Exam 1 - Environmental Emergencies Flashcards
1
Q
What is associated with first degree frostbite?
A
Numbness, central pallor with surrounding erythema and edema, desquamation, dysesthsia, no blisters
2
Q
What is associated with second degree frostbite?
A
Blisters of the skin with surrounding edema and erythema
3
Q
What is associated with third degree frostbite?
A
Tissue loss involving entire thickness of the skin, hemorrhage blisters
4
Q
What is associated with fourth degree frostbite?
A
Tissue loss involving the entire thickness of the part, including deep structures, resulting in the loss of the part
5
Q
What is the management for frostbite?
A
- Immersion in water between 101.5F - 102.2F until erythematous and pliable (20-30 min)
- Consider IV opioids for pain (anticipate severe pain with rewarming)
- Aloe cream every 6 hours with non-occlusive dressing
- Ibuprofen 400-600 mg ever 6 hours
- Tetanus immunization PRN
- Monitor and start abx at earliest sign of infection
6
Q
If patient has cyanosis proximal to the ITP joints, what additional management should you consider with frostbite?
A
CT angiography or bone scan to assess circulation/tissue viability
7
Q
What type of frostbite is able to be discharged home if they have appropriate follow up?
What should their discharge plan be?
A
Superficial frostbite
- Ibuprofen PO every 6 hours
- Continue aloe cream every 6 hours
- Discourage tobacco use
8
Q
What is the definition of hypothermia?
A
Involuntary drop in body temperature below 95F
9
Q
What is the difference between primary and secondary hypothermia?
A
Primary: Typically occurs in cooler climates; due to exposure (wind, rain, water, snow)
Secondary: Due to lack in thermoregulation
10
Q
What are secondary causes of hypothermia?
A
- Alcoholism
- Other medical conditions
- Medication
- Newborns, malnutrition, neuromuscular disease
- Blood transfusion and other cold infusions
11
Q
What temperature is associated with the mild stage of hypotheramia (HT I)?
What is the state of the patient in this stage and what are associated symptoms?
A
Core temp 89.6-95F
Conscious, may be confused, tachycardia, increased shivering
12
Q
What temperature is associated with the moderate stage of hypotheramia (HT II)?
What is the state of the patient in this stage and what are associated symptoms?
A
Core temp 82.4-89.6F
Lethargy, bradycardia, arrhythmia, loss of pupillary reflexes, decreased shivering
13
Q
What temperature is associated with the severe stage of hypotheramia (HT III)?
What is the state of the patient in this stage and what are associated symptoms?
A
Core temp below 82.4F
Vital signs present, unconcious, hypotension, arrhythmia, pulmonary edema, rigidity
14
Q
What temperature is associated with HT IV?
What is the state of the patient in this stage and what are associated symptoms?
A
Core temp 82.4-89.6F
Absent vital signs, cardiac arrest
15
Q
What type of thermometers should not be used to determine hypothermia?
A
Oral and infrared tympanic membrane thermometers should not be used
16
Q
What are some recommended studies to obtain in moderate to severe hypothermia?
A
- Fingerstick glucose (insulin ineffective below 86F)
- ECG and CXR (hyperkalemia may be masked on ECG until patient rewarmed)
- BMP
- CBC with diff (Hemtocrit increases 2% with each 1C drop in temp)
- Coagulation studies
- ABG
17
Q
What is the management of HT I?
A
- Remove wet clothes
- Passive external rewarming
- Cover with warm blankets
- Warm drinks
- Encourage active movement
18
Q
What is the management of HT II?
A
- ABC’s
- Endotracheal tube if needed
- Monitor for hypotension with rewarming
- Avoid rough movements as may induce fatal arrhythmias
- Active external and internal rewarming
- Warmed, humidified oxygen, forced air warming systems
19
Q
What should you be aware of when rewarming a patient with hypothermia?
A
Beware of initial paradoxical drop in core temp due to return of cold blood from the extremities to the core
20
Q
What is the management of HT III?
