Environmental Emergencies (Exam #1) Flashcards
How does the rethawing process in a cold injury cause tissue damage (3 steps)?
- Arachidonic acid = vasoconstrict
2. Platelets aggregate = clots 3. Ischemia, necrosis, gangrene
What two symptoms may be seen prior to rethawing in a cold injury?
- Pale, waxy, hard/cold skin
- Paresthesias
What are the four degrees of cold injury?
- 1st Degree: numbness, central pallor with surrounding erythema/edema, desquamation, NO blisters
- 2nd Degree: blisters with surrounding erythema/edema
- 3rd Degree: tissue loss of entire thickness of skin; hemorrhagic blisters (deeper)
- 4th Degree: tissue loss of entire thickness of skin + deeper structures = amputation
Treatment of heat injury (4)?
- Immerse in water (101.5/102.2 F, 20-30 min.)
+/- IV opioids for pain - Apply aloe vera
- Give Ibuprofen
What indicates a poor prognosis with cold injury? What two diagnostic tests should be ordered?
Cyanosis proximal to ITP joints
- CT angiography
- DEXA scan
What are six causes of secondary Hypothermia (HT)?
- Alcoholism
- DKA
- Meds (antihyperglycemics, BB, opioids)
- Newborns
- Malnutrition
- Infusions/transfusions
With a hypothermic patient, what is the preferred method to check temperature (2)? Which is used on an unconscious patient?
- Rectal/bladder thermometer (conscious)
- Esophageal temp probe (unconscious)
What are the four clinical stages of Hypothermia (HT), and what is the body temperature range for each?
- Mild (HT I) = 89.6-95 F
- Moderate (HT II) = 82.4-89.6 F
- Severe (HT III) = <82.4 F
- HT IV = 82.4-89.6 F
Which clinical stage of Hypothermia (HT) involves conscious, confused, tachy, inc. shivering? What is the temperature range for this stage?
Mild (HT I) = 89.6-95 F
Which clinical stage of Hypothermia (HT) involves lethargic, brady/arrhythmias, loss of pup. reflexes, dec. shivering? What is the temperature range for this stage?
Moderate (HT II) = 82.4-89.6 F
Which clinical stage of Hypothermia (HT) involves VS present, unconscious, hypotension, arrhythmias, pulm. edema? What is the temperature range for this stage?
Severe (HT III) = <82.4 F
Which clinical stage of Hypothermia (HT) involves absent VS, cardiac arrest? What is the temperature range for this stage?
HT IV = 82.4-89.6 F
What two clinical signs/changes may be seen before and after rewarming with Hypothermia (HT)?
- Hyperglycemia → normal/hypoglycemia
- Normal → hyperkalemia
What is the treatment for Mild (HT I)?
- Rewarm using blankets, fluids
What is the treatment for Moderate (HT II) (2)?
- ABCs +/- intubation
- Internal AND external rewarming (trunk first)
If a patient is Hypothermic and you are treating them, what movements should be avoided, and why?
Avoid rough movements
- Can cause arrhythmias
What is the treatment for Severe (HT III) (3)?
Same as Moderate + pleural/peritoneal irrigation with warm saline
- ABCs +/- intubation
- Internal AND external rewarming (trunk first)
What is the treatment for Severe (HT III) (3)?
- Start CPR
- ACLS protocol
- Thoracic lavage with NS
What two general treatments are always recommended with a Hypothermic patient?
- Remove wet clothes
- Rewarm
What are four important complications associated with rewarming a Hypothermic patient?
- Hypotension
- Electrolyte abnormalities
- Rhabdomyolysis
- Late pulm/renal/neuro complications
What heat emergency is more common in “salty sweaters” and those who are not heat acclimated?
Heat Cramps
What condition involves muscle pain/spasm, low Na+/K+/Mg? What is the recommended treatment?
Heat Cramps
- Tx: rehydrate, rest
How can you differentiate Heat Stress/Exhaustion from Heat Stroke (2)?
- Heat Stress/Exhaustion = <104 F, NO CNS impairment
- Heat Stroke = 104+ F, AMS
What condition involves normal/slightly elevated temp. (<104 F); NO CNS impairment?
Heat Stress/Exhaustion
What condition involves heat cramps + HA, N/V, dizziness?
Heat Stress/Exhaustion
When treating a patient with heat emergency, what is the goal body temperature?
