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ER 1 > Environmental Emergencies > Flashcards

Environmental Emergencies Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Exertional heat illness

- 4 conditions

A
  1. heat cramps
  2. Heat syncope
  3. Heat exhaustion
  4. Heat stroke
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2
Q

Heat Cramps

- overview

A
  • Heat does not trigger cramping
  • Usually involves exercise to high intensity or to exhaustion
  • Occurs more often in heat, can occur in cooler temps
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3
Q

Heat Cramps

- tx

A
  • Hydration, sodium (oral just as good as IV)
  • Stretching: especially young athletes
  • Prevention - sodium load before activity
  • “salt losers” more at risk
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4
Q

Heat syncope

- overview

A
  • Heat does not cause syncopal events, should be called exercise associated collapse
  • Pt cannot stand/walk dt lightheadedness or syncope
    Usually after endurance event
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5
Q

Heat syncope

- mechanism

A
  • abrupt decrease in venous return after activity is complete.
  • High systemic vascular resistance during exertion
  • Stop exertion and get vasodilation from loss of skeletal muscle pressure –> precipitous decline in venous return
  • results in collapse
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6
Q

Heat syncope

- presentation and treatment

A
  • Core temp normal or only slightly elevated
  • Tx: hydration, rest
  • Mental status changes quickly resolve (<15 min)
  • Failure to improve within 20 min should prompt a syncope workup (sent to hospital)
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7
Q

Heat Exhaustion

- overview

A
  • Inability to maintain adequate CO dt strenuous physical exercise and environmental heat stress
  • during exercise, free water loss exceeds electrolyte loss (including Na)
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8
Q

Heat Exhaustion

- presentation

A
  • Can manifest as collapse, person cannot continue with activity
  • Core temp usually elevated, 101-104
  • No sig CNS dysfn, no AMS, Sz, delirium (one way to differentiate from heat stroke which does have CNS alterations)
  • Tachycardia +/- hypotension, dehydration
  • Weak, lightheaded, lack of coordination
    HA, abd cramps, nv/d
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9
Q

Heat Exhaustion

- treatment

A
  • Place supine with feet elevated
  • Move to cool area
  • Cool until body temp 101
  • Cool by immersion, spray with cool water
  • Rehydrate orally if no vomiting, IV with normal saline if necessary
  • No rapid improvement - send to ER
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10
Q

Heat stroke

- characteristic sx

A

CNS dysfunction, some form of AMS

- disorientated, HA, irrational, irritable, emotional unstable, confusion, AMS, coma, seizure

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11
Q

Heat stroke

- core body temp

A

elevated

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12
Q

Heat stroke

- effect on organs and tissue

A

rhabdo, kidney, liver injury

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13
Q

Heat stroke

- clinical

A
  • tachycardia
  • hypotension
  • nvd
  • weak
  • profuse sweating**
  • thirst
  • cramps
  • ataxia
  • dehydration
  • loss of muscle function.
  • *Not true that when you stop sweating it is a problem!!! Many people think this
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14
Q

Heat stroke

- treatment

A
  • Rapid cooling!! Get a core temp
  • Cold water immersion - ideal, with ice
  • Ice/wet towel rotation
  • High flow cold water dousing, use fans
  • Cool first, transport second!! (try to cool to 102.2F), if no thermometer, cool until they shiver or immersion for 15-20 minutes
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15
Q

Heat stroke

- workup

A

general stuff:

CBC, CMP, CK, coag, serum lactate, ABG, CXR, CT head, ongoing monitoring

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16
Q

Heat stroke

- Treatment

A
  • Cooling
  • IV fluids
  • Electrolyte abnl correct (Na, K)
  • Treat complications: rhabdo, kidney injury, DIC, cardiac dysfunction, liver failure
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17
Q

Heat stroke

- points to remember

A
  • Severity of heat illness might not be apparent initially
  • Body temp can continue to increase!
    Morbidity and mortality related to duration of elevated temp
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18
Q

Hypothermia

  • define temps
  • how to measure temps
A
  • core temp <95
  • Mild 90-95
  • Moderate 82-90
  • Severe <82
  • **Not super important to know the difference…
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19
Q