A
- ABC’s
- Endotracheal tube if needed
- Avoid rough movements as may induce fatal arrhythmias
- Active external and internal rewarming PLUS pleural and peritoneal irrigation with warm saline
21
Q
During what stages of hypothermia can arrhythmias be induced and how can you treat them?
A
HT II and HT III
- ACLS prn
- Defibrillation rarely successful at core temps of 86F or less
22
Q
What is the management of HT IV?
A
- Start high-quality CPR
- Prevent further heat loss, rewarming (extracorporeal options: hemodialysis, cardiopulmonary bypass, continuous arteriovenous rewarming)
- Thoracic lavage (chest tube) with NS (100.4F-107.6F)
- ACLS protocol (reasonable to attempt up to three cycles of advance ACLS then defer until core temp increases or patient clinically improves)
23
Q
What are some complications of rewarming a patient with hypothermia?
A
- Hypotension
- Electrolyte abnormalities
- Rhabdomyolysis and multi-system organ failure
- Late pulmonary, renal and neurological complications (often fatal)
24
Q
What is the 1st line treatment of hypotension due to rewarming of a hypothermic patient?
A
Aggressive fluid resuscitation with isotonic crystalloid
25
What are heat cramps?
- Intense muscle pain and spasm with no other signs of exertional heat stroke
- In limited area and short in duration; not at risk for rhabdomyolysis
26
What is the management for heat cramps?
- Rest in cool environment
- Hydrate and replace sodium losses, encourage oral PO
- IV fluids if not taking PO
- Relax and stretch muscles involved
27
What causes heat stress (exhaustion)?
What are symptoms associated with it?
Due to water and sodium depletion.
Symptoms:
- Intense muscle pain and spasm
- Headache
- Nausea/Vomiting
- Dizziness
- Orthostatic hypotension, +/- near syncope
28
What is typically found on physical exam in a patient with heat stress (exhaustion)?
- Temp normal or elevated; < 104F
| - NO signs of CNS impairment
29
What diagnostic studies should be ordered in a patient with heat exhaustion?
- BMP (electrolytes abnormalities)
| - CBC (hemoconcentration common)
30
What is the management for heat exhaustion?
- Remove from hot environment
- Bolus infusion of moderate amount of IV fluids (1-2 liters with short-term; 1.5 increase in maintenance)
- Patients with CHF or significant electrolyte abnormalities may require admission for a longer or slower duration of fluid replacement
- Patients not responding within 30 minutes of fluid replacement and removal from hot environment may require external cooling (until core temp reaches 102.2F)
31
What are cardinal features of heat stroke?
Temp > 104F, PLUS AMS:
- Irritability
- Confusion
- Irrational behavior
- Decorticate and decerebrate posturing
- Seizures
- Coma
32
What differentiates heat exhaustion from heat stroke?
Heat exhaustion does NOT have CNS involvement and temp remains below 104F while heat stroke does have CNS involvement and temp reaches over 104F.
33
What is the management of heat stroke?
- Start fluid resuscitation, monitor core temperature
- Want to cool quickly without inducing hypothermia (goal is 102.2F)
- Admit to hospital; ICU if hemodynamically labile or intubated
34
What are the methods to cool an individual suffering from heat stroke?
Evaporative cooling: remove clothing, spray water on skin, direct a fan over the patient
Ice packs: axillae, neck, groin
Immersion cooling: patient placed partially in tub of ice water
Invasive cooling: cardiopulmonary bypass
35
In what populations are electrical injuries typically seen?
- Adult males (work related)
| - Children < 6 years old (at home)
36
What are the two different currents that occur with electrical injuries?
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Alternating current (AC): alternates directions in cyclic pattern
- electricity in homes, transmission power lines
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Direct current (DC): goes in a direct pathway
- Lightning, batteries
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37
What is the typical description associated with an AC current injury?
- Repetitive muscle contraction where patient cannot let go of electrical source
- Entrance wound only
38
What is the typical description associated with a DC current injury?
Causes a single muscle spasm that hurls the patient away from the current source (shorter duration of exposure than AC)
- Entrance and exit wound
39
What are the four classes of electrical injuries with a brief description for each one?
