Environmental Trauma Flashcards
Heat Cramps
Etiology
- hot environments with inadequate volume
- deficient in K+, Na & Mg
Presentation
- cramps/spasm of muscle
Management
- fluid and salt replacement in cool space
Heat Exhaustion (heat Stress)
Etiology
- hot enironment and inadequte volume replacement
- water depleted: think eldery and workers
- sodium depleted: those who are only replacing with water, not with electroyltes
Symptoms
- HA
- N/V
- dizzy
- malaise
- cramps
- tachydarida, ortho. hypotension
- normal or elevated temperauter
- normal mental status
Diagnosis
- if you think you need to : get labs for electrolytes or to assess for rhabdomylosis)
Management
- fluids to replace (oral hydration with electroyltes) or IV fluids (LR or NS)
- cooler environment will help them; if they need you can active cooling with fan and water spritzing
Heat Stroke
worst of the heat pathologies: can be fatal!
Etiology
- life-threatening if not treated
- cerebellum doesnt like to get hot: ataxia, neuro findings
- can lead to end organ damange
Symptoms
- the heat exhastion symptoms PLUS
- hyperthermia of 104+ (40)
- altered mental status
- hallucinations, confusion, odd behavior,etc.
Diagnosis
- can be simialr to sepsis: get a good history
- labs: glucose, CMP, CBC, CK, EKG; can get head CT or culutres if sepsis, etc.
Treatment
- IV fluids 1-2 L LR or NS
- remove clothing = cool environment
- goal cooling: get them to 39C (102.2) but prevent shivering
- ice packs to the places
- evaporative cooling with fan and water
- immersion cooling in a tub
- invascive cooling: ECMO, gastric/bladder lavage
- admit them
Frostbite
Etiology
Degrees (1st-4th) & Presentation
Etiology
- cold expsoure prolonged = tissue freezing/injured = thawing causes additional injury
- head,hands and feet
Presentation by Degree
1st degree: :”nip”
- NO BLISTERS
- numbness, stinging, dryness, mild edema
2nd Degree:
- full thickness freeze
- edema
- BLISTERS
3rd degree
- damange extends deeper to subdermal plexus (fat)
- development of hemorrhagic blisters: due to vessel involvement
4th Degree
- damage that can get to the bone
- darker, black echar color
Frostbite
management
management
- prevent further injury, remove from the cold and remove wet clothing
- rewarm without refreezing
- use warm circualting WARM water: not hot: 37-39C water
- leave blisters in place
- severe could be amputated
Hypothermia
etiology
Mild
moderate
severe
Etiology
- dropping of core temperature before 35C/95F
- can lead to cardaic arrest
- can be due to environment but also could be impaired thermoreg.
Mild Hypothermia
temp
symptoms
treatment
Mild : core temp 35-32
- awake, alert, shivering
Treatment
- warm environment, clothing & blankets
Moderate Hypothermia
temp
symptoms
treatment
Moderate: core temp 32-28
- some impaired consciousness
- shivering Moderate Hypothermia
Treatment
- active rewarming
- bear hugger blankets
- warm IV fluids
- shivering is good
- monitor their cardaic and respiratory function
Severe Hypothermia
temp
symptoms
treatment
Severe: core temp < 28
- unconscious but has vital signs
- high risk of cardiac arrest
Treatment
- active rewarming with warm IV fluids, bear hugger blankets
- airway mangement + intubation if needed with warm air ventiliation
- bladder lavage or gastric lavage
- thraocic lavage with chest tubes
- ECMO if failure to improve with other methods
- watch arrythmias, hypotensions and respitroay failure with refractor acidosis
Hypothermic Cardiac Arrest: what to do
when to pronounce dead in hypothermic
Hypothermic Cardiac Arrest
- hypotension or cardiac arrest?