Hypothermia

- how to measure temps

A
  • Core temp: rectal temp normal 99.6F/37C, 95-99.6 is normal
  • How to measure: usually a rectal temp? But most thermometers don’t’ measure less than 93 temps (made to measure elevations, not lows)
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20
Q

Hypothermia

- causes

A
  • Increased heat loss or decreased heat production
  • Environmental exposure (usually alcohol is involved)
  • Metabolic: Hypopituitary, hypoadrenal, hypothyroid (not common)
  • Insufficent fule: Hypoglycemia, malnutrition
  • Neuromsk: Extremes of age, Impaired shivering, Inactivity
  • Other: Sepsis, esp at extremes of age, be very concerned when have cold baby or old person!
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21
Q

Hypothermia

- risk factors

A
  • Alcohol use, homeless, psych, elderly

- When get cold, body tells you to react, if impaired or psych illness, you don’t do it…

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22
Q

Hypothermia

- Symptoms key

A

follow mental status

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23
Q

Hypothermia

- mild sx

A
  • Mental status is normal
  • Tachypnea, tachycardia, ataxia, dysarthria, impaired judgement
  • Shivering
  • Cold diuresis - vasoconstrict peripherally, all fluid centrally, including to kidney = increased urine output
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24
Q

Hypothermia

- moderate sx

A
  • Altered mental status
  • Bradycardia, CNS depression, hyporeflexia,
  • Loss of shivering, paradoxical undressing
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25
Q

Hypothermia

- severe sx

A
  • Basically unconscious
  • Hypotension, bradycardia, ventricular arrhythmias
  • Areflexia, coma
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26
Q

Hypothermia

- PE

A
  • Heart is very sensitive to movement, be careful moving them, try not to jostle
  • Measure core temp best you can
  • Don’t forget to exam the entire patient, look for trauma, infection source
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27
Q

Hypothermia

- Labs

A
  • Routine: cbc, cmp, drug screan, ck, fsbs, etc. etc. TSH, T4, cortisol if old person from nursing home
  • Main takeaway: know the hgb! Will be artificially increased due to volume reduction. If have a LOW hgb, something else is going on
28
Q

Hypothermia

- EKG findings

A
  • Slow impulse conduction
  • All intervals are prolonged!
  • Afib is common, esp during re-warming
  • **Osborn wave or J wave classic finding. Taller the wave, usually the colder the patient, best seen V2-V5. Also seen in SAH, brain injury, etc.
29
Q

Hypothermia

- tx

A
  • ABCs
  • CPR
  • Treat underlying condition!!!
  • A lot of drugs don’t’ work at these temps (insulin, epinephrine, etc.)
    Rewarm as soon as possible
30
Q

Hypothermia

- rewarming techniques

A
  • Passive’ blanket, warm room
  • Active external: Bair hugger (blows warm air), warm blanket. Wrap head
  • Active core: warm IV fluids (hard to get them THAT warm), heated humidified air (surface area of lungs is huge, this works well), peritoneal irrigation, thorax irrigation
  • Extracorporeal (severe cases): hemodialysis, cardiopulmonary bypass, ECMO (being used more often, the heart lung machine)
    • can take a long time! Hours and hours
31
Q

Hypothermia

- complications related to rewarming

A
  • Hypotension from cold diuresis, dehydration and fluid shifts (isotonic fluid, pressors?)
  • Electrolyte changes
  • Rhabdo is common
  • Arrhythmias: usually brady (don’t’ treat) same with afib and a flutter. Ventricular arrhythmias: need to warm the patient!!
32
Q

Nobody is dead until…

A

they are WARM and dead

33
Q

Chilblains/pernio

- description

A
  • Cold induced erythocyanotic skin lesion
  • Abnl vascular response to cold, vasoconstriction/vasospasm, inflammatory response. Not sure why it happens in some people. Exaggerated response to cold.
34
Q

