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PEM Lectures dirigées > Environmental Emergencies + Mass casualties > Flashcards

Environmental Emergencies + Mass casualties Flashcards

1
Q

Risk factors for drowning

A

Male
Epilepsy
infants/toddlers

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2
Q

How does fresh water cause electrolyte/vascular volume abnormalities

A

aspirated - into circulation - hemodilution - can contribute to cerebral and pulmonary edema

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3
Q

How does salt-water aspiration affect intravascular volume

A

lowers, causes hemoconcentration
can cause massive hemolysis

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4
Q

What is the pathophysiology of drowning (fresh water)?

A

Fresh water - disrupts surfactant - increased surface tension - alveolar instability - fluid leak into alveoli - pulmonary edema

decreased pulmonary compliance, increased airway resistance + pulmonary artery pressure, diminish pulmonary flow
Non-ventilated alveoli are perfused = intrapulmonary shunt = decreased PaO2 = metabolic acidosis

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5
Q

What is the pathophysiology of drowning (salt water)?

A

no denaturing of surfactant
creates osmotic gradient - fluid accumulation in lungs - dilution of surfactant

decreased pulmonary compliance, increased airway resistance + pulmonary artery pressure, diminish pulmonary flow
Non-ventilated alveoli are perfused = intrapulmonary shunt = decreased PaO2 = metabolic acidosis

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6
Q

Risk factors for worse prognosis in drowning

A

duration of submersion
degree of pulmonary damage by aspiration
effectiveness of initial resuscitative measures
degree of hypothermia

Asystole on arrival in ED
Hyperglycemia
Fixed, dilated pupils on arrival

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7
Q

Target sat for drowning victim

A

92%+ for home
90% + for in-hospital

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8
Q

Management of drowning victim with normal O2 sat

A

observation 6-12 hours with repeat sat or abg

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9
Q

Investigations to order for drowning victim

A

CXR
ABG
CBC
Lytes
Urinalysis

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10
Q

Ways to improve gas exchange in drowning patient with resp compromise

A

fluid restriction (1/2 maintenance)
Diuretic eg. furosemide 0.5-1mg/kg (max 20mg/dose)

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11
Q

Characteristics of a fence for around the pool

A

4 sided fence
prevents direct access to the pool
4 feet high minimum
climb-resistance
distance between bottom of fence + ground < 4 inches
self-latching, self-closing

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12
Q

Effects of smoke inhalation on lower airway

A

loss of ciliary action
mucosal edema
bronchiolitis
alveolar epithelial damage
impaired gas exchange
ateletasis/air trapping
loss of surfactant activity - ventilation perfusion mismatch
later - sloughing of tracheobronchial mucosa, mucopurulent membrande formation

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13
Q

Burning of polyurethane, vinyl, wool, silk, plastic produces what toxic gas?

A

cyanide

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14
Q

What physical exam findings signal probable smoke inhalation?

A

facial burns
singed nasal hairs
pharyngeal soot
carbonaceous sputum

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15
Q

CXR findings of inhalation injury

A

diffuse interstitial infiltration
local areas of atelectasis and edema

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16
Q

Treatment of cyanide toxicity

A

hydroxycobalamin IV 70mg/kg (max 5g)

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17
Q

When should elective tracheostomy be considered in inhalation injury

A

if placing or securing ETT will further traumatize an edmatous airway or severe facial burns

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18
Q

Investigations for inhalational injury

A

ABG
CO level
cyanohemoglobin level
troponin
CXR

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19
Q

Indications for intubation with inhalation injury

A

Upper airway obstruction
PaO2 < 60mmHg on 60% O2
CNS depression with loss of cough+ gag reflexes

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20
Q

Preferred method of delivering humidified O2 in inhalation injury

A

mask or artificial airway - prevent inspissation of debris and occlusion of the airway

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21
Q

Medication adjunct to increase cardiovascular stability in inhalational injury

A

diuretics - furosemide 0.5-1mg/kg IV

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22
Q

Inhaled medication adjuncts to aid in inhalation injury

A

aerosolized heparin, NAC, tiotropium - decreased incidence of atelectasis, reintubation and moretality

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23
Q

Minimum amount of time to monitor someone in ED with suspected inhalation injury

A

6 hours

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24
Q

How does CO cause hypoxia?

