Environmental Injuries - Exam 2 Flashcards
Who are the at risk individuals for a heat illness?
Young/elderly
Obese
Chronic physical/mental illness
Impaired by drugs/ETOH
Anyone denied access to hydration/nutrition
What is heat edema? Why does it happen?
Mild swelling of dependent extremities due to heat exposure
Results from muscular and cutaneous vasodilation combined with venous stasis
What is the treatment for heat edema?
self-limiting with elevation, rest, cooling, oral rehydration
Why does heat syncope happen?
results from vasodilation leading to intravascular volume redistribution
What is the clinical presentation of heat syncope? **What is the core temperature?
Core temp is normal, skin is cool and diaphoretic, weak pulse, transient hypotension
**Core temp is normal
What is the management of heat syncope? What is the disposition?
Rule out other causes of syncope: hypoglycemia, arrhythmias, and fixed myocardial or cerebrovascular lesions
Lie patient supine with legs elevated, remove from heat, (+/-) external cooling, IV/oral rehydration
Disposition home after appropriate tx and patient education
What are heat cramps? What is the underlying cause?
painful spasms of voluntary muscles of the abdomen and extremities resulting from salt depletion
due to salt depletion!
What will the core temperature be in heat cramps? What tests should you order? What will there electrolyte panel be?
core temp normal or slightly elevated
intense work-up is rarely indicated! but should order CMP for electrolytes
low-normal Na, (+/-) low K+ and Mg
What is the management for heat cramps?
Remove from heat and begin external cooling
Oral electrolyte solution (pedialyte or Gatorade) or IV NS
Replace K+ and Mg if needed
What is the disposition for heat cramps? How long should the patient rest?
Discharge home
Rest for 1-3 day - avoid physical exertion and heat exposure
What is heat exhaustion characterized by? If left untreated, what will it evolve into?
Characterized by the inability to maintain adequate cardiac output due to strenuous physical exercise and environmental heat stress
Rapidly evolves to heat stroke if no intervention
What are the two types of heat exhaustion? Which one is seem more often?
Hypernatremic (primary water loss): results from lack of water access
Hyponatremic (primary sodium loss): fluid loss replaced with water only
a combination of the 2!
Temperature often mildly elevated
Diaphoresis, HA, N/V, malaise, weakness,
Muscle cramps, dizziness, (+/-) dark urine
Tachycardia, hypotension
normal CNS exam
What am I?
**What is the highlighted factor?
heat exhaustion
Temperature often mildly elevated - usually will not exceed 40°C (104°F)
How can you differentiate heat exhaustion from heat stroke?
No evidence of CNS dysfunction
aka no AMS, syncope or seizures
What tests should you order for heat exhaustion?
BMP: electrolytes and renal function
UA: myoglobinuria
CK
LFT
ABG
EKG
______ needs to be assessed during heat exhaustion
UA- > looking for myoglobinuria
thinking rhabdo
What is the management for heat exhaustion?
Remove from heat, (+/-) external cooling
Oral electrolyte solution if able to tolerate PO intake
Alt: IV NS or LR²; hypertonic saline used if marked hyponatremia due to water intoxicatio
What are the criteria to admit someone from heat exhaustion?
moderate-to-severe symptoms
comorbid illnesses
patients at extremes of age
lab abnormalities: Elevated CPK, creatinine, LFTs, cardiac abnormalities, hyponatremia, persistent acidosis
social concerns
Define heat stroke. **What is the super underlined finding?
Characterized by a dysfunction of the heat regulating mechanism with hyperthermia and end-organ damage
will have core body temp > 104 AND end-organ damage
**What 4 tissues are the most sensitive to heat stress?
Neural tissue
hepatocytes
nephrons
vascular endothelium
What are the 2 types of heat stroke? How do they differ?
exertional (rapid onset)
non-exertional (slow onset)
HA, dizziness, nausea, diarrhea, visual disturbances
Skin is hot, flushed, usually dry
CV: rapid, bounding pulse, hypotension indicates CV collapse
confusion, seizure, delirium, ataxia, coma
may have DIC
What am I?