- Classic: body becomes part of the circuit with entry and exit wounds
- Flash (Arc): current arc strikes skin but does not enter body
- Flame injury: clothing catches fire in presence of an electrical source
- Lightening: shock wave transmitted through body
40
What type of current does lightening produce?
What can be seen on physical exam in a patient who was struck by lightening?
DC current
"Lichtenberg figures" (flowers)
41
Compare the duration of contact in lightning, high-voltage, and low-voltage electrical injuries.
Duration of contact:
Lightening: Instantaneous
High-voltage: Brief
Low-voltage: Prolonged
42
Compare the cardiac arrest in lightning, high-voltage, and low-voltage electrical injuries.
Cardiac arrest:
Lightening: Asystole
High-voltage: Ventricular fibrillation
Low-voltage: Ventricular fibrillation
43
Compare the muscle contraction in lightning, high-voltage, and low-voltage electrical injuries.
Muscle contraction:
Lightening: Single
High-voltage: Single (DC), Tetany (AC)
Low-voltage: Tetany
44
Compare the burns in lightning, high-voltage, and low-voltage electrical injuries.
Burns:
Lightening: Rare, superficial
High-voltage: Common, deep
Low-voltage: Usually superficial
45
Compare the blunt injury in lightning, high-voltage, and low-voltage electrical injuries.
Blunt injury:
Lightening: Blast effect
High-voltage: Fall (muscle contraction)
Low-voltage: Fall (uncommon)
46
Compare the acute mortality in lightning, high-voltage, and low-voltage electrical injuries.
Acute mortality:
Lightening: Very high
High-voltage: Moderate
Low-voltage: Low
47
What is the disposition for a low-voltage electrical injury versus a high-voltage?
Low voltage: Discharge home if normal EKG and physical exam
High-voltage: Admit for observation even if no apparent injury and asymptomatic
48
What is the typical presentation associated with a black widow spider bite? Compare mild, moderate, and severe envenomation.
Pain within 3 hours of bite; systemic effects in 4-6 hours
Mild envenomation: Local wound
Moderate envenomation: Spasms and muscle pain in bitten extremit, back, chest and abdomen; diaphoresis
Severe envenomation: Severe pain, spasm and systemic features (n/v. headache, tachycardia, HTN)
49
What is the presentation associated with a Brown Recluse envenomation?
- Mild to intense pain and itching 2-8 hours following bite.
- Lesion: depressed macule, pale grey, eroded in center with halo of inflammation and hemorrhage
- Lesion may be very tender and extend to muscle tissue
- Necrosis is infrequent and would appear a week or more after the bite
- Infrequent systemic symptoms
50
What is the management for a Black Widow spider envenomation?
- Self-limiting, duration of symptoms typically 24-48 hours
- Analgesics, moderate to severe envenomation may require opioids
- Muscle relaxants PRN
- Antivenom available, limited quantity
- Consult with toxicologist if symptoms severe enough to warrant antivenom
51
What is the management for a Brown Recluse spider envenomation?
- Typically wound improves within 5-10 days
| - No antivenom available in the US
52
What is the general presentation of a Bark Scorpion sting?
- Initial symptoms are pain and paresthesia over involved area
- Swelling usually absent with few skin changes
53
In addition to the initial pain and paresthesia of a Bark Scorpion sting, what else may an adult patient experience?
- Tachycardia
- Hypertension
- Tachypnea
- Weakness
- Muscle spasms and fasciculation
- Respiratory difficulty is rare
54
In addition to the initial pain and paresthesia of a Bark Scorpion sting, what else may a child experience?
- Restlessness, anxiety, agitation
- Muscle spasms
- Abnormal, random head, neck and eye movements
- Weakness
- Diaphoresis and excessive drooling/salivation
- Respiratory difficulty is rare
- Have resulted in death in children < 6 years of age
55
What is the management for a Bark Scorpion sting?
- Supportive care with ice packs, oral NSAIDS, muscle relaxants for spasms, control of HTN/agitation, pain control
- Monitoring for 8-12 hours after sting
- Antivenom should be given to all patients with severe symptoms who are unresponsive to supportive care
- Tetanus prophylaxis
56
What are some clinical features of a rattlesnake bite?
