widow vs. Brown Recluse

Identifying feature, venom, clinical effects, tx, antivenin

A

Q#441388 table

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13
Q

Venom of black widow

A

Neurotoxin - causes release of acetylcholine and norepinephrine at nerve terminals

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14
Q

Clinical effects of black widow venom

A
  • Severe muscle cramping (typically abdominal wall, back, and legs)
  • CNS and peripheral nerve hyperactivity
    —> dizziness, restlessness, profuse sweating, difficulty speaking, ptosis, HTN, tachycardia
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15
Q

Tx for black widow envenomation

A
  • Supportive with opioids and benzos
  • Antivenin reserved for severe symptoms (autonomic instability and hemodynamic collapse) due to risk of anaphylaxis and serum sickness as it is derived from equine serum
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16
Q

Alkali burns cause what kind of necrosis?

A

Liquefactive

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17
Q

Acidic burns cause what kind of necrosis?

A

Coagulation necrosis

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18
Q

Spectrum of clinical presentation in heat exposure

A
  1. Heat Cramps
    - Inadequate intake of fluids and electrolytes
    - Muscle cramping of calves and abdomen
  2. Heat Exhaustion
    - Dehydration
    - N/V
    - General weakness
    - May have temperature, but <104
  3. Heat Stroke
    - Mental status change
    - Organ damage
    - Anhidrosis (not universal)
    - Temperature >104
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19
Q

What animal in the US has the greatest incidence of rabies?

A

The bat

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20
Q

Pathophysiology of arterial gas embolism

A

Rapid decrease in ambient pressure caused by ascent from high-pressure environment of a deep dive to atmospheric pressure results in precipitation of air bubbles, which then embolize systemically

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21
Q

What lab test is almost universally abnormal, and remains so the longest, in patients with heat stroke?

A

LFTs

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22
Q

Tx for heat stroke

A

Rapid cooling to 39C within 10-20 mins; evaporative or cold water immersion
Avoid antipyretics

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23
Q

Why do drugs become ineffective during hypothermia?

A

Increased protein binding

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24
Q

Degree of hypothermia and characteristics

A

Mild (33-35C) - amnesia, dysarthria, shivering

Moderate (29-32C) - stupor, dysrhythmias, decreased level of consciousness, shivering extinguished

Severe (22-28C) - v-fib susceptibility, loss of reflexes, pulmonary edema, decreased cerebral blood flow

Profound (9-20C) - flat EEG, asystole

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25
Q

Tx of hypothermia

A

Mild: passive rewarming
Severe without CV instability: active external rewarming
Severe with CV instability: invasive core rewarming

26
Q

Middle ear barotrauma 2/2 diving is due to ascent or descent barotrauma?

A

Descent - most common complaint of scuba divers

27
Q

When is nitrogen narcosis most likely to occur?

A

Depths greater than 100 ft, but can occur at shallower depths. Ascent reverses symptoms

28
Q

What is the most common cause of death from high altitude illness?

A

High Altitude Pulmonary Edema

29
Q

Clinical progression of high altitude pulmonary edema

A

Initial (2-4 days after arrival at new altitude)
- subtle, nonproductive cough, dyspnea on exertion

Progression

  • dyspnea at rest
  • clear or pink frothy sputum
  • tachycardia, tachypnea, fever
  • pulse ox 10 points lower than expected for altitude

Cxrs progress from interstitial to localized alveolar and then generalized alveolar infiltrates

30
Q

Management of high altitude pulmonary edema

A
  • Immediate descent is definitive tx of choice
  • Supplemental oxygen
  • Nifedipine
  • Portable hyperbaric chamber
31
Q

What animal envenomation is associated with heightened sensitivity to touch in the affected area, along with local numbness and weakness?

A

Scorpion

32
Q

Clinical features of scorpion bites

A
  • Local reaction with edema and erythema
  • Heightened sensitivity to touch in area of sting
  • Local numbness/weakness
    Systemically:
  • anxiety/restlessness
  • muscle spasms
  • n/v
  • excessive salivation
  • diaphoresis
  • hyperthermia
  • myoclonus
  • hemiplegia
  • syncope
33
Q

Criteria for 4-6 hours of observation after submersion/drowning event

A
  • No evidence of respiratory distress or pulmonary compromise (rales, rhonchi, retractions)
  • O2 saturation >95% on room air
  • GCS > 13
34
Q

What is the mammalian diving reflex?

