Environmental / IPV Flashcards
IPV Risk Features
Delay in seeking care
Incongruent Hx
Unwilling to disclose
Hx that changes over time
Posterior rib fracture
Restraint injuries
Repeat visit
Chronic pain syndromes
Mental health concerns
Substance Use Disorder
Commonly used drugs in DFSA
Alcohol (#1)
Rohypnol
Benzos
GHB
Sexual Assault History
Helps to guide the medical and forensic exam:
- Agenda setting; tell as much as comfortable. Can take a break at any time. Only asking to help.
- Use quotation marks
- Don’t include superfluous information
- What acts were completed
- Restraints etc
- Assessing HIV transmission
IPV Escape Plan
Safe place / Shelter, friends, family etc.
Have to be willing to cut all ties (“Witness protection”)
- Bank accounts, phone, social media (d/c or change), password changes
Police statement (may make it, does not mean charges - makes a history available)
Tell Others (family, friends etc)
Safety planning for those who plan to stay
advise:
- come back any time
- as in escape plan
- vital docs (passport, birth cert, etc.)
Human Trafficking
ED is usually only place for care.
Needs to be kept safe. Must be inside walls of ED, not waiting room etc.
Police have HT departments.
Sexual assault physical exam ./ documentation
Describe all of the PE acts prior to the exam
- Treat as a normal trauma exam.
- Head to toe unnecessary
- Base physical exam on history
Document: Patient states, etc. “ “ if it matters
- If you don’t document it, it didn’t happen
- EPIC .sampselsex
HIV PEP in Sex Assault
Source + Type of exposure
- Known HIV
- High risk HIV
- Multiple assailants
+
- Non-consdenual
- Unknown if barrier
- Vaginal Penetration
- Unknown exposure
Unkown HIV + anal or unknown if barrier used - the 3 day HIV PEP.
Truvada and Tivacay po od x 28 days
Must start by 72 hours post exposure
Hypothermia Stages (temps and symptoms and treatment)
HT1: 32-35. Conscious and shivering
Tx: Warm environment, warm sweet drinks, active movement if possible
HT2: 28-32. Impaired consciousness, no shivering - Increased risk AFib
Tx: Cardiac monitoring, minimal and cautious movements to avoid arrhythmias, horizontal and immobilized, full body insulation, active external warming, warm parenteral fluids
HT3: 24-28: Unconscious vital signs present - Increased risk of VFib with moving patient
Tx: HT2 + airway management, ECMO or CPB with cardiac instability
HT4: < 24: Vital signs absent
Tx: HT 2/3 + CPR and UP TO 3 doses Epi and defibrillation, ECMO or CPB or CPR with external warming.
OR
AVPU
Stage I - A
Stage II - V
Stage III - P/U
Stage IV - U and VSA
Heat Related Illness Characteristics
Heat Rash -> Heat Cramps -> Heat Edema -> Heat Tetany -> Heat Syncope
Heat Exhaustion:
- NORMAL MENTAL STATUS
- Dizzy, H/A, perspiration, N/V, temp 38-40 C
- Possibly abnormal electrolytes
- LFTs Norm
Heat Stroke:
- Classic vs Exertional
- Classic - Elderly, during heat waves
- Exertional - Young with exercise/partying in hot environment
- Symptoms: ALTERED MENTAL STATUS (Neurologic dysfunction with cerebral edema), possible seizure, anhidrosis, temp > 40.5, jaundice (late), lab abnormalities
Often liver injury as well.
Abnormal hemostasis / bleeding prone
Heat stroke treatment
Rapid cooling:
- Immersion in cold water preferred
- Can use cold water blankets, cool IV fluids, evaporative cooling with mister and fan, ice packs in groin/pits
- MOVI
- ECG
- Can use benzos or paralysis to prevent shivering
Poor Prognostic Features:
- Coma, ALT > 1000, delay in cooling, DIC, hypotension, renal failure in < 48 hours, lactate
Complications:
- ARDS, electrolytes abnormal, renal failure, DIC, hepatic injury, rhabdomyolysis
Cold Related Injury Spectrum and Characteristics
Chilblains: Painful/inflamed skin lesions, may evolve to plaques or ulceration ,lesions at 12-24 hours post
Trench Foot (Immersion foot): Cold wet feet (0-10degrees) over hours to days.
