Environmental Emergencies Flashcards
Define hyperthermia
- Heat production (exercise) or exogenous (environmental) heat load exceeds heat loss capacity
- Results in some degree of symptoms/effects
Define heat exhaustion
Clinical syndrome of dehydration related to excess body heat
Define heat stroke
- Excess heat buildup results in protein denaturation
- This causes thermoregulatory mechanism failure
Heat stroke consequences on the body
- Core temp over 104.9
- AMS
- Possible end organ damage
- Coagulation abnormalities
Treatment of hyperthermia
- Immediate cooling
- Avoid shivering by paralysis (produces heat)
- Antipyretics
- IVF
- Replace K and/or gluc if needed
Methods of immediate cooling treatment of hyperthermia
- Ice packs to groin/axillae
- Evaporative cooling (by dampening skin and using fans)
When to admit patients with hyperthermia?
- Heat stroke (exhaustion can go home)
- Elderly, children, obese, multiple comorbidities
Define hypothermia
Core temp under 95 degrees F
Define primary hypothermia
Environmental exposure
homeless, alcoholic, wilderness, burns
Define secondary hypothermia
Medical etiology (sepsis, trauma, hypoendocrine, hypothalmic)
Define iatrogenic hypothermia
Provider neglect (cool IVR or prolonged ED/post-op exposure)
Define frost nip
- Mild form of frostbite
- Skin pales or turns red, feels very cold
- Continued exposure leads to prickling and numbness
- NO permanent damage
When does pain and tingling occur with frost nip?
As skin rewarms (prickling and numbness prior)
Define frostbite
Dermis and/or SC tissue damage 2/2 cold
Progression of frostbite
- Begins as frost nip
- Progresses to blistering w/clear fluid
- Hemorrhagic blisters w/some tissue necrosis
- Blue or black discoloration
- Substantial edema
How are reflexes affected by hypothermia?
Reflexes decline as temperature becomes lower
Possible EKG findings of hypothermia
- Prolonged PR, QRS, QT
- Osborne (J) waves
- T inversions
- Bradycardia, AF, blocks
Treatment of hypothermia
- Gradual rewarming to avoid VF (bear hug, NS warmed to 40-42 F)
- Peritoneal lavage, dialysis or cardiac bypass if severe
- Never dead until “warm and dead”
Treatment of frostbite
- Rapid rewarming w/warm water bath
- Avoid re-freezing
- Avoid wt bearing until thawed
- Update Td
- tPA may be necessary
Define 1st degree burn
- Epidermal injury only
- Erythema w/o blisters
- Generally heal within 3-5 days and w/o scars
Describe 2nd degree burn
- Superficial partial thickness
- Deep partial thickness
Define superficial partial thickness burn
- Type of 2nd degree burn
- Injury extends into dermis
- Pink, moist, blanchable, blisters/bullae
- Healing time 2-3 wks w/minimal scarring
Define deep partial thickness burn
- Type of 2nd degree burn
- Injury extends TO SC tissue but NOT into
- Waxy white, mottled pink/cherry red, nonblanchable, impaired sensation
- 3 or more wks healing WITH scars
Define 3rd degree burn
- Full thickness
- Injury extends into SC tissue
- White, charred, dry, insensate
- Requires grafting to heal
Define 4th degree burn
- Muscle and bone involved
- Requires grafting to heal
What type of burns require grafting to heal?
3rd and 4th degree
What may mask the depth of a burn injury?
Early presentation
How can blanchability and sensation be tested in burn victims?
Sterile cotton swab
What is important in order to determine fluid resuscitation of a burn victim?
Total body surface area (TBSA)
*NOT for 1st degree burns
How to determine total body surface area involvement of a burn injury?
- Rule of 9s/palms
- For adults, 1 palm is 1%
- For kids, 1 hand is 1%
What needs to be updated for all burn victims?
Td
Treatment of minor burns
Bacitracin
Treatment of major burns
Silver sulfadiazine (Silvadine)
How should blisters/bullae be treated in burns?
- Should be left intact if possible
- Debride ruptured ones
Treatment of burns (generally)
- Update Td (tetanus/diptheria)
- Leave blisters/bullae in tact (or debride ruptured ones)
- Non-adherent bulky dressing changed daily
- Pain management and recheck in 1-2 days
- Fluid resuscitation based on pt specifics
Guidlines for fluid resuscitation treatment for burn victims
- Adults over 20% TBSA
- Children over 15% TBSA
- Infants over 10% TBSA
What is the Parkland formula?
Estimates fluid replacement in first 24 hrs of burn pts
-IV lactated ringers 4 mL/kg/% TBSA for first 24 hrs (half of total volume over first 8 hrs, remainder over next 16 hrs)
When should a burn pt be referred to burn center?
- Partial thickness burns over 10% TBSA (or 5% if under 16 yo)
- Chemical, electrical, or ionizing radiation burns
- Major burns involving certain areas of body
- Any full thickness burn
- Concomitant injuries
Voltages of various sources?
Taser: 50,000 V (but low amperage) Power lines: 7,620 V 3rd rails: 600 V Entering house: 220 V Household: 110 V
How do electrical injuries affect the body?
- Muscle contracture (resulting in fx, dislocation, rhabdo)
- Secondary trauma from being “thrown”
- Arrhythmias
- Seizures, confusion, agitation
- Burns (entry and exit sites, deep partial thickness or 3rd degree)
Cardiac monitoring of electrical injuries?
