Environmental emergencies Flashcards
1
Q
what is Heat Illnesses?
At risk pts?
A
- one is unable to adequately regulate body temperature
- Young/elderly, Obese, Chronic physical/mental illness, Impaired by drugs/ETOH, Anyone denied access to hydration/nutrition
2
Q
Mild swelling of dependent extremities due to heat exposure
Results from muscular and cutaneous vasodilation combined with venous stasis
dx?
mgmt?
A
- heat edema
- self-limiting with elevation, rest, cooling, oral rehydration
3
Q
- Syncope after exertion in the heat
- results from vasodilation leading to intravascular volume redistribution
- Core temp is normal, skin is cool and diaphoretic, weak pulse, transient hypotension
dx? mgmt?
A
- Heat Syncope
- R/o other causes of syncope (hypoglycemia, arrhythmias, and fixed myocardial or cerebrovascular lesions)
- supine with legs elevated, remove from heat, (+/-) external cooling, IV/oral rehydration
- DC after tx and pt ed
4
Q
painful spasms of voluntary muscles of the abdomen and extremities resulting from salt depletion
core temp normal or slightly elevated, (+/-) muscle fasciculations, skin is moist or dry and cool or warm
dx?
w/u?
mgmt?
A
- Heat Cramps
- w/u rarely needed - possible hemoceoncetration, low-nml Na, +/- low K+ & Mg
- Remove from heat and start external cooling, PO lyte (pedialyte or Gatorade) or IV NS, Replace K+ and Mg if needed
- DC home, Rest x 1-3 d - avoid physical exertion and heat exposure
5
Q
inability to maintain adequate CO d/t strenuous physical exercise and environmental heat stress
Rapidly evolves to heat stroke if no intervention
dx?
A
Heat Exhaustion
6
Q
2 types of Heat Exhaustion
A
often a combination
- Hypernatremic (water loss): results from lack of water access
- Hyponatremic (sodium loss): fluid loss replaced with water only
7
Q
- Temperature often mildly elevated - usually will not exceed 40°C (104°F)
- Diaphoresis, HA, N/V, malaise, weakness,
- Muscle cramps, dizziness, (+/-) dark urine
- Tachycardia, hypotension
- No evidence of CNS dysfunction
dx?
A
heat exhaustion
8
Q
difference between heat exhaustion vs heat stroke?
A
Heat exhaustion does NOT have evidence of CNS dysfunction
9
Q
w/u and mgmt for heat exhaustion
A
- BMP, UA, additional labs depending on presentation (CK, LFT, ABG, EKG)
- Remove from heat, (+/-) external cooling, PO lytes if tolerable; Alt: IV NS or LR; hypertonic saline if marked hyponatremia d/t water intoxication
10
Q
criteria to admit for heat exhaustion
A
- moderate-to-severe symptoms
- comorbid illnesses
- patients at extremes of age
- lab abnormalities - Elevated CPK, creatinine, LFTs, cardiac abnormalities, hyponatremia, persistent acidosis
- social concerns
Home: mild cases who don’t meet criteria below
11
Q
- dysfunction of the heat regulating mechanism with hyperthermia (core body temp >104°F) and end-organ damage
- Cardiovascular collapse due to vascular volume loss
dx?
A
heat stroke
12
Q
what structures are most senstive to heat stress? (4)
A
- Neural tissue
- hepatocytes
- nephrons
- vascular endothelium
13
Q
2 types of heat stroke
A
- exertional (rapid onset)
- non-exertional (slow onset)
14
Q
after a hot day a pt is now presenting with:
- HA, dizziness, nausea, diarrhea, visual disturbances
- Skin is hot, flushed, usually dry
- CV: rapid, bounding pulse, hypotension indicates CV collapse
- Neuro: confusion, seizure, delirium, ataxia, coma
- hematuria, hematemesis, bruising, petechiae, and oozing at sites of venipuncture
dx?
hematuria, hematemesis, etc are signs of what?
