Mock Exam Part 2, #1-15 Reviewer Flashcards
Standard of care for the treatment of AMS (Mild to moderate)
Acetazolamide
dose of 125-250 milligrams PO twice daily
reserved for cases of moderate to severe AMS because of potential side effects
Dexamethasone
Dose of 4 milligrams PO, IM, or IV every 6 hours
Used in the prevention and TREATMENT of HAPE
But NO value in AMS or HACE
not necessary if supplemental oxygen available
Nifedipine
Dose of 20–30 milligrams extended-release PO every 12 h
Adverse effects of Acetazolamide
Common: paresthesias, polyuria, altered taste of carbonated beverages
Less common: drowsiness, nausea
What is SUBMERSION vs IMMERSION?
SUBMERSION
> majority of drowning
> patient goes under water, suffers hypoxic cardiac arrest, develops hypothermia
> unlikely to benefit from prolonged resuscitation EXCEPT children
IMMERSION
> less common
> immersed in cold water but able to breathe air, cooling ensues, and the patient eventually suffers a presumed hypothermic cardiac arrest and may or may not become secondarily submerged
> benefits from prolonged resuscitation
first definitive step of frostbite therapy
Rapid rewarming
should be initiated as soon as the risk of refreezing injury can be avoided
In rewarming frostbite, place the injured extremity in gently circulating water heated to a temperature of _________°C for approximately 20 to 30 minutes, until the distal extremity is pliable and erythematous.
37 to 39 deg C
The cardinal features of heat stroke are
hyperthermia >40°C
and
altered mental status
Management of Stingray Injuries
> Irrigate wound
Remove visible pieces of the spine
Control bleeding and immerse in hot water
During hot water soak, the wound can be explored and foreign material removed
Provide oral or parenteral analgesics
Obtain SOFT TISSUE IMAGING to visualize retained foreign material
In Stingray injuries hot water submersion between temperature of __________°C can denature the venom protein and provide pain relief within 10 to 30 minutes
43.3°C and 45.6
Clinical indications for immediate antivenom therapy
evidence of neurotoxic effects (ptosis, cranial nerve involvement, progressive muscle weakness, or diaphragmatic involvement)
coagulopathy
rhabdomyolysis
renal failure
cardiac collapse
significant local tissue injury
vomiting unresponsive to antiemetics
Administration of Snakebite (Elapid) ANTIVENOM
IV always.
If IV access is unavailable, consider IO administration.
IM administration is strongly discouraged due to slow absorption and potential complications of anticoagulation.
Skin testing before antivenom administration is not recommended
Dilute anti- venom about 1:10 in normal saline, then infuse 20 to 30 mins
Same dose in children
5-day course of steroids (e.g., prednisone, 1 milligram/kg PO once daily) may be prescribed to reduce the incidence of serum sickness, but lacks evidence
The clinical conditions of barotrauma of ASCENT
Mnemonic:
Akyat na dahil VERy DEEP na
VERtigo (alternobaric)
DEcompression sickness,
Embolism (arterial gas) - neurologic symptoms
Pulmonary barotrauma - Dyspnea, chest pain, subcutaneous air, extra-alveolar air on radiograph
clinical conditions resulting from barotrauma of DESCENT
Kapit ka (Squeeze) kapag BABABA
BArotitis (ear squeeze),
external ear Squeeze,
sinus BArotrauma,
inner ear BArotrauma,
and face, tooth, or dry-suit Squeeze
Ear Squeeze - Pain, fullness, vertigo, conductive hearing loss from inability to equalize middle ear pressure
Sinus barotrauma - Pain over affected sinus, possible bleeding from nares
Inner ear barotrauma- Sudden onset of sensorineural hearing loss, tinnitus, severe vertigo after forced Valsalva
What TYPE of Decompression Sickness (DCS) presents with
Deep pain in single joint (knee/ shoulder) and extremities, unrelieved but not worsened with movement
Skin changes—mottling, pruritus, and color changes
Type I: “pain-only” DCS
What TYPE of Decompression Sickness (DCS) presents with
Pulmonary (“chokes”)—cough, hemoptysis, dyspnea, and substernal chest pain
Cardiovascular collapse can occur
Neurologic—sensation of truncal constriction, ascending paralysis, usually rapid in onset
Vestibular (“staggers”)—vertigo, hearing loss, tinnitus, and disequilibrium
Type II: “serious” DCS
What TYPE of Decompression Sickness (DCS) presents with
Symptoms of “staggers”, “chokes” and STROKE SSx occuring on ascent or immediately upon surfacing
Type III: combination of DCS and arterial gas embolism
The San Diego Diving and Hyperbaric Organizations criteria for arterial gas embolism uses a cut point of _____ points for the diagnosis of arterial gas embolism
≥2
- Initial tingling to numbness then localized edema, erythema, cyanosis, plaques, nodules, and, in rare cases, ulcerations, vesicles, and bullae, 12 to 24 hours after exposure
- With pruritus and burning paresthesias
- Tender blue nodules on rewarming.
