Environmental Emergencies Flashcards
Distribution of Electrical Injuries
Young children
Adults
Severity of Electrical Injuries
Voltage Duration Type (AC, DC) Current path through body Environmental factors
Greatest Damage in the Body from Electrical Injuries
Nerves
Blood vessels
Muscle
Which wound site is often larger than the other in electrical injuries?
Exit wound site
Low Voltage AC Current Effects
Muscular tetany
Continuous grasping of source
High Voltage AC and DC Current Effects
Single violent muscular contraction
Throw victim from source
Increased risk of blunt/blast injury
Electrical Cardiac Changes in Low Voltage AC Current
V-fib
Electrical Cardiac Changes in High Voltage AC and DC Current
Asystole
Respiratory arrest
Physical Exam in Electrical Injuries
Primary survey Secondary survey ABC's C-spine immobilization 2 large bore IVs
CNS Physical Exam Findings
Transient LOC
Agitation, confusion
Coma
Visual disturbances: pupils fixed and dilated or asymmetric
Spinal Cord Injuries from Electrical Injuries
Fractures
Ascending paralysis
Spinal cord syndromes
Peripheral Nerve Injuries from Electrical Injuries
Involve hand touching a power source
Cutaneous Wounds in Electrical Injuries
Entry/exit points
Degree of burns of entry/exit points
Treatment of Burns from Electrical Injuries
Cleansed and dressed with silver sulfadizine
Careful neuromuscular compromise and compartment syndrome
Oral Injuries with Electrical Injuries
Kids
Vascular injury to labial artery
What section of the body generates the greatest amount of heat when exposed to electrical current?
Long bones
Which areas have the greatest destruction in electrical injuries?
Deep tissue surrounding long bones
Treatment of Electrical Burns
ABCs C-spine Dysrhythmias Aggressive fluid replacement Labs EKG Watch electrolytes closely Wound care Myoglobinuria Tetanus prophylaxis Treat seizures General surgeon consult ENT consult (kids) OB consult
Labs in Electrical Burns
Electrolytes BUN/Creatinine Creatine kinase Serum and urine myoglobin (rhabdo) CBC
Monitoring in Electrical Burns
CV monitoring Development of compartment syndrome I&O: 100+ mL/h Rhabdomyolysis Renal Failure
Types of Lightening Strikes
Direct strike
Side flash
Ground current
Step potential
What kind of current is lightening?
DC current
Effects of Lightening Strikes
Immediate cardiac arrest (sustained asystole)
Respiratory arrest
Minor Injuries Associated with Lightening Strikes
Stunned patient Confusion, amnesia Short term memory problems Headache Muscle pain Parasthesias Temporary visual or auditory problems
Other Signs or Symptoms of a Lightening Strike
Pupil dilation
Anisocoria
Ruptured TM
Fern-like erythematous skin marking
Treatment of Lightening Strikes
Aggressive resuscitation ACLS and CPR Cardiac monitoring, SAO2, BP 2 large bore IVs High flow O2
Secondary Survey for Occult Injuries with Lightening Strikes
Cutaneous burns
Ocular involvement
Auditory involvement
Musculoskeletal fractures
Labs for Lightening Strikes
Electrolytes BUN/Creatinine Creatine kinase Serum and urine myoglobin (rhabdo) CBC
Treatment for Lightening Strikes
Labs
Tetanus prophylaxis
Moderate to severe: CCU
Mild: admit, monitor cardiac and neuro status
What is the 3rd most common cause of accidental death in the US?