102.2 F
What is the recommended treatment for Heat Stress/Exhaustion (BE SPECIFIC)?
IV fluids
- 1-2 L NS short-term + 1.5x increase for maintenance
What condition involves 104+ F AND AMS? What symptoms may present?
Heat Stroke
- Irritability
- Confusion
- Irrational behavior
- Decorticate/decerebrate posture
- Seizures
- Coma
For Heat Stroke tx, which cooling method involves remove clothing, spray water on patient’s skin, direct a fan over the patient?
What is the con associated with this method?
Evaporative cooling
- Con: hard to keep cardiac electrodes on skin for monitoring
For Heat Stroke tx, if using the ice pack cooling method, what three specific body parts should they be applied to?
What is the con associated with this method?
- Axillae
- Neck
- Groin
- Con: poorly tolerated
For Heat Stroke tx, which cooling method involves patient placed partially in tub of ice water?
What are the three cons associated with this method?
Immersion cooling
Cons:
- Electrodes cannot be on patient
- Poorly tolerated
- Cannot defibrillate if needed
For Heat Stroke tx, which cooling method involves cardiopulmonary bypass?
What are the two cons associated with this method?
Invasive cooling
Cons:
- Invasive
- Not readily available
How can you differentiate AC from DC electrical injuries symptomatically (2)?
- AC = repetitive muscle contraction, entrance wound ONLY
- DC = single muscle spasm (shorter duration), exit AND entrance wound
What condition involves repetitive muscle contraction, entrance wound ONLY?
AC Electrical Injury
What condition involves single muscle spasm (shorter duration), exit AND entrance wound?
DC Electrical Injury
What are the four types of Electrical Injuries? Describe each…
- Classic: body part of circuit
- Flash/arc: strikes skin, but doesn’t enter body
- Flame: clothing catches fire
- Lightning: DC = shock wave through body; “Lichtenburg figures”
What specific finding is seen with a Lightning Electrical Injury?
“Lichtenburg figures”
What two systems are often affected with a High Voltage Electrical Injury?
- Neuro
- Vascular
With Electrical Injuries, what is the duration of contact for each type (Lightning vs. High Voltage vs. Low Voltage)?
Duration of Contact
- Lightning: instant
- High: brief
- Low: prolonged
With Electrical Injuries, what is the type of current for each type (Lightning vs. High Voltage vs. Low Voltage)?
Type of Current
- Lightning: DC
- High: DC or AC
- Low: mostly AC
With Electrical Injuries, what cardiac arrest dysrhythmia is seen with each type (Lightning vs. High Voltage vs. Low Voltage)?
Cardiac Arrest
- Lightning: Asystole
- High: V Fib
- Low: V Fib
With Electrical Injuries, what muscle contraction is seen with each type (Lightning vs. High Voltage vs. Low Voltage)?
Muscle Contraction
- Lightning: single
- High: single if DC; tetany if AC
- Low: tetany
With Electrical Injuries, what type of burn is seen with each type (Lightning vs. High Voltage vs. Low Voltage)?
Burn
- Lightning: superficial = rare
- High: deep = common
- Low: usually superficial
With Electrical Injuries, what blunt injury is seen with each type (Lightning vs. High Voltage vs. Low Voltage)?
Blunt Injury
- Lightning: blast effect
- High: fall (muscle contraction)
- Low: fall = uncommon
With Electrical Injuries, how common is acute mortality seen with each type (Lightning vs. High Voltage vs. Low Voltage)?
Acute Mortality
- Lightning: very high
- High: moderate
- Low: low
With High Voltage Electrical Injuries, what is the recommended diagnostic criteria (4)?
TRAUMA protocol…
- FAST
- CT scans
- XR
- Labs (CBC, CMP, etc)
With Low Voltage Electrical Injuries, what is the recommended diagnostic criteria (2)?
Perform PE and EKG
- NO labs or imaging unless sxs/abnormal findings
What is the recommended disposition for High Voltage Electrical Injuries? Low Voltage Electrical Injuries?
- High: ADMIT ALWAYS (even if asxs or no apparent injury)
- Low: home if norma PE/EKG
What type of bite involves pain within 3 hours of bite → systemic sxs 4-6 hours post-bite?
Black Widow Spider Bite
What type of bite involves mild-intense pain and itching 2-8 post-bite?