- eitehr way = CPR
- 3 cycles of defibrillation + epinephrine
- airway management with intubation and warm air
- bladd/gastric lavage
- thoracic lavage chest tubes
- ECLS if able
Prounoucement of Death
- not dead until warm and dead
- if serum potassium > 12 = dead
- core temp > 32 with no return of spontaneous circulation = dead
Acute Mountian Sickness (AMS)
where does this occur & why
symptoms
treatment
Where and Why
- elevations > 8000 ft. = hypoxic environment (the PP of oxygens decreases)
- body attempts to increase ventilation: respiratory alkalosis
- renal excretion of bicarb to comp. for alkalosis
- EPO levels increase for Hgb carrying
- Increase HR
- vasodilation
- takes 4-7days to weeks to acclamate
Clinical Presentation : Lake Lousie AMS questions
- HA
- GI symptoms
- Fatigue/weakness
- dizzy/lightheaded
- difficulty sleeping
- mild = 2-4, moderate 5-9 severe = 10-15
Treatment
- dont go any higher, go back down if you can
- hault ascent: gets better 12-36 hours
- decend 300-1000 m (gamow bag)
Medications
acetazolamide (CAI) causes a metablic acidosis to reduce renal bicarb reabsorpbtion, stimulating ventilation
symptomatic: ibuprofen, ondansetron
dextamethasone taper or + acetazolamide
High Altitude Pulmonary Edema (HAPE)
etiology
symptoms
Etiology
- an increase in pulmonary vascualr resistance (without any change to the heart)
- due to a rapid ascent, heavy exersion, prior experience, “stong and fit dude” climbing mountian too quick
Symptoms
Early
- dry cough, crackles/rails
- SOB
- decreased pulse Ox. more than what you would expect at that altitude
Later
- tachycardia, tachypena, SOB
- fatigue, weakness, producitve cough
Treatment
- immediate decent
- supplemental oxygen : consider hyperbarid bag
- nifedipine, tadafinil, inhaled salmeterol etc. to vasodilate
High Altitude Cerebral Edema (HACE)
etiology
symptoms
management
Etiology
- high altitude = neurologic decline + ataxia due to increased intracrainal pressure
Symptoms
- AMS/confusion
- ataxia
- focal neruologic deficts
- coma
Management
- immediate decent
- oyxgen!!!
- dextamethasne + acetazolamide can help
Barotrauma of Decent (Diving)
volume of gas/air in the cavities decreases with decent = vacuum created
Symptoms
- pain in the ears, sinuses
- sensation of pain or pressure within the face
Management
- “pop” ears with Valsalava
- ascend
Barotrauma of Ascent: plane
decreasing pressure in the outside: volume of air increases in side
- can injury surrouidng strucutres: ears, sinuses or lungs
Symptoms
- pain
- inner ear = vertigo
- Lungs = PTX or pneumomediastium! (if significant enough)
Management
- symotomatic
- wathc for other signs of decompression sickness or air embolsims
Decompression Sickness
etiology
type I and II
Etiology
- a decrease in ambient pressure = results in bubble formation in the vessels and tissues
- can lead to ischemia and inflammation
- occurs in divers or high altitude pilots
- dive tables can help
Presentation
Type 1 = pain only
- pain in joints, extremities
- akin changes (color, itching)
- lymph. obstruction
Type II: serious
- chest: cough, dyspnea, hemoptysis, chest pain
- neuroloigc: parlysis, vertigo, hearing loss
- autonomic dysfucntion of CV collapse
Decompression Sickness:
Arterial Gas Emobli
Treatment of all decom. sickness
pulmonary barotrauma = air enters the left heart circulation
can lead to stroke symptoms and cardiac arrest
Decompression Sickness
- 100% O2
- IV fluids
- hyperbaric oxygen: to recompression (decrese bubble size, increase ppO2 adn decrease edema)
Drowning
etiology
Etiology
- submersion = respiratory arrest or difficulty
- decgree of hypoxia and CNS injuryguides outcome
Symptoms
- always consider this in C-spine diving injuries
- if they’re doing ok= probably will be
- if they’re not = they wont
Treatment
minimal symptoms
- evaulte and VS
- GCS > 13 + pulse ox > 95% = observe 4-6 hours, hte discharge
symptomatic
- consider hospitalization to observe
- ARDS is a risk here
Animal Bites
Bugs for…
- cat
- dog
- human
- rodants
- rabies!