Drowning
Near Drowning Risk Factors
Inability to swim Overestimation of swimming capabilities Risk-taking behaviors ETOH or drugs Inadequate supervision Hypothermia Concomitant trauma, CV, MI Hyperventilation
Pathophysiology of Drowning
Period of panic Loss of normal breathing pattern Reflex inspiratory efforts Aspiration Reflex laryngospasm
Pathophysiology of Dry Drowning
Laryngospasm
Hypoxia
LOC
Pathophysiology of Wet Drowning
Aspiration of water Dilution and washout of surfactant Diminished gas transfer Atelectasis V/Q mismatch
Pathophysiology of Fresh Water Drowning
Transient hemodilution
Blood cells swell and burst
Pathophysiology of Salt Water Drowning
Draws blood out of blood stream
Build up of sodium in alveoli
Decreased/stopping of oxygen from reaching blood
Pulmonary End Organ Effects of Drowning
Fluid aspiration Wash out of surfactant Non-cardiogenic edema Acute respiratory distress S/S of ARDS
Neurologic End Organ Effects of Drowning
Neuronal damage
Cerebral edema
Elevated ICP
CV End Organ Effects of Drowning
Arrhythmias
Sinus bradycardia
Fibrillation
Acid-Base and Electrolyte Effects of Drowning
Metabolic and/or respiratory acidosis
No significant electrolyte imbalances
Prehospital Drowning Management
CPR
Neck in neutral position
Rescue breathing
Rewarming
ER Management of Drowning
Prehospital efforts continued
Seek out head and spinal cord injuries
Re-warming initiated
Re-warming Efforts in Drowning
Blankets
Bair hugger
Overhead warmers
Resuscitative efforts until 32-35C
Drowning Victims with CGS 13+ Management
O2
Observation 4-6 hours
Possible discharge home with someone
Reassess/admit
Drowning Victims with GCS Less than 13 Management
O2
CXR
Labs
Labs in Drowning Victims
ABGs CBC CMP PT/PTT UA CK Urine myoglobin Urine drug screen
Inpatient Management of Neurologic Issues in Drowning Victims
Duration of LOC
Neuro state at presentation
Prevent secondary injury
Secondary Neurologic Injuries in Drowning Victims
Cerebral edema Hypoxemia Fluid and electrolyte imbalances Acidosis Seizure activity
Inpatient Management of Pulmonary Issues in Drowning Victims
Intubation for PEEP delivery
CXR when indicated
Bronchospasm: beta agonists
Factors Associated with a Poor Prognosis in Drowning
Duration of submersion (10+ minutes) Time to effective BLS (10+ minutes) Resuscitation duration (25+ minutes) Hypothermia with core temp less than 33C GCS of 5 Less than 3 years Persistent apnea and CPR in ER Arterial pH less than 7.1 Water temp 50+ F
Define Hypothermia
Core temperature less than 35C or 95F
Core Temperature of Mild Hypothermia
90-95F
Core Temperature of Moderate Hypothermia
82-90F
Core Temperature of Severe Hypothermia
Less than 82F
Individuals at Risk for Hypothermia
Elderly
Neonates
Individuals with altered sensorium
How is heat loss from the body?
Evaporation
Radiation
Conduction
Convection
How is heat preserved by the body?
Peripheral vasoconstriction
Shivering
Increase in metabolic rate
Presentation of Mild Hypothermia
Tachypnea Tachycardia Hyperventilation Ataxia Dysarthria Impaired judgement Shivering "Cold diuresis"
Presentation of Moderate Hypothermia
Reduction in pulse and CO Hypoventilation A-fib CNS depression Hyporeflexia Decreased renal flow Loss of shivering Paradoxical undressing
Presentation of Severe Hypothermia
Pulmonary edema Oliguria Areflexia Coma Hypotension Bradycardia Ventricular arrhythmias Asystole
Diagnosing Hypothermia
Low-reading thermometer
Labs
EKG: Osborne or J waves
Labs in Diagnosing Hypothermia
Electrolytes
Hematocrit
Coagulation studies
ABGs
Management of Hypothermia
ABCs Passive external rewarming Active external rewarming Active internal rewarming Treat arrhythmias
Methods of Active External Rewarming
Warm blankets Radiant heat Warm baths Forced warm air CORE FIRST
Methods of Active Internal Rewarming
Pleural and peritoneal irrigation Hemodialysis Cardiopulmonary bypass Warm humidified oxygen Warm IV fluids Bladder or GI irrigation
What arrhythmias occur with hypothermia?