- Feet appear cold, mottled and pale. After warming - red, painful and swollen
Frostnip: Superficial freezing without tissue loss or destruction. Transient numbness that resolves. Superficial blistering may occur.
Frostbite: Ice crystal formation in skin leads to tissue destruction, microvasular compromise, thrombosis, ischemia
- Degrees:
1st - central white plaque with surrounding hyperemia
2nd - clear blisters
3rd - Hemorrhagic blisters, eschar and tissue loss
4th - Full thickness affecting skin, muscle and bone
OR: Superficial (no tissue loss) vs Deep (tissue loss and underlying tissues are hard)
Frostbite treatment
Rapid rewarming in immersion at 37-39 C. (20 mins +/- 5 min breaks). REMOVE RINGS
- Will require opioids for pain, ASA or NSAIDS
Tetanus prophylaxis
Aspirate clear blisters, LEAVE hemorrhagic
For Grade 3-4 / deep:
< 24 hrs, MR angiography, thrombolysis per protocol or iloprost infusion.
Technetium bone scan @ 48 hrs.
Iloprost SE: Headache, hypotension, flushing, palpitations
Other grading systems by level of penetration:
1 - peripheral DIP
2 - PIP
3 - MCP
4- Carpals
Severe: Perfusion assess, TPA within 48 hrs, Enox, rescan at 48 hours, consider Iloprost if chance for improvement.
Hypothermic Arrest Management
CPR
Consider ECMO, CBS, or dialysis
Defib defer until warmed
Only 1 shock in Vfib until T > 32
Core afterdrop can occur when circulation retrns - cold peripheries return to core.
Electrical Injuries Current Thresholds
AC
1-4 mA: tingling sensation
6-9 mA: “let go” threshold” - results in tetanic contraction
>70 mA: cardiac depolarization, VF
DC:
- High voltage results in extensive tissue damage (non-visible)
Electrical Work Up
ECG, Labs (CBC, electrolytes, Cr, CK, UA), LFT lipase.
- On Monitors - need normal ECG ( no PVCs no PACs)
Full exposure and assess - look for EXIT wounds
Electrical Injury Tx
IV fluids - goal UO 1-2 cc/kg/hr
Treat rhabdo
FULL TRAUMA assess
Tetanus
Wound/burn care
Asymptomatic, low voltage injuries can often be sent home
Corneal burns / cataracts / retinal injury
Lightning Injury mechanism of death / other findings
Primary asystole -> 2nd respiratory arrest from paralysis
Other findings:
- Seizure, confusion amnesia
- Anisocoria
- Pulmonary contusion, rupture TM (blast injury)
- Burns
- Keraunoparalysis: blue mottled, pulseless extremeties. Self resolving
High-Altitude Illness Spectrum Pathophysiology
Acute mountain sickness (hours)
High Altitude Pulmonary Edema (days of exposure)
High-Altitude Cerebral Edema
Age > 50 decreases risk
Low inspired O2 hypoxia - pulmonary artery HTN, fluid retention, cerebral hypoxia
Acute Mountain Sickness Describe and Tx
Occurs at > 8000 ft
- Similar to a viral syndrome / hangover
Usually self limited
NO FURTHER ASCENT UNTIL SYMPTOMS RESOLVE - descend if not improving
Tx: Acetazolamide, supp O2, Dex, Tylenol or Aspirin
AVOID: Narcs, EtOH, Benzos (resp suppress)
HAPE (def’n and tx)
2-4 days post exposure
Pulmonary vasoconstriction -> pulmonary HTN -> damage and leak
- Patent PFO exacerbates hypoxia
Symptoms: AMS, cough, dyspnea at rest, tachypnea, tachycardia, rales
Tx:
- Descent
- Supp O2
- Minimize exertion
- Nifedipine
- Bronchodilators, PDE5 inhibitors
HACE (def’n and tx)
Most severe - Altitude > 12,000 ft
AMS, HAPE, cerebral ataxia (++ sensitive sign), stupor, seizure, cranial nerve palsies
Dx: AMS + ataxia!!!
Tx: Descent, O2, acetazolamide, dex for mod-severe, hyperbaric O2, furosemide or mannitol can be used with caution)
Dysbarism - Descent (diving injury description)
Descent: Nitrogen narcosis, O2 toxicity, vertigo
Ascent: Barotrauma, decompression sickness, arterial air embolism
Descent: Increased air pressure in air-filled spaces.