What are the signs of DIC?
heat stroke
hematuria, hematemesis, bruising, petechiae, and oozing at sites of venipuncture
aka these pts are usually found sitting under a tree, +/- sweating with increased HR and confusion
How often should you check a CMP in a heat stroke pt? What additional lab needs to be ordered in heat stroke?
need to reassess every hour
Phosphate (hypophosphatemia)
Why does hypophosphatemia occur with heat stroke?
Hypophosphatemia occurs due to renal dysfunction leading to a lack of PO4 reabsorption
What is the management for heat stroke? What do you tx the severe shivering with?
rapid cooling
supplemental O2 if needed
continuing to monitor temp via rectal temps
IV fluids
Significant AMS - ventilate/intubate or GCS score less than 8
if unresponsive to above tx: -> internal lavage
Tx severe shivering with IV BZD
What is the preferred method for rapid cooling in a heat stroke?
ice water submersion!!
cooling blanket with ice pack over great vessels: axilla, neck and inguinal areas (avoid direct skin contact)
What way should you monitor core temperature in a heat stroke pt? When can you d/c checking?
RECTAL temps!!
Discontinue once core temp reaches 101.5 - 102℉
If the pt is unresponsive to rapid cooling measures in heat stroke, what should you do next?
internal lavage - peritoneal, gastric, bladder, and/or rectal
What should the pt’s urine output be in a heat stroke?
UO should be 50–100 mL/h
What is the disposition for a heat stroke? Give both ICU and general floor indications?
Admit to ICU if hemodynamic instability, severe LFT elevation or rhabdomyolysis
All others admit to general floor (med/surg)
Paresthesias, pruritus of tissue involved; loss of sensation and fine motor control
MILD frostbite
decreased ROM, blister formation, edema, tissue appears white, firm/hard, cool to touch
Mod/severe frostbite
What are the clinical findings associated with tissue once it has been rewarmed post-frostbite
Stinging, burning, aching, throbbing, tenderness
Tissue discoloration, loss of elasticity and mobility
Profound edema, hemorrhagic blisters, necrosis, gangrene
When should you assess the extent of damage of frostbite?
AFTER the pt has been rewarmed
What are the 4 degrees of frostbite? include the layers of skin involved
1st degree: erythema and edema without blister, skin peeling -> epidermis
2nd degree: serous filled blister -> epidermis and dermis
3rd degree: skin necrosis: hemorrhagic blister with subcutaneous involvement -> epidermis, dermis, hypodermis
4th degree: full-thickness (includes bone), non-blanching cyanosis; dry, black mummified eschar formation; loss or deformity of body part -> epidermis, dermis, hypodermis and muscles, tendons and bones
What degree will have the MOST pain with rewarming?
third degree will be the MOST painful and 4th degree will not feel anything!
first and second degree also are painful during rewarming
What is the tx for frostbite? What if the pt is also hypovolemic?
Rapid rewarming in CIRCULATING water at 98.6–102.2°F for 15-60 minutes until red/purple color appears on skin then allow to air dry
rewarming can be painful so NSAIDs or opiates may be needed
wound care -> needs to be sterile, topical aloe vera q6hours, splint if needed to prevent contracture and elevate extremity
update tetanus
WARM oral/IV fluids if evidence of hypovolemia
What is the wound care treatment for tissue that has died due to frostbite?
Clean/debride superficial dead tissue in a whirlpool BID x 3 wks
What is the disposition for frostbite?
Home: limited area with only 1st degree injury
Hospital: extensive area of 1st degree and all 2nd, 3rd, 4th degree
What is hypothermia defined as? What methods of acquiring temperature are valid?
Defined as a core body temp < 35°C (< 95°F)
By rectal, bladder or esophageal thermometer
What are secondary causes of hypothermia?
Burns
hypoglycemia
hypothyroidism
hypoadrenalism
hypopituitarism
CNS dysfunction
sepsis
drug intoxication
trauma
Impaired shivering
What persons are at risk of hypothermia?
advanced or very young age
malnutrition
physical exhaustion
neuromuscular disease
What are the 4 stages of hypothermia? Draw the chart
______ is the key to diagnosing hypothermia. ______ progress with decrease in temperature
low core body temp
Cardiac arrhythmias get worse the lower the body temp
What will the K leave do in both mild and severe hypothermia? ______ will be elevated with cell death
hypokalemia with mild HT, hyperkalemia with severe HT results from cell death/ARF
lactic acid will be elevated with cell death
What is the treatment for mild hypothermia?