A
- heat stroke
- signs of DIC
15
Q
ddx heat stroke
A
- Infectious: sepsis, meningitis, encephalitis, malaria, typhoid, tetanus
- Endocrine: DKA, thyroid storm
- Neuro: CVA, status epilepticus
- Other: toxin exposure, serotonin syndrome, neuroleptic malignant syndrome, and anticholinergic toxicity
16
Q
w/u for heat stroke
A
- CBC, PT/PTT - evidence of hemoconcentration and DIC
- CMP - reassess electrolytes every hour
- hyperkalemia is seen with ARF secondary to rhabdomyolysis - Phosphate (hypophosphatemia)
- UA - concentrated, with protein, myoglobin and tubular casts
- CK
- EKG
- CXR
17
Q
mgmt heat stroke
A
- Rapid cooling - Ice water submersion (preferred method)
- severe shivering - IV BZD
- Continuous temp (rectal) - DC when 101.5-102℉
- If unresponsive: internal lavage - peritoneal, gastric, bladder, and/or rectal
- CV support - IV fluids
- 1-2 L bolus NS if hypotension or rhabdo
- fluid rate high enough to maintain UO - Goal UO: 50–100 mL/h
- O2 if needed
- Significant AMS - ventilate/intubate
- Admit to ICU if hemodynamic instability, severe LFT elevation or rhabdomyolysis; All others admit to general floor (med/surg)
18
Q
frostbite - Initial clinical findings before re-warming
A
- Mild: Paresthesias, pruritus of tissue involved; loss of sensation and fine motor control
- Mod-Severe: decreased ROM, blister formation, edema, tissue appears white, firm/hard, cool to touch
19
Q
frostbite - clinical findings after warming
A
- Stinging, burning, aching, throbbing, tenderness
- Tissue discoloration, loss of elasticity and mobility
- Profound edema, hemorrhagic blisters, necrosis, gangrene
20
Q
when to assess severity of frostbite?
A
after rewarming
21
Q
Degrees of frostbite - describe each
A
- 1st degree: erythema and edema without blister, skin peeling
- 2nd degree: serous filled blister
- 3rd degree: skin necrosis: hemorrhagic blister with subcutaneous involvement
- 4th degree: full-thickness (includes bone), non-blanching cyanosis; dry, black mummified eschar formation; loss or deformity of body part
22
Q
mgmt for frostbite
A
Tx as burn
- tx systemic hypothermia before frostbite
- Avoid partial rewarming/refreezing
-
Rapid rewarming in circulating water at 98.6–102.2°F
- 15-60 min; until red–purple color appears and skin becomes pliable - allow skin to air dry
- can be painful - parenteral NSAID/opiates - Warm oral/IV fluids if evidence of hypovolemia
- Extremity/Wound Care - aloe q6h, consult/refer for superficial dead tissue in a whirlpool BID x 3 wks
- splint + elevate limb
- tetanus
23
Q
disposition for frostbite
A
- Home: limited area with only 1st degree injury
- Hospital: extensive area of 1st degree and all 2nd, 3rd, 4th degree
24
Q
Long-term sequelaes from frostbite
A
- Cold sensitivity
- loss of sensation
- hyperhidrosis
- loss of digit/limb
25
Defined as a core body temp < 35°C (< 95°F)
By _rectal, bladder or esophageal thermometer_
dx?
causes?
**Hypothermia**
* **Primary causes**: Environmental exposure (alc/drugs); Therapeutic: targeted temperature management
* **Secondary causes**: Burns, hypoglycemia, hypothyroidism, hypoadrenalism, hypopituitarism, CNS dysfunction, sepsis, drugs, trauma; Impaired shivering
26
s/s mild hypothermia
* Conscious, shivering, HR/RR increase
* 35–32°C ( 95-89.6°F)
27
s/s moderate hypothermia
* Mild alteration in consciousness, loss of shivering reflex, HR/RR drop
* < 32–28°C (89.6-82.4°F)
28
s/s of severe hypothermia
* Unconscious, VS present, areflexia, fixed dilated pupils, hypotension, pulmonary edema, cardiac arrhythmia and arrest, coma
* < 28°C (82.4°F)
29
s/s of hypothermia (HT) IV?
