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Emergency/Surgery > Exam 1 - Environmental Emergencies > Flashcards

Exam 1 - Environmental Emergencies Flashcards

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1
Q

What is associated with first degree frostbite?

A

Numbness, central pallor with surrounding erythema and edema, desquamation, dysesthsia, no blisters

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2
Q

What is associated with second degree frostbite?

A

Blisters of the skin with surrounding edema and erythema

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3
Q

What is associated with third degree frostbite?

A

Tissue loss involving entire thickness of the skin, hemorrhage blisters

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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

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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
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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

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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
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8
Q

What is the definition of hypothermia?

A

Involuntary drop in body temperature below 95F

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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

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10
Q

What are secondary causes of hypothermia?

A
  • Alcoholism
  • Other medical conditions
  • Medication
  • Newborns, malnutrition, neuromuscular disease
  • Blood transfusion and other cold infusions
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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

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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

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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

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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

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15
Q

What type of thermometers should not be used to determine hypothermia?

A

Oral and infrared tympanic membrane thermometers should not be used

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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
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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
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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
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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

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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
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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
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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)
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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)
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24
Q

What is the 1st line treatment of hypotension due to rewarming of a hypothermic patient?

A

Aggressive fluid resuscitation with isotonic crystalloid

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25
Q

What are heat cramps?

A
  • 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
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26
Q

What is the management for heat cramps?

A
  • Rest in cool environment
  • Hydrate and replace sodium losses, encourage oral PO
  • IV fluids if not taking PO
  • Relax and stretch muscles involved
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27
Q

What causes heat stress (exhaustion)?

What are symptoms associated with it?

A

Due to water and sodium depletion.

Symptoms:

  • Intense muscle pain and spasm
  • Headache
  • Nausea/Vomiting
  • Dizziness
  • Orthostatic hypotension, +/- near syncope
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28
Q

What is typically found on physical exam in a patient with heat stress (exhaustion)?

A
  • Temp normal or elevated; < 104F

- NO signs of CNS impairment

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29
Q

What diagnostic studies should be ordered in a patient with heat exhaustion?

A
  • BMP (electrolytes abnormalities)

- CBC (hemoconcentration common)

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30
Q

What is the management for heat exhaustion?

A
  • 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)
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31
Q

What are cardinal features of heat stroke?

A

Temp > 104F, PLUS AMS:

  • Irritability
  • Confusion
  • Irrational behavior
  • Decorticate and decerebrate posturing
  • Seizures
  • Coma
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32
Q

What differentiates heat exhaustion from heat stroke?

A

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
Q

What is the management of heat stroke?

A
  • 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
Q

What are the methods to cool an individual suffering from heat stroke?

A

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
Q

In what populations are electrical injuries typically seen?

A
  • Adult males (work related)

- Children < 6 years old (at home)

36
Q

What are the two different currents that occur with electrical injuries?

A 
Alternating current (AC): alternates directions in cyclic pattern
- electricity in homes, transmission power lines
Direct current (DC): goes in a direct pathway
- Lightning, batteries
37
Q

What is the typical description associated with an AC current injury?

A
  • Repetitive muscle contraction where patient cannot let go of electrical source
  • Entrance wound only
38
Q

What is the typical description associated with a DC current injury?

A

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
Q

What are the four classes of electrical injuries with a brief description for each one?

A
  • 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
Q

What type of current does lightening produce?

What can be seen on physical exam in a patient who was struck by lightening?

A

DC current

“Lichtenberg figures” (flowers)

41
Q

Compare the duration of contact in lightning, high-voltage, and low-voltage electrical injuries.

A

Duration of contact:
Lightening: Instantaneous
High-voltage: Brief
Low-voltage: Prolonged

42
Q

Compare the cardiac arrest in lightning, high-voltage, and low-voltage electrical injuries.

A

Cardiac arrest:
Lightening: Asystole
High-voltage: Ventricular fibrillation
Low-voltage: Ventricular fibrillation

43
Q

Compare the muscle contraction in lightning, high-voltage, and low-voltage electrical injuries.

A

Muscle contraction:
Lightening: Single
High-voltage: Single (DC), Tetany (AC)
Low-voltage: Tetany

44
Q

Compare the burns in lightning, high-voltage, and low-voltage electrical injuries.

A

Burns:
Lightening: Rare, superficial
High-voltage: Common, deep
Low-voltage: Usually superficial

45
Q

Compare the blunt injury in lightning, high-voltage, and low-voltage electrical injuries.

A

Blunt injury:
Lightening: Blast effect
High-voltage: Fall (muscle contraction)
Low-voltage: Fall (uncommon)

46
Q

Compare the acute mortality in lightning, high-voltage, and low-voltage electrical injuries.