A

Body is submerged in cold water, reflexive bradycardia and peripheral vasoconstriction

35
Q

Clinical presentation of arterial gas embolism

A
  1. LOC on ascent or within 10 min of surfacing
    Coronary: dysrhythmias, MI, cardiac arrest
    Cerebral: focal motor, sensory, visual deficits, seizures, death
    Musculocutaneous: cyanotic marbling and focal pallor of tongue
    Kidney: hematuria, proteinuria, renal failure
    Uterine and GI bleeding
36
Q

Management of arterial gas embolism

A
  • Immediate 100% O2 and IVF to improve tissue perfusion and oxygenation
  • Place patient in supine position
  • Hyperbaric oxygen
37
Q

What is the cause of the symptoms of heat exhaustion?

A

Dehydration and hyponatremia cause cramping, nausea, dizziness, tachycardia, orthostatic hypotension (NOT core body temperature)

38
Q

In non-fatal drowning incidents, what are criteria for patients able to be observed 4-6 hours and discharged from ED?

A
  • GCS > 13
  • Normal pulmonary exam or only mildly symptomatic with normal CXR
  • O2 saturations >94% on ED arrival
39
Q

What intervention needs to occur within 30 minutes for heat stroke?

A

Rapid cooling with goal temperature of 38.9 (102F)
No danger in rapid cooling - evaporative methods are safe and fast - continually wet patient with tepid water while fanning skin. Immersion in ice water baths also effective

40
Q

What is the role of benzodiazepine in hyperthermia?

A

To manage agitation and shivering (due to rapid cooling)

41
Q

What is the importance of type of fluid medium (fresh vs. salt water) in submersion injury?

A

Type of fluid does not have clinical relevance

42
Q

What is chilblains?

A
  • Also called pernio
  • Inflammatory skin lesions precipitated by protracted and intermittent exposure to damp, non-freezing ambient temperatures
  • Localized edema, erythema, cyanosis, nodules, rarely ulcerations and bullae
  • Pruritus, numbness, burning paresthesias
43
Q

Associated disorders with chilblains - “Secondary pernio”

A
  • Hematologic disorders
  • Autoimmune disease
  • Viral hepatitis
  • Malignancy
44
Q

What physical exam finding is classically associated with a brown recluse spider bite?

A

A “bull’s eye” lesion with circumferential erythema and a necrotic center

45
Q

What causes high altitude pulmonary edema?

A

High microvascular pressure in pulmonary arterial bed

46
Q

What is the most lethal illness of high altitude?

A

High altitude pulmonary edema

47
Q

Patients with anaphylaxis to which antibiotics should avoid acetazolamide?

A

Sulfa (although risk of cross-reactivity very low)

48
Q

What is the initial neurologic finding in patients with heatstroke?

A

Ataxia

49
Q

What is the primary enzyme responsible for necrosis caused by brown recluse spider bites?

A

Phospholipases D

50
Q

What may help prevent local effects of envenomation from brown recluse spiders if given within 48 hours of bite?

A

Dapsone, but otherwise local wound care is primary management

51
Q

What is the toxic component of black widow spider bites?

A

Alpha-Latrotoxin

52
Q

Chilblains vs. immersion foot vs. frostbite

A

Find the questions and organize better

53
Q

Elapidae species snakes

A
  • Coral
  • Cobra
  • Kraits
  • Mambas
  • Sea snakes
  • Pygman copperhead
54
Q

Envenomation by elapidae snakes

A

Minimal local reaction with marked systemic neurotoxicity - salivation, dysarthria, diplopia, ptosis, miosis, dysphagia, seizure

Death from respiratory failure

Symptoms may be delayed several hours

55
Q

Pathophysiology of envenomation of elapidae family snakes

A

Venom irreversibly binds acetylcholine receptors

56
Q

Viperidae family of snakes

A

Also called crotalids

  • Rattlers
  • Cottonmouths
  • Copperheads
  • Western diamondback
57
Q

Effects of envenomation by viperidae family of snakes

A

Local effects - very painful, edema, erythema, bullae, rhabdomyolysis
Systemic - weakness, paresthesias, metallic taste, chest pain, dyspnea
Hematologic - coagulopathy, thrombocytopenia, bleeding, rhabdomyolysis

58
Q

Management of Viperidae family bites

A
  • Observe “dry” bites for 8 hours prior to discharge

- Otherwise crofab (sheep product with few allergic manifestations)

59
Q

Management of bite from elapidae family snake?

A

Antivenom for all symptomatic eastern coral snake bites, otherwise supportive care

But all require admission for observation

60
Q

What exposure can bypass decontamination and should be immediately assessed for systemic toxicity?

A

Chlorine gas and all other fully dispersed gases

61
Q

What is most sensitive sign of high altitude cerebral edema?

A

Cerebellar ataxia

62
Q

What is most likely to determine the degree of pulmonary insult suffered by patient with submersion injury?

A

Amt of liquid aspirated

Rosh Review (22 decks)

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