* Vital signs absent
* < 24°C (75.2°F)
30
w/u for hypothermia
**Do not delay tx for labs**
1. CBC
1. CMP - hypokalemia with mild HT, hyperkalemia with severe HT results from cell death/ARF
1. TSH - severe untreated hypothyroidism
1. Cortisol - look for signs of adrenal insufficiency
1. Coags - elevated if complicated by coagulopathy (DIC)
1. Lactic acid - elevated with cell death
1. Blood gas
1. EKG
31
mgmt for all hypothermia pts
1. Continuous VS monitoring including core body thermometer
1. Ventilate if needed
1. Remove wet clothing, dry and cover up
1. Handle gently to avoid fatal dysrhythmia
2. KEEP supine in ALL CASES
3. Rewarm in warm (24 C)environment, warm IV fluids, heat blankets or 75 F
32
mgmt for mild hypothermia (HT I)
1. Place in warm environment - room temp at or above 28°C (82°F)
1. Encourage active movement
1. Warm oral sugary drinks
1. If significant trauma, comorbidities or suspected secondary hypothermia treat as Moderate( HT II)
33
mgmt for moderate (HT II) hypothermia
* Rewarming: warm environment with chemical, electrical, or forced air heating packs or blankets
* Start warm IV fluids
* Full-body insulation, horizontal position, and immobilization
34
mgmt for severe hypothermia (HT III)
1. Airway management likely needed
1. Sinus bradycardia, afib and flutter will resolve with rewarming
1. _V fib will not respond until pt is rewarmed_ - **one defibrillation before rewarming; do not repeat until core temperature is 30C (86 F)**
1. **Rewarming** - external heating device (as in HTII), warm IV fluids; rewarming via **ECMO preferred**, if available, d/t high risk of cardiac arrest
35
mgmt for hypothermia IV
1. Initiate CPR and provide airway management
1. Transport to ECMO if available
1. Prevent further heat loss (insulation, warm environment)
1. Continue resuscitation until core temperature reaches 32°C (90°F)
36
other tx considerations for hypothermia
1. **Coma cocktail** - dextrose, thiamine, naloxone
1. Treat underlying:
- **Hypothyroidism**: levothyroxine 400 mcg IV + hydrocortisone 100 mg IV
- **Hypoadrenalism**: hydrocortisone 200 mg IV
- **Sepsis** - broad-spectrum abx
37
_Admit all hypothermia pts_ **unless all** of criteria are met: (3)
1. No comorbidities
1. No AMS
1. Presenting core temp >34°C (93.2°F)
38
Stinging results in envenomation, causing one of 3 presentations:
1. localized reaction
1. systemic reactions
1. anaphylaxis
39
a small **pruritic, painful, erythematous**, edematous lesion at the sting site due to venomous injection
occasionally lesion will be **> 5 cm**
dx?
Localized bee sting - MC reaction
40
* sterile pustule, evolves of 6-24 h
* may result in necrosis and scarring
dx - sting?
Fire ant sting
41
s/s of Systemic/toxic (non-allergic) reaction from sting?
* MC with **> 50 stings**
* N/V/D with **urticarial lesions distant from site of sting**
* **subside within 48 h**
* complications - rhabdo, hepatorenal failure, hemolysis, thrombocytopenia, DIC
42
s/s Anaphylactic reaction: true allergic reaction from sting?
* **Occurs with in 6 h** (most with in 15 min)
* Itchy eyes, urticaria, cough, respiratory failure, CV collapse
43
w/u for Wasp, Bees and Stinging Ants
* do not delay life-saving intervention
* Indicated **only for systemic and anaphylactic reactions**
* directed by complications: **CBC, CMP, coags, CK**
44
Anaphylaxis tx
for Wasp, Bees and Stinging Ants
Anaphylaxis treat as anaphylactic shock
1. Intubation if needed
1. **EPI** 1:1000
- Adults: 0.3-0.5 ml SC/IM
- Children: 0.01 mg/kg (max 0.5 mg)
1. IV **methylprednisolone** (Solu-medrol) 2 mg/kg (max 125 mg)
1. IV **diphenhydramine** (Benadryl) 1 mg/kg (max 50 mg)
1. IV **famotidine** (Pepcid) 0.5 mg/kg IV (max 40 mg)
1. NEB albuterol 2.5-5 mg for bronchospasm
45
mgmt for Localized reaction only stings?