- TM rupture, seventh nerve palsy, sinus obstruction/pain. hemoptysis/pulmonary edema (if holding breathe on descent)
- Nitrogen Narcosis: > 100 ft depth, breathing N2 and O2 at depth. Mechanism: Increased partial pressure of N2 at depth and increased dissolved in blood. Tx: SLOW ascent
- Oxygen Toxicity: Tunnel vision, tinnitus, N/V dizziness, confusion, twitch/seize. Tx: slow ascent, < 21% O2 heliox
Dysbarism - Ascent
Alternobaric Vertigo: Ear pain and TM rupture possible. Severe vertigo. N/V.
Pulmonary Barotrauma: Air dissects into pulmonary tissue, sub Q emphysema, PTX and Pneumomediastinum (POPS)
Tx: O2 as needed. rest. Chest tube for large PTX
Arterial Gas Embolism: Expanding gas ruptures the alveoli, air enters blood stream
- Cerebral embolization most common - sudden stroke like symptoms.
Tx: 100% O2 by mask. Recumbent position, IV fluids, rapid recompression in hyperbaric O2
Decompression Sickness (the bends):
- Nitrogen bubble formation in tissues - generally longer exposures
1) The Bends: skin and joint tissues. Shoulder most common.
2) CNS / Ear Lungs: more serious. Mental status changs, headache, visual changes, upper lumbar spine susceptible (weakness and paralysis)
The Staggers: vertigo, nystagmus
The Chokes: dyspnea, cough, chest pain
Tx: Rapid recompression, 100% O2, recumbent, IV fluids.
RF: Old, fatigue, obesity, diving at altitude, rapid ascent, flying after diving
Indications for reverse START triage
In lightning strike - resp arrest treated first 2nd to medullary concusion
Mechanism of injury in electrical exposure
Direct electrical
Thermal energy
2nd trauma
Indications for Monitoring after electrical
High Tension > 1000 V
LOC
Abnormal ECG
Risk factors for ,… see lectures for more
XR signs of Pneuommediatstinum
SubQ emphysema
Distinct heart border
Continuous diaphragm sign
Peribronchial and perivascular air
Dive History
Depth and length
decompression stop times
dive computer used
how many dives in 72 hrs
delay from dive to fly
symptoms on descent or ascent
Symptoms at surfacing or delayed
Drowning markers of bad outcome
Submersion > 5 min
Delay in CPR > 10 min
Severe Acidosis < 7.1
Coma in ED
Asystole in ED
Fixed dilated pupils (in non-hypothermic state)
Resus > 25 mins
Hyperkalemia > 10 mmol.L
Age > 14
Hypothermia Resus
Warm to 30 degrees then run ACLS as per protocol
Fluids: NS warmed
D5 _ NS after at 41C
No RL
Dopamine preferred
No pacing if < 28 degrees - Bradycardia is physiologic
Avoid pacemakers / atropine
Safe to intubate
Hypothermia “ALCS”
If cold and goes into VFib:
< 30 degrees
No CPR if perfusional.
Can do 3 shocks every 2 degrees
Epi + Amiodarone - best outcome - 1 time dose Q2 degrees degrees until > 30 degrees
Vasopressin possible as option preferred pressor in hypothermia (single dose) - Bolus 40mg, lasts ~ 40 min x 1 dose
VBG will appear as respiratory alkalosis when real life is metabolic acidosis
If fail to rewarm:
- Sepsis, adrenal insufficient, hypothyroid myxedema, etc
Avalanche Resuce Prognostics
Burial > 35 min
Airway packed with snow
Asystole
K>12 (suggest 8)
pH < 6.9
Lactate > 13.3
Transport trauma medicine: preparation
- Fluids replace air (ETT tube)
- Vent ostomies in flight
- NG
- Foley
- PTX
- Boyle’s Law
Code Orange: Phases of disaster
Risk Assess
Mitigation
Preparedness
Response
Recovery
Code Orange: Plan
1 - Initial notification of Incident
2 - Confirmation of alert
3 - internal alert
4- activation of disaster plan
5 - executive fan-out
6 - recall ED staff and fan-out
7 - entrance to ER & hospital
8 - Unit command post and operation
9 - Triage, registration
10 -
