Lecture 7: Environmental Emergencies (Elkins) Flashcards
What is heat illness?
Inabiity to regulate body temperature adequately
What characterizes Heat Edema & how do you tx?
- Mild swelling of extremities
- Tx: Self-limiting, just rest, ice, elevate, drink water
Cutaneous and muscular vasodilation redistributes intravascular volume to the periphery of the body. Volume loss and prolonged standing (pooling in the lower extremities) also contribute to the development of inadequate central venous return and insufficient cerebral perfusion.
What is heat syncope and what is the clinical presentation?
- Heart syncope is syncope after exerting yourself in the heat.
- NORMAL CORE TEMP
- Skin will be cool, sweaty; weak pulse, transient hypotension
2 pathophysiologic processes:
vasodilation of the skin and muscles redistributes intravascular volume to the periphery of the body
volume depletion in addition to prolonged standing leads to inadequate cardiac return and cerebral perfusion
How do you manage heat syncope?
- R/o other possible causes
- Lie supine, elevate legs, cool externally and rehydrate IV/PO
Get them out of the heat and rehydrate.
What are heat cramps and the clinical presentation?
- Painful muscle spasms of abd + ext due to salt depletion
- NORMAL or SLIGHTLY ELEVATED CORE TEMP
- +/- muscle fasciculations
- Skin can be anything (dry or moist, cool or warm)
What would you see on labs for heat cramps if you decided to order them?
Rarely indicated.
- Low to normal Na
- Low to normal K
- Low to normal Mg
Just a little lyte depletion
I think of bananas for cramps, so cramps = electrolyte issue
Management of heat cramps?
- Remove from heat, externally cool
- Oral electrolytes (pedialyte/gatorade) or IV NS
- Replace K and Mg PRN
Discharge home and rest for 1-3 days.
What characterizes Heat Exhaustion?
Inability to maintain adequate CO
Will lead to heat stroke if no intervention!
Running on Empty, no output
What are the two underlying types of heat exhaustion?
- Hypernatremic (Primary water loss): LACK OF WATER
- Hyponatremic (Primary salt loss): Only getting free water instead of water + lytes
How does heat exhaustion present clinically?
- Mild core temp elevation up to 104F
- Diaphoresis, HA, N/V, malaise, weakness
- Cramps, dizziness, +/- dark urine
- Tachy, hypotensive
- NO EVIDENCE OF CNS DYSFUNCTION (Key distinguishing from heat stroke)
What is a key feature of the clinical presentation that suggests heat exhaustion over heat stroke?
No evidence of CNS dysfunction
What UA finding suggests subclinical rhabdomyolysis?
- UA showing blood
- Microscopy showing little to no RBCs
If a patient presents with suspected heat exhaustion, what will your workup include?
- BMP
- UA
- CK
- LFTs
- ABG
- EKG
Rhabdo + lyte abnormalities
What are the management steps for heat exhaustion?
- Remove from heat
- Externally cool
- PO lytes if they can
- If not, IV NS or LR.
- If primarily marked hyponatremic due to water intoxication, use hypertonic NS
When would you admit for heat exhaustion?
- Mod-severe
- Cormorbid illnesses
- Old af or young af
- Lab abnormalities
- Social concerns
What is the underlying mechanism that characterizes heat stroke?
Dysfunction of heat regulation, leading to hyperthermia & end-organ damage
What tissues and cells are MOST SENSITIVE to heat stress?
- Neural tissue (Brain)
- Hepatocytes (Liver)
- Nephrons (Kidney)
- Vascular endothelium (blood vessels)
Brain, liver, kidney, blood
Define hyperthermia
Core body temp > 104F or 40C
What are the two types of heat stroke?
- Exertional (rapid)
- Non-exertional (slow)
What are the primary S/S that suggest heat stroke over anything else?
- Confusion
- Seizure
- Delirium
- Ataxia
- Coma
Neuro!
What life-threatening condition can heat stroke cause?
DIC
What would you order in a workup for heat stroke?