1. Oral diphenhydramine (Benadryl) 25-50 mg
1. Oral pain control: NSAID, acetaminophen (Tylenol)
46
mgmt for Systemic reactions for stings
IV methylprednisolone, diphenhydramine, famotidine
47
wound care for stings?
* Do not delay tx of systemic reactions to care for wound
* Remove stinger with scraping technique
* Wash wound
* Ice and elevation
* Tetanus update
48
disposition for local stings? systemic rxn?
1. _Local_ - DC
1. _Systemic_
- **admit**: children, elderly, comorbidities, >=50 stings, or prolonged rxn
- otherwise healthy pts - observe x 6 hrs, if no rebound sx, repeat labs before DC, Rx EpiPen, f/u with allergist
49
Most scorpions produce what type of reaction
localized reaction
50
only systemically toxic scorpion in US
infants and children are at highest risk of systemic toxicity
southwestern US
bark scorpion
51
* Sting is **painful w/o** initial **erythema/swelling**
* Exquisite pain with light percussion **“tap sign”**
* Neuromuscular excitation - muscle spasms, CN dysfunction, roving eye movement, diplopia, difficulty swallowing, hypersalivation
* CV toxicity - tachycardia, HTN, pulmonary edema, and cardiogenic shock
dx?
mgmt?
* **Scorpions**
* _symptomatic tx_ - pain meds, **benzo** for motor control; _severe_ - monitor, IV access, antivenom (**Anascrop**)
* Anascorp - MC SE: N/V, pyrexia, rash, pruritus
* Anaphylaxis is rare
52
Large triangle shaped head with a heat sensitive depression “pit” between their eyes
Venom is cytotoxic
Pit Vipers - Rattlesnakes, copperheads, water moccasin
53
* **fang marks with pain, edema, hemorrhage and necrosis around the bite** and extending out from the bite if severe envenomation
* Usually **< 30 min** but may be **delayed up to 12h**
* Systemic: N/V, Hemolysis, thrombocytopenia, coagulopathy, rsp failure with CV instability and collapse
dx?
what if there are no sx after >12 hrs?
w/u?
mgmt?
**pit vipers**
* If no S/S after 12 h = **dry bite**
* CBC, CMP, coags, CK, urine myoglobin, type and crossmatch
* monitor & IV access; **Immobilize**; **Remove constriction** proximal to bite; **Serial (30 min) wound eval** - edema, _compartment syndrome_
* **Antivenom (CroFab)** - _Compare severity of envenomation to SE of antivenom_
* Td update
54
SE of CroFab
* **urticaria, rash, N, pruritus and back pain**
* **hypersensitivity** in 5-19% pts
* recurrent **coagulopathy** occurred in 50 % (in clinical trials)
55
disposition for pit viper bites?
* Observe in ER for 8-12 hours - d/c home if no local progression and all labs are WNL
* Admit (ICU) for severe reaction and those receiving antivenom
56
* A spectrum of diseases that results from traveling to high elevations
* Effects are most often seen at elevations at or >**1500 m (4800 ft)**
* **Hypoxia** is the underlying physiologic insult
High Altitude Sickness
57
The body’s physiological response causing High Altitude Sickness
1. increased RR
1. renal excretion of HCO3
1. vascular changes
1. increasing the blood’s oxygen carrying capacity
58
* resembling a “**hangover**”
* _HA plus one of the following_: anorexia, N/V, weakness, fatigue, dizziness, light-headed, fluid-retention, insomnia, oliguria, dyspnea, AMS
* sx occur within 48 hours of rapid ascent
* Complications such as **HAPE** and **HACE**
Acute Mountain Sickness
59
mgmt for acute mountain sickness
1. DC ascent until sx resolve completely
1. Descent to lower elevation if no improvement - 300-1000 m
1. sx tx: low-flow O2; acetaminophen/NSAID; ondansetron
1. Mild - better in 12-36 hrs after descent
1. Moderate - hyperbaric O2 therapy if available; acetazolamide + dexamethasone
- acetazolamide for prevention too
1. Gink biloba (low)
60
disposition and pt ed for acute mountain sickness
1. DC if responses to intervention
1. _avoid_: rapid ascents, overexertion, alc and rsp depressants
2. _acetazolamide prophylatic_ - 1 d prior to ascent and continue for 2 d after reaching highest altitude
61
* Hypoxic vasoconstriction and elevated right heart pressures results in noncardiogenic pulmonary edema
* a continuum of untreated Acute Mountain Sickness
* MCC of death in high altitude sickness and **can be fatal within hours of onset**
* can occur in as little as a 2400 m (8000 ft) ascension
dx?