Brown Recluse Spider Bite
What condition involves depressed macule/pale grey with erosion in center and halo of inflammation/hemorrhage?
Brown Recluse Spider Bite
Are systemic sxs more common with a Black Widow Spider Bite or Brown Recluse Spider Bite? What four symptoms may be seen?
Black Widow Spider Bite
- N/V
- HA
- Tachycardiac
- HTN
What is the recommended treatment for Spider Bites (3)? Which type involves an antivenom?
Often self-limiting
- Clean wound
- Tetanus prophylaxis
- Analgesics
Antivenom = Black Widow
Scorpion Stings are often harmless, except which type? What symptoms may be seen with this Scorpion (6)?
How are sxs different for children (3)?
BARK Scorpion = venomous
- Pain/paresthesias
- Tachycardia
- HTN
- Tachypnea
- Weakness
- Muscle spasms
Children: restless, muscle spasm, random head movements
What is the recommended treatment for Scorpion Stings (3)? What if severe?
Monitor for 8-12 hours
- Supportive (ice packs, NSAIDs, muscle relaxants)
- Severe = antivenom
What is the recommended treatment for both Rattlesnake Bites and Coral Snake Bites?
ADMIT to ICU
- Start antivenom
What type of bite involves fang marks, local tissue injury, thrombocytopenia?
Rattlesnake Bites
What are three signs of progressive sxs with a Rattlesnake Bite?
- Worsening local injury
- Abnormal labs
- Systemic sxs
With snake antivenom administration, what condition may develop and how do you treat it?
Serum sickness
- Treat with oral Prednisone (1mg/kg/d for 1-2 weeks)
What is an important consideration in the presentation/treatment of Coral Snake Bites?
Neurotoxic venom can take hours to take effect BUT once effects present = irreversible
What condition requires prolonged bite for envenomation? What diagnostic test should be ordered?
Gila Monster Bites
- Order XR
What is the recommended treatment for Gila Monster Bites (4)?
- Remove lizard
- Clean wound/remove teeth
- Admit
- Begin abx
What are the two types of Barotrauma, and which is more severe?
- Descent
- Ascent = more severe
What condition involves EAC occluded → cannot equalize pressure between TM and EAC during descent?
Barotitis (Ear Squeeze)
- Descent Barotrauma
What condition involves pain/fullness vs. conductive hearing loss, hemotympanum → ruptured TM, vertigo?
Barotitis (Ear Squeeze)
- Descent Barotrauma
What condition involves sinuses occluded → air cannot enter sinuses during descent to equalize?
Sinus Barotrauma
- Descent Barotrauma
What condition involves sinus pain, possible epistaxis?
Sinus Barotrauma
- Descent Barotrauma
What is the recommended treatment for both Barotitis and Sinus Barotrauma (2)? What additional consideration should be made for Sinus Barotrauma?
- Decongestant
+/- abx PRN
Also, ENT referral for Sinus Barotrauma
What condition involves occluded Eustachian tube + attempted Valsalva to equalize pressure in middle ear → oval/round window ruptures?
Inner Ear Barotrauma
- Descent Barotrauma
What are the three types of Descent Barotrauma, and which is most severe?
- Barotitis
- Sinus Barotrauma
- Inner Ear Barotrauma = most severe
What condition involves severe pain; sudden onset sensineural hearing loss, tinnitus, severe vertigo?
Inner Ear Barotrauma
- Descent Barotrauma
What is the recommended treatment for Inner Ear Barotrauma?
URGENT ENT consult
- Head of bed up
- No nose blowing
- Antivertigo meds
What condition is also called “Burst Lung Syndrome”; involves lung overinflation?
Pulmonary Barotrauma
- Ascent Barotrauma
What two symptoms are seen with Pulmonary Barotrauma? What other condition may present?
- SOB
- CP
Possible PTX
What is the recommended treatment for Pulmonary Barotrauma (2)?
Supportive if only pneumomediastinum
- PTX = intervention
What condition involves ANY neuro sxs in setting of documented pulmonary barotrauma?
Arterial Gas Embolism
- Ascent Barotrauma
What condition involves neuro sxs immediately after rapid/uncontrolled ascent (air into arterial system)?
Arterial Gas Embolism
- Ascent Barotrauma
What is the recommended treatment for Arterial Gas Embolism (5)?
URGENT neuro consult
- ABCs
- HBOT
- High flow O2
- IV hydration