- CBC, PT/PTT (DIC)
- CMP
- Phosphate (hypo occurs due to renal dysfunction)
- UA
- CK
- EKG
- CXR
UA findings include protein, myoglobin, and tubular casts.
UA can be concentrated with protein due to kidney leakage.
What is the first step in managing heat stroke?
RAPID COOLING
- Ice water submersion (preferred)
- Disrobe/spray water + fan blowing
- Cooling blanket with ice packs over great vessels
If a patient is shivering severely in heat stroke, what can you give them?
IV BZD
What is the preferred temperature monitoring technique for heat stroke?
Rectal until its down to 102F
If Rapid cooling & IV BZDs all fail for heat stroke, what is your last resort?
Internal lavage
What is ideal Urine Output in Heat stroke?
50-100 mL/h
Adjust IV fluids PRN to reach this.
Bolus 1-2L if hypotensive or rhabdo
When would you ventilate/intubate in heat stroke?
Significant AMS
When do you admit to ICU for heat stroke?
- Hemodynamic instability
- Severe LFTs
- Rhabdo
Everyone else to med-surg
Heat stroke always requires admit then?
What are the unfavorable prognostic signs for heat stroke?
- Extreme hyperpyrexia (> 42C/107.6F)
- Persistent coma after cooling
- Markedly elevated LFTs
- Hyperkalemia + extensive rhabdo
How does mild frostbite present prior to re-warming?
- Paresthesias
- Pruiritis of tissue involved
- Loss of sensation and fine motor control
How does mod-severe frostbite present prior to re-warming?
- Decreased ROM
- Blister formation
- Edema
- Tissue appears white
- Firm/hard
- Cool to touch
How does frostbite present once you have rewarmed them?
- Stinging/burning/aching/throbbing/tender
- Tissue discoloration + loss of elasticity and mobility
- Profound edema, hemorrhagic blisters, necrosis, gangrene
Describe the 4 degrees of frostbite.
- Erythema & edema, no blister, skin peeling
- serous blister
- Necrosis, hemorrhagic blister, SQ involvement
- Full-thickness down to bone, dry, black, mummified eschar, ded
What are the 2 things to remember when treating frostbite initially?
- Treat systemic hypothermia first
- If you’re gunna rewarm, you gotta do it completely!
How do you rewarm frostbite?
Rapid rewarming in circulating water at 98.6F-102.2F
Can give NSAIDs cause it might hurt
15-60 minutes, until skin turns red-purple and pliable. Air dry.
After you rewarm some frostbitten fingers, what is next for wound care?
- Keep sterile
- Topical aloe vera Q6h
- Debridge in whirlpool if dead tissue
- Splinting to prevent contracture
- Elevate extremity to lessen edema
- Update tetanus
Aloe vera helps with collagen recomposition.
When can you send frostbite home?
Only with a limited 1st degree injury.
Everything else needs admit
Define hypothermia
Core body temp < 35C/95F
Rectal, bladder, or esophageal thermometer
What usually causes primary hypothermia?
Out in the cold after drugs/alcohol use
Who is most at risk for impaired shivering?
- Age extremities
- Malnutrition
- Physical exhaustion
- Neuromuscular dz
How do cardiac arrhythmias progress in hypothermia?
- Bradycardia
- Afib with slow response
- VF
- Asystole
Usually around HT 3, which is < 28C
What are the 4 levels of hypothermia?
- Mild 32-35C
- Moderate 28-32C
- Severe < 28C
- Pretty much dead < 24C (no vitals left)
First step in managing hypothermia 1 & 2
Warm em up
How is HT 1 managed?
- Warm em up
- Active movement
- Warm oral sugary drinks
How do we manage HT 2?
- Full rewarming via blankets
- Warmed IV fluids
How do we manage HT 3?
- Airway management
- Rewarming can treat rhythms besides VF
- Defibrillate once prior to rewarming if in VF
What is the ideal rewarming method for HT 3?
ECMO