High Altitude Pulmonary Edema (HAPE)
62
s/s of High Altitude Pulmonary Edema (HAPE)?
w/u and findings?
1. Onset: **day 2-4** after ascent
1. **Decr exercise capacity** - 1st sx noticed
1. _2 of the following must be present_: dyspnea at rest, cough, rales, tachypnea, weakness, decreased performance, chest tightness, tachycardia, signs of pulmonary HTN
2. **CXR** - alveolar infiltrates, enlarged pulmonary arteries, normal cardiac size
63
mgmt for High Altitude Pulmonary Edema (HAPE)
1. O2 sat **>90%** - O2 x 72h after decent if severe
1. **TOC - Immediate descent**
- **avoid excessive exertion** during descent
1. Hyperbaric tx if descent isn’t possible
1. **Pulm vasodilators** if O2 or descent is unattainable - Sildenafil, tadalafil, nifedipine
- can be prophylactic if h/o HAPE
64
DC criteria in HAPE
all must be met
1. O2 on room air is maintained > 90%
1. sx resolve
1. CXR has improved
65
An end-stage manifestation of AMS or HAPE
High Altitude Cerebral Edema (HACE)
66
s/s of High Altitude Cerebral Edema (HACE)?
w/u?
mgmt?
* hx consistent with Acute mountain sickness; AMS, ataxia, stupor, coma; incr ICP: retinal hemorrhage, papilledema
* MRI - cerebral edema
* **O2 >90%**, **descent**/hyperbaric therapy, **dexamethasone**, **admit if symptomatic >2 after descent**
67
pathophys of near drownings/water aspiration
water washes out **surfactant** resulting in **diminished gas exchange**, **VQ mismatch** and **hypoxia**
68
s/s near drowning
w/u?
mgmt?
1. Minimal water aspiration can lead to **pulmonary injury** and **ARDS** - ARDS can occur up to _6-24 h after aspiration_
1. Prolonged hypoxia = **multiorgan failure**
1. **Hypothermia** - can occur even in warm water submersions
2. **CPR; high flow O2 ASAP; Goal is SaO2 >95%**
3. all asx pts need 4-6 hrs observation
3. CXR, CBC, CK, urine myoglobin
4. acid-base status; Investigate why - urine drug screen, etoh level.
69
Most fire-related deaths are due to ?
smoke inhalation
70
MOI of inhalation injury
1. **Thermal injury** - affects upper airway = acute airway compromise
1. **Inhalation of particulate matter** - bronchospasm and edema
1. **Inhalation of toxic gases**
- CO - suspected in all fire inhalation injuries
- hydrogen cyanide - burned wool, silk, polyurethane, vinyl
71
s/s of inhalation injury
mgmt?
* Facial burns
* Singed nasal hair
* Soot in nose or mouth
* Hoarseness
* Carbonaceous sputum
* Wheezing
* CO poisoning possible
* Humidified O2 (100%) via facemask; ET intubation; Bronchodilators; Pulmonary toilet
72
Exposure to gas heat or smoke inhalation
Need to identify source
Multiple pts with same presentation from same residence
Flu-like sx, HA, dizziness, N/V, DOE, irritability, fatigue, vision changes, tachycardia, confusion, lethargy, syncope, convulsions, coma
dx?
w/u?
* **CO Poisoning**
* **CO-oximetry - most reliable**; carboxyhemoglobin level - elevated; ABG
*Pulse ox is **not** reliable*
73
mgmt for CO poisoning
1. do not wait for confirmation test
1. **High flow O2** via non-rebreather or ET intubation
1. **Hyperbaric O2** therapy for **severe poisoning**
- LOC, AMS, MI, focal neuro deficit, pregnancy
74
disposition for CO poisoning
1. **asx** - safe home environment and no suicide attempt - d/c home
1. **Moderate** - HA, N/V
- observe x 4 h with 100% O2 - assess home safety before DC - DC home if sx resolve
1. **Severe** - CNS sx, CP, EKG changes
- Admit and consult with hyperbaric specialist
75
MCC thermal burns
scalding, direct thermal and flame burns
76
descriptors used for burns on body surface area?