- freshwater
Cats
- pastuerella, bartonella henselae (cat scratch)
Dogs
- pasturella, strep, staph, capncytophage canimorsus (hurts those without a spleen)
Human
- staph, streph, eikenella
Rodants (squirrels, rats)
- strepbacillus moniliformis
Rabies!!!!
Freshwater
- aeromonas
Salt Water
- vibrio
Presentation and Diagnosis of Bites
Presentation
- they’ll tell you
- assess pt. factors (immunocomp., DM, etc.)
- fight bites (knuckle to face) = tendon injury
Rabies
- can you monitor animal? up to date?
- bite v non-bite expsoure
Treatment
- local wound care: wash and irrigate +/- closure
- antibiotics: amoxicllin-clav. should cover most human/animal/dog bites
- update tetanus vaccine if > 5-10 years
Rabies
- day 0 = give vaccine IM + rabies immuniglobin at the site
- day 3 = vaccine
- day 7 = vaccine
- day 14 = vaccine
Superfisical (1st degree burns)
presentation
treatment
What
- epidermis burned only
- red, painful
- NO BLISTERS
- this is a sunburn
- they’ll peel and heal
Treatment
- aloe
- NSAIDS
- NO STEROIDS
- moizturize
Partial- Thickness Burn (2nd degree)
what
treatment
What
- involves epidermis and some of the dermis
- very painful
- blisters can form
____________________________________
can be either…
Superfisical partial-thickness
- blisters
- red, moist & painful
- blanch with pressure
- prone to infection
- heal well
Treatment
- irrigation
- pain control
- clean with soap and water
Deep partial thickness
- deeper dermis affected (the hair follicles)
- blisters: wet to waxy in appearance
- do NOT blanch
- heal in 3-9 weeks
- hypertrophic scarring = could need grafting
Treatment
- clean with soap and water
- if the blister is broken: debridment
- small and intact: leave it be (dont needle)
Full Thickness Burn - 3rd degree
What
- all dermal layers, even the subQ could be impacted
- no sensation; so not painful
- waxy, leathery in appearance
- no blanching or blisters
- contractors will occur within grafting
Treatment
- skin graft
Deep Tissue Burns: 4th degree
involing what
WHAT
- very deep
- through the skin and into underlying tissues: bone and muscle invovlement
- sever injury with amuptation most likely
Evaluation of Burns
Rule of Nines
Evaulation
- ABCs first
- type of burn
- depth
- calculate TBSA % burned : this only includes partial and full thickness burns not 1st degree
Rule of Nines
- head =9%
- each arm = 9%
- torso = 18%
- leg = 18%
- 1% = genitals
(can also use the pt. palm as 1% and estimate TBSA that way)
Lund-Browder Chart is most accurate
Referral Criteria for Burn Center
- partical thickness burns > 10% of TBSA
- face, hands, gentials, or major joints involved
- third degree burns at all anyone
- electrical burns & chemical ones
- inhalaition injury
- those with complex. medical history
- burn + trauma: stablize the trauma then send
- child
Thermal Burns
what are they
concerns
treatment
What are they
- flames, hot liquids, steam
Concerns
- figure out why and how
- assess airway
- assess trauma, CO & cyanide
Treatment
- irrigate with tap water, sterile water or saline
- NO iCE
- prevent hypothermia with larger burns
Inhalation Injury
upper v lower airway conerns
toxins that can be inhaled
Upper Airway
- inflammation above the vocal cords
- heat or chemicals are causing direct edema
Lower Airway
- subglottic
- usually inhaled particles, not usually heat related
- pulmonary edema can occur