A

Binds to hemoglobin with an affinity 200 to 300 times greater than that of oxygen

Shifts the oxyhemoglobin dissociation curve to the left and changes the shape from sigmoidal to hyperbolic - only allows oxygen release at lower-than-normal tissue oxygen levels

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25
How does tissue hypoxia (eg. from CO) cause cerebral edema?
increases cerebral blood flow, cerebrospinal fluid pressure, cerebral capillary permeability
26
Symptoms of carbon monoxide poisoning
dull headache weakness dizziness dyspnea nausea vomiting confusion blurred vision loss of consciousness
27
Symptoms of CO poisoning at the following carboxyhemoglobin percentages; 20% 20-40% 40-60% > 60%
20% - headache, dyspnea, visual changes, confusion 20-40% - drowsiness, faintness, nausea and vomiting, tachycardia, dulled sensation, decreased awareness of danger 40-60% - weakness, incoordination, loss of recent memory : 60% - coma, convulsions, death
28
Management of CO poisoning
Remove from contaminated environment 100% O2 Labs - ABG, CO level, troponin, CBC, Lytes, Urinalysis (myoglobin) Monitoring Keep HGB > 100
29
End point for O2 administration in CO poisoning
Carboxyhemoglobin < 5%
30
Metabolic acidosis with normal carboxyhemoglobin and methemoglobin suggests what?
coexistent cyanide pisoning
31
How does hydroxocooalamin work?
hydroxyl group of the vitamin (B12) binds to free cyanide forming nontoxic cyanocobalamin
32
Indications to consider hyperbaric O2 in CO poisoning
neurologic symptoms or signs Signs of cardiac ischemia or metabolic acidosis Pregnancy
33
Treatment of myoglobinemia or myoglobinuria in CO intoxication
vigorous hydration diuresis with furosemide or mannitol to preserve renal function
34
Who needs admission from CO poisoning?
appear well on presentation to eD but have significant history (eg. LOC at scene) or elevated cO levels
35
What are poor prognostic indicators for CO poisoning
low GCS high leuks high Troponin at presentation
36
Key differentiating factor between heat stroke vs heat exhaustion
presence of hyperpyrexia and anhidrosis with circulatory failure and/or severe CNS dysfunction
37
Why are children more susceptible to heat illnesses?
produce more metabolic heat core temperature rises faster during dehydration small organs less efficient at heat dissipation
38
Children with which conditions are more susceptible to heat stroke?
cystic fibrosis congenital absence of sweat glands receiving meds that cause oligohidrosis eating disorders diabetes insipidus obesity uncontrolled diabetes young athletes
39
Where in the brain controls sympathetic tone + heat conduction?
posterior hypothalamus
40
What are the 4 ways for the body to reduce excess heat?
convection conduction radiation evaporation
41
What precipitates heat cramps?
adequate water replacement without adequate salt replacement
42
What usually triggers heat cramps?
triggered by cold when relaxing after significant stress
43
Lab findings in heat cramps
low NaCl, urine Na Increased BUN (slight)
44
What are the 2 types of heat exhaustion?
Predominant water depletion Predominant salt depletion
45
History + physical findings of predominant water depletion heat exhaustion
temp < 39 progressive lethargy thirst inability to work/play headache vomiting CNS dysfunction low BP high HR
46
Lab findings in predominant water depletion heat exhaustion
high Na, Cl, HCT urine specific gravity high
47
History + physical findings of predominant salt depletion heat exhaustion
temp > 39 weakness, fatigue headache GI symptoms muscle cramps tachycardia orthostatic hypotension
48
lab findings of predominant salt depletion heat exhaustion
low Na HCT high very low urine Na
49
History + physical findings of heat stroke
temp 41+ hot, dry skin circulatory collapse severe CNS dysfunction rhabdomyolysis renal failure
50
lab findings of heat stroke
high or normal Na, Cl CK high low Ca
51
Treatment of heat cramps