NOT necessary if initial EKG is normal
What electrical injuries require admission for monitoring?
Anything over 600 V
How should pregnant women with electrical injuries be monitored?
If pregnant over 20 wks, minimum of 4 hr fetal monitoring and US
Describe lightning injuries
- 70-90% survive
- Typical voltage: 10 mil - 2 bil V, 20K-200K Amps
How do lightning injuries affect the body?
- Flashover phenomenon (current travels over body surface)
- Cardiac arrest (myocardium depolarization)
- Respiratory arrest (medullary depolarization)
- Ocular flash burns (UV keratitis)
How may a nearby lightning strike affect the body?
Shockwave effect - blunt internal injuries
How do most lightning strike patients present?
Lower extremity paralysis (temporary)
What are Lichtenberg figures?
Branching electrical discharges that appear on the body surface of someone struck by lightning
What type of burns may lightning strike patients experience?
Punctate burns
Possible EKG findings of lightning injuries
- Asystole
- ST elevation from vasospasm
- Long QT
- T inversions
Cardiac monitoring of lightning injuries?
Required for most patients (due to delayed sequelae)
Complications of lightning injuries
- Delayed cataract formation
- TM injury
- Vasospasm
- Compartment syndrome
Potential sources of CO poisoning?
- Vehicle or generator exhaust
- Charcoal
- Wood
- Kerosene
What patients will have mildly elevated levels of CO?
Chronic cigarette smokers
Properties of CO
- Odorless, colorless gas
- 250x higher binding affinity w/hemoglobin than O2
- Half life is 3-4 hrs on room air, 60 mins on O2, 15-30 mins on hyperbaric O2
Neuro effects of CO
HA, confusion, dizzy, difficulty concentrating, nausea, lethargy
CV effects of CO
Ischemia, palpitations, mottled skin, poor cap refill, hypotension, cardiac arrest
Labs for CO workup
- Carboxyhemoglobin (COHb) via blood gas
- CBC
- Cardiac enzymes
Possible EKG findings of CO poisoning
Ischemia
Arrhythmia
Pulse ox evaluation of CO poisoning
NOT a useful indicator of oxygenation
Treatment of mild CO poisoning
Nothing - will resolve with time
Treatment of moderate CO poisoning
4 hrs of O2 therapy
Treatment of severe CO poisoning
Hyperbaric oxygen therapy
How is the need for hyperbaric oxygen therapy determined for CO poisoning patients?
Based on symptoms NOT COHb levels
When should a CO poisoning patient be admitted?
- LOC
- Amnesia
- MI
- Seizures
- Comorbidities
How many Americans will be bitten by a dog in their lifetime?
50% (mostly kids)
What pathogens are MC a/w dog bites?
Pasteurella mixed w/strep and staph
Treatment of dog bites
- Irrigation is important
- Loosely close only large wounds or those of cosmetic concern
- Abx for deep wounds or if closing (Augmentin or Clinda+Cipro, 5 days if proph, 10 days if infected)
Describe cat bites
- 60-80% infection rate
- MC Pasteurella multocida
Treatment of cat bites
- Irrigation is difficult d/t small puncture wound
- Abx for all (except most superficial wounds)
- Augmentin or Doxy or Cefuroxime for 7 days (10 days if infected)
MC pathogen of cat bites?
Pasteurella multocida
Describe cat scratch disease
- Regional lymphadenopathy 7-12 days after bite or scratch
- Caused by Bartonella henselae
- Treated with Azythromycin
MC pathogen of human bites?
Streptococcus
Who needs rabies prophylaxis?
Those bit by:
- Domestic animal that can’t be observed for 10 days
- Bats (possible bite or significant feces exposure)
- Wild animals (specific guidelines depending on animal)
What does rabies prophylaxis consist of?
- Immune globulin 20U/kg or 250 units
- Vaccine 1 mL IM days 0, 3, 7, 14
Describe brown recluse spiders
- Spider has violin shape on dorsal surface
- Commonly found in/around wood piles (mostly S, W US)
Describe brown recluse bites
- Bluish discoloration w/vesicles progressing to necrotic wound
- Systemic effects are rare (hemolysis, thrombocytopenia, fever)
Treatment of brown recluse bites
- Supportive care
- Abx if infected
- Dapsone (?)
Describe black widow spiders
- Orange red hourglass shape on body
- Found in basements, garages, wood piles
Describe black widow bites
- Venom causes significant pain and erythema w/in 60 mins
- Site can turn into target lesion
- Usually a/w muscle cramping, abd pain, HTN
Treatment of black widow bites
MAP
- Muscle relaxant
- Antivenom (if available)
- Pain control
Describe jellyfish stings
- Most result in localized erythema or wheal formations
- Moderate pain
- Anaphylactic reaction is possible
Treatment of jellyfish stings
CLAP
- Careful removal of tentacles
- Local application of vinegar (or rubbing alcohol)
- Apply HEAT rather than ice
- Pain management
Treatment of snake bites
- Antivenom ASAP (CroFab for diamondback, Mojave, or cottonmouth snakes)
- Constriction band may be helpful
- NO longer recommended to incise and suction OR tourniquets
Constriction band treatment of snake bites
- Apply with enough tension to restrict superficial venous flow
- BUT maintain distal pulses and capillary refill
- Reduces systemic toxicity of venom
How should snake bites be monitored?
Minimum 8 hr observation, low threshold for admission