Place in warm environment - room temp at or above 28°C (82°F)
Encourage active movement
Warm oral sugary drinks
If significant trauma, comorbidities or suspected secondary hypothermia treat as Moderate( HT II)
What is the treatment for moderate hypothermia?
Rewarming: warm environment with chemical, electrical, or forced air heating packs or blankets
Start warm IV fluids
Full-body insulation, horizontal position, and immobilization
What is the treatment for severe hypothermia?
Airway management likely needed
Sinus bradycardia, a. fib and a. flutter will resolve with rewarming
V fib will not respond to therapy until pt is rewarmed
Rewarming: external heating device (as in HTII), warm IV fluids
**Preferred treatment is rewarming via ECMO, if available, due to the high risk of cardiac arrest
consider coma cocktail
What does the AHA recommend with regards to defibrillation and severe hypothermia?
AHA recommends one defibrillation attempt prior to rewarming
What is in the “coma cocktail?”
dextrose 50 ml IV, thiamine 100 mg IV/IM, naloxone 2 g IV
What is the disposition for hypothermia? What is the textbook answer?
in the real world, everyone gets admitted!!
criteria for disposition:
No comorbidities
No AMS
Presenting core temp >34°C (93.2°F)
What am I? What size is the lesion usually?
bee sting
occasionally lesion will be > 5 cm, most of the time LESS
What am I? When do the pustules resolve?
fire ant sting
sterile pustule, evolves of 6-24 h
When will stings usually have a systemic/toxic reaction? Where does it usually itch? When do symptoms usually subside within?
more common with > 50 stings
N/V/D with urticarial lesions distant from site of sting
within 48 hours
If the pt is going to have an anaphylactic reaction, when is it going to occur? When are labs indicated?
Occurs within 6 h (most within 15 min)
Indicated only for systemic and anaphylactic reactions
What is the treatment for anaphylactic shock due to sting?
Intubation if needed
Epinephrine 1:1000
IV methylprednisolone, diphenhydramine, famotidine
nebulized albuterold for bronchospams
What is the tx for localized reaction to a sting? Systemic but non-anaphylaxis reaction?
Oral diphenhydramine
Oral pain control: NSAID, acetaminophen (Tylenol)
_______
IV methylprednisolone, diphenhydramine, famotidine
What is the wound management tx in a sting? When should you treat the wound?
Remove stinger with scraping technique, ice and elevation. update tetanus
do NOT delay treatment of systemic reactions to care for the wound
When should you admit for a sting?
admit children
elderly
comorbidities
50 or more stings
prolonged reaction
What is the disposition for a healthy pt who has a sting? What is the highlighted one?
observe for 6 hours, if no rebound symptoms, repeat labs before discharge
Rx EpiPen
f/u with allergist
______ is the only systemically toxic scorpion in the US. Where is it found?
Bark Scorpion
southwestern US
What is the presentation for a scorpion sting? What is the PE sign?
Sting is painful without initial erythema/swelling
Exquisite pain with light percussion “tap sign”
muscle spasms, cranial nerve dysfunction, roving eye movement, diplopia, difficulty swallowing, hypersalivation
tachycardia, HTN, pulmonary edema, and cardiogenic shock
What am I?
What is the symptomatic tx?
scorpion sting
Oral or IV pain medication
Benzodiazepine for motor control
What is the tx for a severe scorpion sting?
Cardiac monitoring and IV access and fluids
Antivenom (Anascorp)
What are the SE of Antivenom (Anascorp)?
vomiting, pyrexia, rash, nausea, and pruritus
How can you identify a pit viper based on appearance? What are the 3? Their venom is _______
Large triangle shaped head with a heat sensitive depression “pit” between their eyes
Rattlesnakes, copperheads, water moccasin
venom is cytotoxic
What is the hallmark presentation of a pit viper bite? What is the timing?
fang marks with pain, edema, hemorrhage and necrosis around the bite and extending out from the bite if severe envenomation
usually within 30 minutes but may be delayed up to 12 hours
If no s/s after 12 hours of pit viper bite, what can you assume?
If no S/S after 12 h = dry bite
What are the systemic s/s of a pit viper bite?