- Fang marks
- Local tissue injury
- Fibrinolysis
- Thrombocytopenia
- Systemic effects (unstable vitals, AMS)
57
What defines progression of a rattlesnake bite?
- Worsening of local injury - pain, ecchymosis or swelling
- Abnormal labs - decreasing platelet count, proloned PT/PTT, decreased fibrinogen
- Systemic manifestations
58
What is the management of a rattlesnake bite once in the ER?
- Antivenom is mainstay of therapy (given IV or intraosseous)
- If hypotensive, administer IV isotonic fluids
- Immobilize limb in neutral position
- Clean bite wound
- Tetanus prophylaxis
- Monitor for bleeding and compartment syndrome
59
What is serum sickness and how is it treated?
Reaction of fever, rash, and arthralgia to antivenom given for rattlesnake bites.
Start oral prednisone 1mg/kg/d for 1-2 weeks.
60
Why must antivenom for a rattlesnake bite be administered in the ICU?
Risk of anaphylaxis to antivenom
61
What does a coral snake bite cause?
Neurotoxic venom that does not cause marked localized injury
62
What is the treatment for a coral snake bite?
- Admit patient with potential envenomation as it can take hours for effects of venom
- Start anti-venom ASAP as once patient suffers from effects of venom, likely irreversible
- Closely monitor respiratory function (may need intubation and ICU)
- Supportive care: clean bite, Tetanus prophylaxis, monitor for serum sickness
63
What can a Gila Monster bite cause?
- Requires prolonged bite for envenomation
| - Fractures and deep tissue injury secondary to strong bite
64
What is the treatment for a Gila Monster bite?
- Remove lizard and clean wound
- Radiographs for fracture
- Tetanus and antibiotics
- Admit and monitor for symptoms of envenomation (weakness, light-headedness, paresthesia, diaphoresis, HTN)
65
What is barotrauma of descent?
Injury related to pressure changes during descent while diving (barotitis, sinus barotrauma, inner ear barotrauma)
66
What are symptoms associated with barotitis?
- Pain/fullness in ear
- Conductive hearing loss
- Hemotympanum
- Vertigo
- Ruptured TM
67
What is the treatment for barotitis?
- Decongestant
| - Consider antibiotics PRN
68
What are symptoms associated with sinus barotrauma?
- Pain over affected sinus
| - Possible epistaxis
69
What is the treatment for sinus barotrauma?
- Decongestant
- Consider antibiotics PRN
- ENT involvement dependent on severity
70
What is inner ear barotrauma due to?
Diver attempts forceful Valsalva maneuver to equalize pressure in middle ear against occluded Eustachian tube, causing a ruptured oval or round window, and/or tearing of vestibular membrane
71
What are symptoms associated with inner ear barotrauma?
- Sudden onset of sensineural hearing loss
- Tinnitus
- Severe vertigo
72
What is the treatment for inner ear barotrauma?
- STAT ENT consult
- Head of bed up
- No nose blowing
- Anti-vertigo medications
73
What causes barotrauma of ascent?
- Usually occurs secondary to rapid or uncontrolled ascent while diving
- Pressure differences in the lungs become so great that tissues rupture, and air is introduced into tissues and spaces
74
What is pulmonary barotrauma (barotrauma of ascent)?
Pulmonary overinflation or "burst lung syndrome"
75
What are symptoms associated with pulmonary barotrauma?
- Dyspnea
- Chest pain
- Subcutaneous air
- Pneumothorax
76
What is the treatment for pulmonary barotrauma?
- Pneumomediastinum requires only symptomatic care
| - If pneumothorax present, may require intervention
77
When must barotrauma of ascent be treated as an arterial gas embolism?
ANY neurologic symptom in the setting of documented pulmonary barotrauma
78
What are symptoms associated with arterial gas embolism due to barotrauma of ascent?
Neurologic symptoms occurring immediately after uncontrolled, rapid ascent while diving
79
What is the treatment for arterial gas embolism due to barotrauma of ascent?
- ABC's
- High flow oxygen
- IV hydration
- Immediate recompression (hyperbaric oxygen)
- STAT neuro consult