Chilblains/pernio

  • presentation
  • tx
A
  • MC fingers and toes, common on kids (esp on cheeks)
  • Confused for bite or infection often!
  • Pruritis, pain, burning with rash
  • 12-24 hours after cold exposure, takes weeks to resolve
  • No treatment - just don’t get cold, stay warm :)
35
Q

Frostbite

- overview

A
  • Freezing of tissue, exposure to subfreezing temps - ice formation extracellularly or inside cells if rapid
  • Inflammatory response and ischemia and ultimately necrosis
36
Q

Frostbite

- two classification schemes

A
  1. based on level at which skin lesions are noted after rapid rewarming, how far along the skin there is cyanosis
  2. Traditional system, based on how deep the tissue is injured, similar to burn classifications
  • more details in press
37
Q

Frostbite

- Treatment

A
  • If pt has possibility of getting cold again, don’t rewarm!! Think about helicopter transport (not very warm)
  • Do not rub, use fire or stove to rewarm
  • Skin will be insensate before, might develop bullae after thawing
  • Rewarm
  • Wound care - long term. Possible amputation
38
Q

Frostbite

- how to rewarm

A
  • Immerse in heated water, gentle motion of the water
  • Complete when tissue is red/purple and soft to touch (15-30 min)
  • Will be painful, will need pain control (IV narcotics??)
39
Q

Trenchfoot/Immersion foot

A
  • WWI trench warfare
  • Nothing to do with temp, more due to exposure to dampness
  • Tight boots exacerbate
  • Feet: red, edematous, numb, painful
  • Can develop hemorrhagic bullae, loose tissue
  • MC with homeless population
40
Q

Drowning

- epidemiology

A
  • Leading cause of death in children <5 in states with beaches and pools (CA, FL, AZ)
  • Highest incidence among males, AA, low socioeconomic state (don’t know how to swim).
  • Second highest males 15-25
41
Q

Drowning

- definition

A
  • “process of experiencing respiratory impairment from submersion or immersion in liquid
  • Bunch of terms but just call it drowning
42
Q

Drowning

- risk factors

A
  • lack of supervision
  • can’t swim or over estimate ability
  • risk taking
  • drug and alcohol use
  • concomitant trauma, stroke, MI
  • hyperventilate prior to shallow dive: reduce PaCO2, while hold breath, PaO2 falls before PaCO2 rises enough to trigger urge to breath, producing hypoxia and LOC
43
Q

Drowning

- pathophysiology overview

A
  • Initial breath holding and panic lead to reflex inspiratory effort leads to aspiration or laryngospasm (water in lungs) leads to hypoxia leads to acidosis and cardiac arrest.
  • Degree of hypoxia, how long under, how much aspirate = how bad
  • Doesn’t take much water to affect O2 exchange
44
Q

Drowning

- pulmonary pathophysiology

A
  • Washes out surfactant - can’t echange gases
  • Causes pulmonary edema, inflammatory response in lungs - no exchange and ARDS
  • SOB, crackles, wheezing. Can happen rapidly or insidously.
  • Work of breathing is important to observe
  • Clinical dx, CXR can vary (and lag behind clinical presentation and improvement)
45
Q

Drowning

- Neuro pathophysiology

A

Hypoxia and ischemia - neuron damage and cerebral edema

46
Q

Drowning

- cardiac pathophysiology

A
  • Arryhtmias usually dt hypoxemia

- Acidosis = tachypnea which leads to bradycardia to PEA to asystole

47
Q

Drowning

- management

A
  • Ventilation is MOST important initial treatment
  • Rescue breaths ASAP
  • C-spine injury: routine c-spine immobility is not recommended without sx of injury (breath is most important unless you are pretty sure c-spine injury)
  • Airway management:
    • Intubation for neuro deterioration, inability to protect airway
    • Bi-PAP: inspiratory and expiratory setting, VERY helpful
  • Trauma eval: look for 2ndary injuries
  • Salt vs. fresh: doesn’t matter
  • CXR: findings lag
48
Q