rehydration with salt
52
Labs to do for heat stroke
CBC Lytes BUN, Cr CK Ca, PO4 Urinalysis ABG
53
What needs monitoring for management of heat stroke?
temperature HR ECG BP Perfusion U/O CNS function
54
Treatment of Heat stroke
Active cooling Fluids Inotropic support - Dobutamine 5–20 mcg/kg/min or Diuresis for myoglobinuria Maintain urine output >1 mL/kg/hr Consider furosemide 1 mg/kg Consider mannitol 0.25–1 g/kg
55
why is dobutamine the vasopressor of choice in heat stroke?
beta-agonist - increases contractility and maintains peripheral vasodilation
56
Definition of hypothermia
core temp < 35
57
Temps to classify hypothermia as mild, moderate, severe
mild: 32-35 moderate: 28-32 severe: 25-28
58
Why are younger children (esp newborns) at higher risk of hypothermia?
large surface:volume ratio small amount of subcutaneous fat can't shiver (neonates)
59
Risk factors for hypothermia
physical disability (esp if immobilized) drug or alcohol ingestion working/playing to exhaustion in cold environment
60
How does the body combat hypothermia
increase muscle tone increase metabolism shivering no sweating vasoconstriction of cutaneous and subcutaneous vessels
61
Cardiac conduction abnormalities in hypothermia
decreased sinus rate T-wave inversion prolongation of intervals J-waves (pathognomonic) afib (<33 degrees) vfib (<28 degrees)
61
Treatment for hypothermia at the following temperatures: > 32 < 32 (Acute) < 32 (chronic)
≥32°C (89.6°F): passive rewarming or simple external rewarming <32°C (89.6°F) (acute): external or core rewarming <32°C (89.6°F) (chronic): core rewarming
61
Reason for hyperglycemia with hypothermia
insulin release stops can cause frank pancreatic necrosis
61
before respiratory depression, what factors predispose a hypothermic patient to airway obstruction and aspiration?
impaired mental status cold-induced bronchorrhea
61
Hematologic abnormalities in hypothermia
plasma loss - increased hct splenic sequestration - fall WBC and PLT DIC
61
Labs for hypothermia
CBC INR/PTT Lytes BUN + Cr glucose amylase ABG (corrected for temp) Urine (drug screening)
61
Temperature at which BP falls in hypothermia
33
61
To what temperature should NS / RL be warmed for a hypothermic patient?
43 degrees
61
At what temperature does defibrillation become more likely to be effective?
30 degrees
61
How do you adjust the ventilatory rate for a hypothermic patient?
put to 1/2 normal (decreased metabolic rate = less CO2 = resp alkalosis if at normal minute-ventilation rate)
61
What are passive rewarming strategies?
removal of patient from cold environment use of blankets
62
What is the temperature "afterdrop"
external rewarming causes early warming of the skin and extremities - peripheral vasodilation - shunting of cold, acidemic blood to the core - dip in temp and BP
63
What are the 3 phases of frostbite treatment?
1. prethaw - take patient out of the cold environment and remove wet clothing. apply soft padding to the affected area. DO NOT RUB. 2. rewarm over 15-30 mins by immersing the affected area in 40-42 degree water. likely need IV analgesics 3. Post-thaw - wound management and application of loose, sterile dressings. Digits separated with cotton and extremities splinted
64
What are the factors that influence the severity of electrical injuries?
-resistance of skin, mucosa and internal structures - type of current (AC or DC) - frequency of the current - intensity - duration of contact - pathway taken by the current
65
In comparing lightning vs high-voltage electrical injury: - type of current - shock wave - cardiac arrhythmia - burns - renal failure - fasciotomy/amputation
lightning - direct -present -asystole -superficial/minor -rare -rare high-voltage - AC -absent -vfib -deep (frequently obscured) -common (2 to myoglobinuria) - common
66
Why is alternating current more dangerous than DC?
able to induce tetanic muscle contraction - creates a "locking on" phenomenon
67