Nausea, vomiting
Hemolysis, thrombocytopenia, coagulopathy
Respiratory failure with CV instability and collapse
What is the management of a pit viper bite?
call poison control!!!!! 1-800-222-1222
cardiac monitoring and IV access
labs
Immobilize biten extremity (similar to fracture tx)
Serial (30 min) wound evaluations and measure affected limb above and below bite and mark border of edema
assess for compartment syndrome
+/- antivenom (CroFab)
update tetanus if needed
What does EBM say about applying constriction bands after a snake bite?
Remove any constriction band applied proximal to bite
EBM doesn’t support this as being effective
When should you give antivenom in a pit viper bite?
Compare severity of envenomation to SE of antivenom
do NOT need to give it every time, only if there is EXTENSIVE swelling
What are the MC SE of antivenom?
urticaria, rash, nausea, pruritus and back pain
hypersensitivity reaction
recurrent coagulopathy
What is the disposition for pit viper bites?
Observe in ER for 8-12 hours - d/c home if no local progression and all labs are WNL
Admit (ICU) for severe reaction and those receiving antivenom
High altitude sickness is commonly seen at elevations at or higher than ______. Why?
at or >1500 m (4800 ft)
decreased partial pressures of oxygen (Po2) at higher elevations leads to hypoxia
What are the bodies 4 physiological responses to hypoxia caused by high altitude?
- increased RR
- renal excretion of HCO3¹
- vascular changes²
- increasing the blood’s oxygen carrying capacity
HA plus anorexia, N/V, weakness, fatigue, dizziness, light-headed, fluid-retention, insomnia, oliguria, dyspnea, altered mental status
What am I?
What are the 2 complications if left untreated?
acute mountain sickness
High Altitude Pulmonary Edema (HAPE)
High Altitude Cerebral Edema (HACE)
When do symptoms of acute mountain sickness start? What do the s/s closely resemble?
Symptoms occur within 48 hours of rapid ascent
Symptoms resembling a “hangover”
What is the management for acute mountain sickness?
descend to lower elevation
tx symptoms:
low-flow oxygen
acetaminophen (Tylenol) or NSAID for HA
ondansetron (Zofran) for N/V
in acute mountain sickness, a decent of ______ can provide prompt relief. In a mild presentation, when can you start to see improvement of symptoms after ascent?
300-1000 m
improvement in 12-36 hours after cessation of ascent
What is the treatment for moderate presentation of acute mountain sickness?
hyperbaric oxygen therapy if available
acetazolamide plus dexamethasone until symptoms resolve
_______ can be used in prevention of Acute Mountain Sickness
acetazolamide
What is the disposition for acute mountain sickness? What is the pt education?
Discharge home if good response to intervention
Pt education:
avoid rapid ascents, overexertion, alcohol and respiratory depressants
use acetazolamide as prophylaxis
start 1 day prior to ascent and continue for 2 days after reaching highest altitude
What is the underlying cause of High Altitude Pulmonary Edema (HAPE)?
Hypoxic vasoconstriction and elevated right heart pressures results in noncardiogenic pulmonary edema caused from untreated acute mountain sickness
______ is the MC cause of death in high altitude sickness and can be fatal within ____ of onset. What altitude is it associated with?
High Altitude Pulmonary Edema (HAPE)
hours
can occur in as little as a 2400 m (8000 ft) ascension
**When does High Altitude Pulmonary Edema (HAPE) typically start? **What is the first symptom noticed?
day 2-4 after ascent
Decreased exercise capacity is the first symptom noticed
dyspnea at rest, cough, rales, tachypnea, weakness, decreased performance, chest tightness, tachycardia, signs of pulmonary HTN
_____ must be present in order to diagnose ______
2 to diagnose High Altitude Pulmonary Edema (HAPE)
**What is the treatment of choice for High Altitude Pulmonary Edema (HAPE)?
Immediate descent is the treatment of choice
and AVOID excessive exertion during descent
What is the management of HAPE?
Supplemental O2 to keep O2 saturation > 90 %
Immediate descent
Hyperbaric treatment if descent isn’t possible
How long should you continue the O2 in severe HAPE cases? What is the treatment for HAPE in the field?
continue O2 for 72 hours after decent in severe cases
Pharmacologic pulmonary vasodilation: Sildenafil, tadalafil, nifedipine
When can you discharge a HAPE pt?