* Rule of 9’s
* Lund and Browder
* Palmar method
77
old vs new system for thermal burns?
1. Old system: 1st, 2nd, 3rd, 4th degree
1. New system
- superficial partial-thickness
- deep partial-thickness
- full-thickness burns
78
quick, easy
used for 2nd and 3rd degree burns
Rule of 9’s
79
more accurate for **infants and children**
provides estimates of BSA based upon age
what system for burns?
Lund and Browder
80
palmar method for burns?
* back of patients hand is 1% of BSA
* used for small burns
81
* Epidermis
* red, painful, tender skin; no blister
* Sunburn
* 7 d; no scar
burn depth?
Superficial
(first degree)
82
* Epidermis & superficial dermis
* blister, exposed dermis is red and moist, very painful
* Hot water scald
* 14–21 d, no scar
burn depth?
Superficial partial-thickness (superficial 2nd°)
83
* Epidermis & deep dermis, sweat glands, and hair follicles
* blister, exposed dermis is pale white to yellow in color; no blanching with pressure; absent pain sensation
* Hot liquid, steam, grease, flame
* 3–8 wk, permanent scar
burn depth?
Deep partial-thickness (deep 2nd°)
84
* Entire epidermis and dermis
* skin is charred, pale, leathery; no pain
* Flame
* Months, severe scarring, skin grafts
burn depth?
Full-thickness (third degree)
85
* Entire epidermis and dermis, as well as bone, fat, and/or muscle
* Flame
* Months, multiple surgeries; Amputation or extensive reconstruction
burn depth?
Fourth degree
86
general mgmt for thermal burns
* O2 and early intubation if needed
* Monitor VS - *radial/femoral arterial cath if unable to use BP arm cuff*
* tx trauma, inhalation, CO poisoning
* **IV opiates**
* **Urinary cath** to measure I&O’s - **UO at 0.5-1** mL/kg/h
* **IV LR** via 2 large bore in unburned area
* Labs - freq ABGs, CBC, CK, CMP, UA for myoglobin, carboxyhemoglobin level
* imaging - CXR, EKG
87
use what formula to determine fluid amounts
**_Parkland formula_** - **LR 4 mL * wt (kg) * % BSA burned** for first 24 h
half for first 8 hrs from time of burn
other half over next 16 hr
88
wound care mgmt for minor burns
* Cleaned with mild soap and water
* Large bullae (>2 cm) or those over mobile joints - Drain or debride; topical 1% Silvadene
* DC to home with PCP follow up
* Update tetanus as indicated
89
wound care mgmt for moderate and sevevere burns?
1. Cover with dry sterile sheet
1. Admit
- moderate - hospital
- severe - burn center
90
* results in a coagulation necrosis leading to eschar formation limiting extent of damage
* partial-thickness with erythema & erosion
type of chemical burn?
acid
91
* results in a liquefaction necrosis resulting in deeper damage
* full-thickness, appear pale, and feel leathery & slippery
type of chemical burn?