nervous system injuries resulting from electrical injury
LOC seizure amnesia disorientation deafness visual disturance sensory deficit hemiplegia/quadriplegia Subdural/epidural/intraventricular hemorrhage SIADH (leading to cerebral edema)
68
Ocular damage secondary to lightning strikes
corneal lesion hyphema uveitis iridocyclitis vitreous hemorrhage choroidal rupture retinal detachment chorioretinitis
69
GI consequences of electrical injury
gastric dilation ileus diffuse GI hemorrhage visceral perforation
70
When is risk of bleeding highest in electrical burns around the mouth?
2-3 weeks post-injury with eschar separation
71
Bacteria that infect electrical injury wounds - extremities - mouth
extremities - staph, pseudomonas, clostridium mouth - strep, oral anaerobes
72
Management of electrical injury
Remove from source of current Cardiopulmonary resuscitation as needed Provide mechanical ventilation until spontaneous ventilation is adequate Immobilize neck and spine assess + Get labs Maintenance fluids: 5% dextrose in normal saline Volume expansion in presence of thermal burns or extensive deep tissue injury: 0.9% sodium chloride or lactated Ringer’s solution Fluid restriction for central nervous system injury Maintain urine output >1 mL/kg/hr Treat arrhythmias Treat seizures Tetanus toxoid; consider penicillin/other antibiotics Consider general, oral, or plastic surgical consultation
73
Labs for electrical injury
CBC BUN, Cr, urinalysis Lytes Troponin ECG
74
When is the greatest risk related to whole-body radiation exposure?
3-4 weeks after exposure when bone marrow depression reaches nadir
75
3 steps that can be taken to minimize adverse effects of a nuclear reactor accident to the public
public should be sheltered or evacuated administer potassium iodide (to prevent uptake of radioactive iodine) monitor the food supply to prevent further ingestion
76
Steps to external decontamination
Try to do this outside the hospital. if not possible, wrap patient in a cotton sheet to transport them inside the hospital Remove clothes Wash with a damp cloth Pay special attention to skin folds and fingernails Cover clean wounds to prevent contamination Prevent external and tepid water contamination from becoming internal Do not abrade the skin
77
How can you tell cyanide poisoning from nerve-agent poisoning?
nerve agent more likely to have - miosis, cyanosis, copious oral and nasal secretions, bronchorrhea, bronchospasm [cholinergic toxidrome]
78
3 zones to have to manage chemically contaminated victims
hot zone = on scene warm zone = receiving area for chemical casualties cold zone = in the ED, separated by a "hot line" after which no liquid contamination is permitted to pass and anyone that comes in is already thoroughly decontaminated
79
Which chemical agents cause a primarily neurologic syndrome?
nerve agents, cyanide
80
Which chemical agents cause a primarily respiratory syndrome?
Phosgene, Chlorine
81
Which chemical agents cause a primarily mucocutaneous syndrome?
Lewisite, mustard
82
What should a decontamination centre look like?
Outdoor facility is best but must ensure adequate water, temperature control, curtains separating males/females showers OR another enclosed facility adjacent to the ED with a separate and high-volume ventilation system vented directly outdoors surface of decontamination facility should allow drainage to prevent slipping
83
Antidotes for nerve-agent toxicity
atropine pralidoxime
84
Mustard gas - clinical findings
erythema, vesicles of skin eye inflammation epithelial denudation with airway obstruction bone marrow suppression
85
Lewisite/arsenic toxicity - clinical findings
eye inflammation ARDS with hypotension
86
Phosgene toxicity - clinical findings
bronchospasm, pulmonary edema
87
Cyanide toxicity - clinical findings
hyperpnea, collapse, seizures, muscle rigidity, apnea, coma
88

PEM Lectures dirigées (28 decks)

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