O2 on room air is maintained > 90%
symptoms resolve
CXR has improved
must have all 3 to go home
_____ is the end-stage manifestation of AMS or HAPE. What is the clinical presentation?
High Altitude Cerebral Edema (HACE)
history consistent with AMS
altered mental status, ataxia, stupor, coma
signs of ICP: retinal hemorrhage, papilledema
Should order _____ in HACE. What will it show?
MRI
reveals cerebral edema
What is the tx for HACE?
Why are near drowning events bad? What 2 things does even minimal water aspiration lead to?
water washes out surfactant resulting in diminished gas exchange, ventilation perfusion mismatch and hypoxia
pum injury and ARDS
When can ARDS occur after a near drowning event?
ARDS can occur up to 6-24 hours after aspiration
What is the GCS cutoff that would change the treatment plan in a near drowning? O2 saturation?
GCS of 13
O2 of 95
Look at this algorithm again. What is the treatment for a pt who has a GCS score over 13+ and O2 95+?
purple boxes
Look at this algorithm again. What is the treatment for a pt who has a GCS score lower than 13 and O2 lower than 95?
green boxes
Most fire-related deaths are due to ______. What are the 3 mechanisms of injury for inhalation injury?
smoke inhalation
Thermal injury
Inhalation of particulate matter
Inhalation of toxic gases
_____ is inhalation of heat and affects the ______ which leads to ______
thermal injury
upper airway
acute airway compromise
_______ results in bronchospasm and edema
inhalation of particulate matter
_______ should be suspected in all fire inhalation injuries. ______ in burned wood, silk, polyurethane and vinyl
carbon monoxide
hydrogen cyanide
What is the management of an inhalation injury?
Humidified O2 (100%) via facemask
Prompt ET intubation
Bronchodilators
Pulmonary toilet
suctioning of the airways, chest physiotherapy, nasotracheal suction, bronchoscopy, incentive spirometry and use of analgesics (pain medications) that do not inhibit breathing, coughing, percussion, prone positioning to promoting drainage of secretions
These are all examples of ______
pulmonary toilet
Why is carbon monoxide poisoning so bad for the pt? How much affinity?
Displaces O2 from hemoglobin = tissue hypoxia
CO has an affinity for hgb that is 260 times greater than O2
Flu-like symptoms, HA, dizziness, N/V, DOE, irritability, fatigue, vision changes, tachycardia, confusion, lethargy, syncope, convulsions, coma
Exposure to gas heat or smoke inhalation
Multiple pts with same presentation from same residence
What am I?
What is the most reliable test?
**What is the most reliable lab? Should also get ______
carbon monoxide poisoning
CO-oximetry - most reliable
**carboxyhemoglobin level - elevate
should also get ABG
What is the management for carbon monoxide poisoning? Should you wait on testing? What if the poisoning is severe?
HIGH flow O2 via non-rebreather or ET intubation
Do NOT wait for confirmation testing!
Hyperbaric O2 therapy for severe poisoning
What is the disposition for carbon monoxide poisoning? Give asymptomatic, moderate and severe symptoms
What are the 3 MC causes of thermal burns? What are the 3 ways to classify the % of body surface area affected?
scalding
direct thermal
flame burns
rule of 9s
Lund and Browder
Palmar Method
What is the rule of 9s? Draw the human picture. When is it used?
quick and easy and used for 2nd and 3rd degree burns
Note the head is a total of 9
(4.5 on front and 4.5 on back)
When is the Lund and Browder method used to estimate burns? Draw the human
more accurate for infants and children
provides estimates of BSA based upon age
What is the Palmar Method for estimating burns? When is it used?
back of patients hand is 1% of BSA
used for small burns
Describe the differences between first and fourth degree burns. Include examples and how it will present
What degree?
superficial
What degree?
superficial partial
What degree?
deep partial
What degree?
Full-thickness
What is the treatment for a thermal burn?
AND
IV LR in the unburned area using Parkland Formula to determine fluid amount
labs
imaging: CXR and EKG
wound care of burns
**What is the Parkland formula? **What is the equation?
used to determine the amount of fluids needed to give a burn pt
using LACTATED RINGERS
What are the complications from a thermal burn?
inhalation injury, carbon monoxide poisoning, bacterial super-infection, sepsis, and multiorgan failure
What is the managment for a MINOR burn?