A fib
A flutter
V fib
Asystole
Define Frostbit
Freezing of tissue
Pathophysiology of Frostbite
Immediate cold-induced cell death
Gradual development of localized inflammation and tissue ischemia
Worse in thawing and refreezing
Describe 1st Degree Frostbite
Central area of pallor and anesthesia of skin surrounded by edema
Superficial
Describe 2nd Degree Frostbite
Blister formation containing clear or milky fluid surrounded by edema/erythema within 24 hours
Superficial
Describe 3rd Degree Frostbite
Injury deeper than 2nd degree
Hemorrhagic blisters
Progress to black eschar over several weeks
Deep
Describe 4th Degree Frostbit
Extends to muscle and bone
Involves complete tissue necrosis
Deep
Presentation of Frostbite
Cold, numbness, and clumsiness of affected area Insensate, white or grayish-yellow skin Hard to waxy to touch Possible bullae Eschars or tissue necrosis
Diagnosis
Clinically
Technetium-99 scintigraphy
Prehospital Treatment of Frostbite
Remove wet clothing Avoid walking on frostbitten feet Don't rewarm if possibility of refreezing Do not rub frostbitten areas Avoid stove or fires to rewarm
Prognostic Factors in Frostbit
Temperature and wind velocity? How long extremity frozen? Refreezing occur? Self-treatment? Recreational drugs or alcohol used? Predisposing medical conditions
Treatment of Frostbite in Hospital
Water bath heated to 40-42 C Dry heat difficult to regulate Thawing (15-30 minutes usually) Bulky dressing Elevation Splinting Tetanus prophylaxis Topical aloe and ibuprofen Possible tPA use Surgical consultation
Managing Blisters in Frostbit
Drain, debride, and bandage non-hemorrhagic bullae that interfere with movement
Hemorrhagic bullae drained by aspiration
Minor bullae should be left alone
Reasons for Surgical Consult in Frostbite
Long term wound care Daily hydrotherapy Repeated debridement Escharotomy Possible delayed amputation
Short Term Complications of Frostbite
Infection
Gangrene
Autoamputation
Long Term Complications of Frostbite
Hypersensitivity to the cold
Increased risk of developing frostbite again
Chronic parasthesias to affected area
Decreased sensation to touch
2 Types of Heat Exhaustion
Water depletion
Salt depletion
Define Water Depletion Heat Exhaustion
Inadequate fluid replacement by individuals working in a hot environment
Define Salt Depletion Heat Exhaustion
Large volumes of thermal sweat are replaced by water with too little salt
Signs and Symptoms of Heat Exhaustion
Weakness Malaise Fatigue Headache Lightheadedness Dizziness N/V Hypotension Tachycardia Tachypnea Diaphoresis Syncope
Treatment of Heat Exhaustion
Cool environment
Volume and electrolyte replacement
Mild: oral replacement
Moderate: 1-2 L saline, guided by electrolytes
Define Heatstroke
Life-threatening emergency that occurs when homeostatic thermoregulatory mechanisms fail
Body temp 105+
4 Factors Tissue Damage is Affected by
Body temp
Exposure time
Work load
Tissue perfusion
Signs and Symptoms of Heatstroke
CNS dysfunction Cerebral edema Ataxia Irritability Confusion Bizarre behavior Combativeness
Pathophysiology of Heatstroke
Functional hypovolemia compensated by vasoconstriction of splanchnic and renal vasculature
Severe Heat Stress Continues in Heatstroke
Splanchnic vasoconstriction will fail
Heated core blood increases ICP
Decreases mean arterial pressure
Diagnosis of Heatstroke
Exposure to heat stress Signs of severe CNS dysfunction Core temp 105+ Dry, hot skin Sweating may persist Marked elevation of liver transaminases
3 Ways Heatstroke can Kill
Vascular shock
Irregular pulse to heart attack
Kidney failure
Treatment of Heatstroke
ABCs Primary survey Cooling Airway control Fluid administration Foley Labs Benzodiazepines (seizures) Admission
Cooling Techniques in Heatstroke
Evaporative cooling Cold-water immersion Ice packing Cold gastric lavage Cold peritoneal lavage
Define Evaporative Cooling
Position fans close to undressed patient then spraying water on patient
Disadvantages of Evaporative Cooling
Shivering
Loss of EKG patches
Define Immersion Cooling
Place undressed patient in tub of ice water deep enough to cover trunk and extremities
Where should ice packs be placed to cool a patient?
Neck
Groin
Axillae
When should cooling efforts be discontinued in a patient with heatstroke?
40C or 104F
Labs for Heatstroke
ABGs CBC CMP Liver enzymes Lactate dehydronase Creatinine phosphokinase Uric and lactic acid PT/PTT