- high mortality
Toxins
- Hydrogen cyanide (HCN) : from synthetic/plastic products pt. will have high lactate
- Carbon monoxide (CO): more affinity to Hgb: check plasma carboxyhemoglobin
- (remeber some COPD and smokers will have carboxyhemo. already like 10%)
Inhalation Injury
Symptoms
Symptoms
- facial burns
- hoarse voice/hypoxia
- soot
Treatment
- if in respiratory distress = INTUBATE and send to burn center
- if not in respirtory distress = 100% O2 and monitor
Chemical Burns
types of burns
Severity Depends on
- chemical
- concentration & temperature & duration
Alkaline (pH > 7)
- bleach, cement, cleaners
- it denatures proteins –> liqefaction necrosis
Acidotic (pH < 7)
-batteries and lab chemicals
- coagulation necrosis (superfisical)
Hydrocarbons/organic compounds
- petroluim/fuel
- dissolves into fat and membranes
- can be locally and systemically toxic
Hydrofluoric acid
- aluminum cleaner; glass etching
- TREAT WITH CALCIUM GLUCONATE
Treatment for Chemical Burns to the Eyes
Eyes
- cehck the pH
- irrigate for 20+ minutes
- recheck pH (get to 7 or keep irrigating)
- slit lap and flouescein
- topical abx. and refer to opth.
Electricaly Injuries
low v high voltage
direct v alternating
Treatment
Low volts = < 1,000
Hight = 1,000 + (lightening)
alternating current = houshold current
direct current = batteries and lightening
touch skin = heat generation
Low Volts Treatment
- minor injuries
- check EKG
- normal EKG + no LOC ? = discharge
Higher Voltage Treatment
- cardiac (EKG)
- Rhabdo. (get CK)
- burn site will appear smaller than actual burn (internal)
- check other trauma
- transfer or monitor on telet 24hr.
General Minor Burn Treatment
Superfisical Partial Thickness Burns
- debriedment of popper blisters, leave otehrs
- wash with soap and water
- topical bacitracin or polysporin
- sliver sulfadiazine (not for sulfa allergies)
- no need for abx. oral prophlaytic
- dressing: nonahearant dressings or gauze
- GIVE TETANUS VACCINE
follow up
- burn clinic for large burns and joints
- small burns = PCP in 48 hours
- change dressing 1-2x daily
Major Burns Treatment
when to intubate
CO treatment
Cyanide treatment
- ABCs
- Trauma Evaluation
- Burns
- GIVE TETNUS VACCINE
when to intubate
- airway concerns (hair singed, wheezing, stridor, etc.)
- flash (grill spark) v prolonged expsoure
CO concerns
- check the CO
- use high flow O2
- consider CO poisioning in family with HA
Cyanide: from plastics and polyurethane
- flushing bright red venous blood
- lactate > 10
- anion gap acidosis
- hydrocobalamin to treat + sodium thiosulfate
- NO NITRATE
Major Burns: Fluid Resusitation
- use LR
- calculate your TBSA %
- Parkland formula: 4mL/kg x %TBSA
then determine rate
- get volume via parkland formula
- the give first 1/2 over 8 hours
- then second 1/2 over 16 hours
dont over resusicate = monitor urine output
Goals of Urine Output
- adults = 0.5 mL/kg/hr.
- kids = 1mL/kg/hr
Excess Fluids…
- lead to edema and more complications
- teh max edema for a burn pt. will occur 24 hours later
Burn Treatment in sum
- address ABCS and trauma
- then irriate the burn and FB
- dry dressing or saline saoked gauze
- prevent hypotehrmia = clean dry sheet
- pain control
- monitor body temp and keep them warm
- GIVE TETNUS not abx.
Escharomty = a constriction area of full thickness burns: wehre you remove the skin – rarely done