Cleaned with mild soap and water
Large bullae (>2 cm) or those over mobile joints
-> Drain or debride
Apply topical 1% silver sulfadiazine (Silvadene)
discharge home with PCP f/u
What is the treatment for a moderate/severe burn?
Cover with dry sterile sheet
Admit
moderate burns - hospital
severe burns - burn center
Update tetanus as indicated
What is super important to identify early in the treatment of chemical burns?
what the chemical was!! was it acidic or alkali?
_______ burns results in a coagulation necrosis leading to eschar formation limiting extent of damage. Usually, partial-thickness with erythema & erosion
Acid burns
_______ burns results in a liquefaction necrosis resulting in deeper damage. Usually full-thickness, appear pale, and feel leathery & slippery
Alkali burns
What is the management of chemical burns?
What are the 2 classifications of an electrical injury?
High voltage (>1000 V): power lines
Low voltage (<1000 V): house things (think children)
What are the 3 types of mechanisms of injury for an electrical injury?
Direct tissue damage (electrical energy)
Thermal damage (heat created)
Mechanical injury (fall or tetanic muscle contraction)
When someone has a direct tissue damage electrical injury, what should you think?
Cardiac dysrhythmias and arrest, seizure, LOC
When someone has a thermal damage from an electrical injury, what should you think?
Severe burns! Size of skin injury does NOT correlate with internal injury
concern for rhabdo
What is the management for electrical injury?
What is the disposition for an electrical injury? **What is important to note?
Discharge if: low voltage injury, asymptomatic, must have normal PE and EKG
Admit all others
What improves survival rates in lightning strike injuries?
lightning most often flashes over skin - improves survival
fatal if lightning travels through the body
_____ is the MC immediate cause of death in lightning injury? _______ is a pathognomonic but transient finding
cardiac arrest
Feathering or fern-shaped burns:
What are the organ systems most at risk with a lightning injury?
brain: LOC, confusion and amneisa
rupture of TM
renal: deep tissue injury, myoglobinuria and renal failure with “through body” injury
cardio: dysrhythmias
What is the tx for a lightning injury?
tx the same as an electrical injury
_______ complications associated with changes in environmental ambient pressure and with breathing compressed gases. What are 2 examples?
dysbarism
barotrauma
decompression sickness
Underwater diving, aircraft cabin decompression, explosions or blasts
Why does barotrauma occur?
occurs when gas-filled cavities of the body contract or expand with pressure changes
What are the 3 options for barotrauma of descent?
Middle ear barotrauma
Inner ear barotrauma
Sinus ostia occlusion
What does middle ear barotrauma lead to? What is the tx?
“barotitis media” - pressure in the middle ear leads to rupture or bleeding of TM
Middle ear - decongestants and analgesics; refer to ENT if TM rupture occurs
What does inner ear barotrauma lead to? What is the tx?
valsalva during equalization can rupture the round or oval window leading to tinnitus, sensorineural hearing loss, vertigo
Inner ear - bed rest with head upright, ENT consult
What does sinus ostia occlusion lead to?
during descent can lead to bleeding from the sinus cavity
What happens during decompression sickness? What 2 populations are at risk?
Results from a release of nitrogen gas bubbles from the plasma into tissues during ascent
Occurs in divers who exceed the dive limits for time & depth and in unpressurized flights
What are the 2 types of decompression sickness?
Type 1: minor symptom complex
Type 2: cardiorespiratory or neurologic symptoms
Describe the s/s of decompression sickness type 1? Where are the 2 MC places?
Deep, aching pain in large joints and extremities
MC elbows and shoulders
Describe the s/s of type 2 decompression sickness. _____ are common in scuba divers. ______ can be seen in high altitude flights
cardiorespiratory or neurologic symptoms
Fatigue, ataxia, spinal paralysis, vertigo, visual or speech disturbance, cognitive deficits
Spinal cord embolism - scuba divers
High-altitude flight - cerebral gas embolism (think air force pilots)
What is the tx for decompression sickness?
Oxygen, 100% by mask for at least 2 hours
Crystalloid IV fluids to maintain hydration
Recompression therapy using a hyperbaric oxygen chamber