Species of insect that cause problems

A

hymenoptera

bees, wasps, yellow jackets, hornets, fire ants

49
Q

Sting

- local reaction

A
  • Redness to sting site, mild, transient
  • Painful swelling
  • 1-2 days, treat with cold compress
  • Fire ants: sterile pustule
50
Q

Sting

  • large local reaction
  • Tx
A
  • 10% of individuals
  • Gradual enlargemetn over 1-2 days
  • Cold compress
  • Low does, short course prednisone
  • NSAIDs
  • Antihistamine
51
Q

Sting

- tx

A
  • remove the stinger, flick it off
  • no need for tetanus
  • secondary infection: 3-5 days after sting, worsening redness, swelling, pain, fever (MC in yellow jackets and fire ants)
  • Anaphylaxis is very uncommon
52
Q

Black widow spider

- bite situation

A
  • lactrodectism
  • Usually with outdoor activities
  • Initial bite: usually LE is asx or mild pain
53
Q

Black widow spider

- presentation

A
  • Systemic sx 30-120 min after bite
  • Muscle pain most prominent feature. Pain in extremities, back, abdomen, agonizing
  • Acute/surgical abd picture (peritoneal signs)
  • Self limited, usually resolves 24-72 hours
  • Diaphroesis corresponding to affected muscle group in 60%
  • Presenting 24 hours after bite, can have burning in sole of feet, pain below knees, sweating of lower legs
54
Q

Black widow spider

- bite characteristics

A

Skin with central clearing area with surrounding red perimeter, infection rare
***no necrosis

55
Q

Black widow spider

- tx

A
  • Wound care
  • Pain care
  • Oral benzo?
  • Severe
    • IV drugs
    • No calcium
    • Antivenom but in short supply and has own problems (can induce anaphylaxis), only for very severe situations
56
Q

Brown recluse spider

- venom enzyme to know

A

phospholipase D

57
Q

Brown recluse spider

- bite

A
  • red plaque or papule, develop central pallor
  • Occasionally vesiclation around site
  • Can develop dark, depressed center, dry eschar 24-48 hours after.
  • Can expand rapidly
  • **Necrosis!!
58
Q

Brown recluse spider

- stages of bite progression

A

Papule develops dusky red or blue –> dry depressed center, may be anesthesia in center –> eschar and then breaks down to form ulcer, may enlarge in gravitational manner

59
Q

Brown recluse spider

- systemic sx

A
  • malaise
  • n/v
  • fever
  • myalgia
60
Q

Brown recluse spider

- mnemonic to differentiate from other skin lesions

A
  • Numerous - usually just one
  • Occurrence - secluded areas in home like attic, garage, closet
  • Timing - Nov - March not usually recluse
  • Red center - recluse usually pale
  • Elevated - recluse is usually flat
  • Chronic – lesions >several weeks unlikely to be recluse
  • Large - usually smaller than 10 cm
  • Ulcerates too early - recluse not until >7 days
  • Swollen: recluse usually not very swollen
  • Exudative: recluse usually not moist or exudative or have frank pus
61
Q

Three snakes to worry about in OK

A
  • copperhead
  • cottonmouth
  • rattlesnake
62
Q

25% of snake bites are

A

dry - no venom

63
Q

Envenomation syndrome from snake bite

A
  • Local tissue damage
  • n/v/d, weakness, diaphoresis, affects coags, can cause rhabdo
  • Tachycardia, hypotension
  • Oral paresthesia, usually taste, fasciculations
64
Q

Snake bite

- comparison of bites from diff snakes

A
  • Rattlesnake - more severe s/sx vs. cottonmouth

- Copperhead usu cause limited local sx

65
Q

How to consider pt identification of snake

A

Pt ID of snake is often wrong or not available… treat based on s/sx

66
Q

overview of snake bite w/u

A
  • Assess pt
  • initial labs
  • treat pain, etc.
  • Look for signs of severe envenomation
67
Q

Snake bite tx

A
  • Remove jewelry
  • Immobilize
  • Clean wound
  • Transport supine
  • Crofab: Purified Fab fragments of sheep IgG, binds venom, might need multiple doses, cleared by kidney

ER 1 (18 decks)

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