Alkali burns
92
mgmt chemical burns
1. Remove clothing (prevent self exposure)
1. Copious irrigation with tap water
1. Cover elemental metals (Na, lithium, Ca, Mg) with **mineral oil** - _water will cause exothermic reaction worsening burn_
1. Contact poison control
1. IV fluid, pain control; Assess for systemic toxicity; Td update if needed
1. Consult surgeon/burn center to determine need for emergency excision
93
classifications of electrical injuries
1. **High voltage (>1000 V)** - Power lines; At risk population: adults
1. **Low voltage (< 1000 V)** - House; At risk population: children
94
3 types of MOI in electrical injuries
1. **Direct tissue damage** (electrical energy) - Cardiac dysrhythmias and arrest, seizure, LOC
1. **Thermal damage** (heat created)
- Severe burns - Size of skin injury doesn’t correlate with internal injury
- Rhabdomyolysis
1. **Mechanical** (fall or tetanic muscle contraction)
95
mgmt electrical injury
1. Stabilize and maintain airway
1. EKG
- **V Tach, Vfib and asystole - ACLS guidelines**
- all other are likely transient
1. Assess as a **general blunt force trauma** - Stabilize neck/back; order imaging if needed
1. **IV fluids**
- Urinary cath - **keep UO 2 ml/kg/h**
1. Labs - CBC, PT/PTT, CMP, CK, urine myoglobin, cardiac enzymes, type and crossmatch
1. Once stable: **full head to toe exam is needed**
2. treat appropriately - seizures, burns, fx
- Large burn: cover with sterile dressing
- Small burn: clean and dress
1. Opiate pain control
1. Td update
1. Children: isolated oral or hand injury; consult ENT or plastics for follow up
96
disposition for electrical injury
DC if: low voltage injury, asx, normal PE **and** EKG
Admit all others
97
s/s electronic control devices?
mgmt?
* High voltage, low-amperage electrical pulses - Electrical injury is unlikely
* Involuntary muscle contraction, neuromuscular incapacitation and pain
* Symptomatic: w/u as blunt trauma or ingestion; asx: DC
98
Electrical injury is unlikely in electronic control devices except when?
psychosis, stimulant drug use, comorbid conditions
99
whenis survival rate better in lightning injury?
1. **lightning flashes over skin (MC)** - improves survival
1. fatal if lightning travels through the body
100
s/s of lightning injury? MCC od death? mgmt?
* MC immediate cause of death is cardiac arrest
* Feathering or fern-shaped burns: pathognomonic, but transient
* Temporary LOC, confusion and/or amnesia
* Rupture of TM
* Deep tissue injury, myoglobinuria and renal failure with “through body” injury
* Work-up and treatment same as electrical injury
101
complications associated with changes in environmental ambient pressure and with breathing compressed gases
Barotrauma
Decompression Sickness
Underwater diving, aircraft cabin decompression, explosions or blasts
Dysbarism
102
occurs when gas-filled cavities of the body contract or expand with pressure changes
Barotrauma
103
Types of Barotrauma of Descent
1. **Middle ear barotrauma** - “barotitis media” - pressure in middle ear leads to **rupture or bleeding of TM**
1. **Inner ear barotrauma** - valsalva during equalization can **rupture the round or oval window** leading to tinnitus, sensorineural hearing loss, vertigo
1. **Sinus ostia occlusion** during descent can lead to bleeding from the sinus cavity
104
What is Barotrauma of Ascent
* Leads to expansion of gas in the body cavities
* Various presentations: Lung overinflation, pneumomediastinum, subcutaneous emphysema, pneumothorax, cerebral arterial gas embolism
105
* Results from a release of nitrogen gas bubbles from the plasma into tissues during ascent
* Occurs in divers who exceed the dive limits for time & depth and in unpressurized flights
Decompression Sickness
106
2 types of Decompression Sickness
Type 1: minor sx complex
Type 2: cardiorespiratory or neurologic sx
107
Deep, aching pain in large joints and extremities - MC elbows and shoulders
what type of decompression sickness
Type 1: minor symptom complex
108
* Fatigue, ataxia, spinal paralysis, vertigo, visual or speech disturbance, cognitive deficits
* Spinal cord embolism - scuba divers
* High-altitude flight - cerebral gas embolism
which type of decompression sickness?
Type 2: cardiorespiratory or neurologic symptoms
109
mgmt for middle ear barotrauma
decongestants and analgesics; refer to ENT if TM rupture occurs
110
mgmt inner ear barotrauma
bed rest with head upright, ENT consult
111
barotrauma - Pulmonary overinflation increases risk of ?
mgmt?
pneumothorax
needle decompression or tube thoracostomy if pneumothorax occurs
112
mgmt decompression sickness
* **Oxygen, 100%** by mask for **at least 2 h**
* **Crystalloid IV fluids** to maintain hydration
* Recompression - **hyperbaric oxygen chamber**
113
mgmt for Frostbitten Raynauds Syndrome
Treat the same as stage 3 frostbite