A

Acute mortality:
Lightening: Very high
High-voltage: Moderate
Low-voltage: Low

47
Q

What is the disposition for a low-voltage electrical injury versus a high-voltage?

A

Low voltage: Discharge home if normal EKG and physical exam

High-voltage: Admit for observation even if no apparent injury and asymptomatic

48
Q

What is the typical presentation associated with a black widow spider bite? Compare mild, moderate, and severe envenomation.

A

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
Q

What is the presentation associated with a Brown Recluse envenomation?

A
  • 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
Q

What is the management for a Black Widow spider envenomation?

A
  • 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
Q

What is the management for a Brown Recluse spider envenomation?

A
  • Typically wound improves within 5-10 days

- No antivenom available in the US

52
Q

What is the general presentation of a Bark Scorpion sting?

A
  • Initial symptoms are pain and paresthesia over involved area
  • Swelling usually absent with few skin changes
53
Q

In addition to the initial pain and paresthesia of a Bark Scorpion sting, what else may an adult patient experience?

A
  • Tachycardia
  • Hypertension
  • Tachypnea
  • Weakness
  • Muscle spasms and fasciculation
  • Respiratory difficulty is rare
54
Q

In addition to the initial pain and paresthesia of a Bark Scorpion sting, what else may a child experience?

A
  • 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
Q

What is the management for a Bark Scorpion sting?

A
  • 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
Q

What are some clinical features of a rattlesnake bite?

A
  • Fang marks
  • Local tissue injury
  • Fibrinolysis
  • Thrombocytopenia
  • Systemic effects (unstable vitals, AMS)
57
Q

What defines progression of a rattlesnake bite?

A
  • Worsening of local injury - pain, ecchymosis or swelling
  • Abnormal labs - decreasing platelet count, proloned PT/PTT, decreased fibrinogen
  • Systemic manifestations
58
Q

What is the management of a rattlesnake bite once in the ER?

A
  • 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
Q

What is serum sickness and how is it treated?

A

Reaction of fever, rash, and arthralgia to antivenom given for rattlesnake bites.

Start oral prednisone 1mg/kg/d for 1-2 weeks.

60
Q

Why must antivenom for a rattlesnake bite be administered in the ICU?

A

Risk of anaphylaxis to antivenom

61
Q

What does a coral snake bite cause?

A

Neurotoxic venom that does not cause marked localized injury

62
Q

What is the treatment for a coral snake bite?

A
  • 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
Q

What can a Gila Monster bite cause?

A
  • Requires prolonged bite for envenomation

- Fractures and deep tissue injury secondary to strong bite

64
Q

What is the treatment for a Gila Monster bite?

A
  • 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
Q

What is barotrauma of descent?

A

Injury related to pressure changes during descent while diving (barotitis, sinus barotrauma, inner ear barotrauma)

66
Q

What are symptoms associated with barotitis?

A
  • Pain/fullness in ear
  • Conductive hearing loss
  • Hemotympanum
  • Vertigo
  • Ruptured TM
67
Q

What is the treatment for barotitis?

A
  • Decongestant

- Consider antibiotics PRN

68
Q

What are symptoms associated with sinus barotrauma?

A
  • Pain over affected sinus

- Possible epistaxis

69
Q

What is the treatment for sinus barotrauma?

A
  • Decongestant
  • Consider antibiotics PRN
  • ENT involvement dependent on severity
70
Q

What is inner ear barotrauma due to?

A

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
Q

What are symptoms associated with inner ear barotrauma?

A
  • Sudden onset of sensineural hearing loss
  • Tinnitus
  • Severe vertigo
72
Q

What is the treatment for inner ear barotrauma?

A
  • STAT ENT consult
  • Head of bed up
  • No nose blowing
  • Anti-vertigo medications
73
Q

What causes barotrauma of ascent?

A
  • 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
Q

What is pulmonary barotrauma (barotrauma of ascent)?

A

Pulmonary overinflation or “burst lung syndrome”

75
Q

What are symptoms associated with pulmonary barotrauma?

A
  • Dyspnea
  • Chest pain
  • Subcutaneous air
  • Pneumothorax
76
Q

What is the treatment for pulmonary barotrauma?

A
  • Pneumomediastinum requires only symptomatic care

- If pneumothorax present, may require intervention

77
Q

When must barotrauma of ascent be treated as an arterial gas embolism?

A

ANY neurologic symptom in the setting of documented pulmonary barotrauma

78
Q

What are symptoms associated with arterial gas embolism due to barotrauma of ascent?

A

Neurologic symptoms occurring immediately after uncontrolled, rapid ascent while diving

79
Q

What is the treatment for arterial gas embolism due to barotrauma of ascent?

A
  • ABC’s
  • High flow oxygen
  • IV hydration
  • Immediate recompression (hyperbaric oxygen)
  • STAT neuro consult

Emergency/Surgery (3 decks)

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