- long-term intermittent exposure to damp nonfreezing ambient temperatures
- most commonly affecting feet (toes), hands, ears, and lower legs
CHILBLAINS or PERNIO
- mild degrees of necrosis of subcutaneous fat tissue that develops during prolonged exposure to temperatures just above freezing
- observed in children exposed to topical cold objects and on the thighs and buttocks of young women involved in equestrian activities
PANNICULITIS
hypersensitivity to cold air or water, which in rare cases may lead to anaphylaxis
Young adults and children and those with atopy are most commonly affected
COLD URTICARIA
Classify the frostbite injury:
Numbness, central pallor with surrounding erythema and edema, desquamation, dysesthesia
First degree
Classify the frostbite injury:
partial skin freezing, erythema, mild edema, lack of blisters, and occasional skin desquamation several days later. The patient may complain of stinging and burning, followed by throbbing
First degree
Classify the frostbite injury:
Blisters of the skin with surrounding edema and erythema
Second degree
Classify the frostbite injury:
- full-thickness skin freezing, formation of substantial edema over 3 to 4 hours, erythema, and formation of clear blisters filled with fluid rich in thromboxane and prostaglandins
- blisters form within 6 to 24 hours, extend to the end of the digit, and usually desquamate and form hard black eschars over several days.
- numbness, followed by aching and throbbing.
Second degree
Classify the frostbite injury:
Tissue loss involving the entire thickness of the skin; hemorrhagic blisters
Third degree
Classify the frostbite injury:
damage that extends into the subdermal plexus.
Hemorrhagic blisters with skin necrosis and a blue-gray discoloration
like a “block of wood,” with burning, throbbing, and shooting pains
Third degree
Classify the frostbite injury:
The skin is mottled, with nonblanching cyanosis, and eventually forms a deep, dry, black, mummified eschar. Vesicles often present late, if at all, and may be small, bloody blebs
Fourth degree
From the DROWNING Algorithm, when do you decide to discharge or admit patient? When do you decide to observe for 4-6 hours?
- progressive neurologic deterioration or ataxia in an individual who has recently ascended to high altitude
- Headache, nausea, and vomiting are common antecedents
- characterized by altered mental status, ataxia, stupor, and progression to coma if untreated
- Focal neurologic signs such as third or sixth cranial nerve palsies.
HACE
HIGH-ALTITUDE CEREBRAL EDEMA
Because early diagnosis is critical, _________ or __________
should raise the suspicion of early HAPE or HIGH-ALTITUDE PULMONARY EDEMA
decreased exercise performance
or
dry cough
hallmark of HAPE or HIGH-ALTITUDE PULMONARY EDEMA
Progression of dyspnea with exertion to dyspnea at rest
HAPE treatment of choice
Immediate descent
Treatment of HACE
oxygen supplementation, descent, and steroid therapy
Descent is the highest priority
Oxygen 2–4 L/min or titrated to SaO2 >90%
Dexamethasone, 8 milligrams PO, IM, or IV, then 4 m illigrams every 6 h
Hyperbaric therapy if patient cannot descend
Treatment for Periodic breathing/ insomnia
Acetazolamide, 62.5–125.0 milligrams PO at bedtime as needed
High-altitude pulmonary edema treatment
Immediate descent or evacuation
Oxygen 4 L/min or titrated to SaO2 >90%
Nifedipine, 30 milligrams PO extended-release every 12 h, or tadalafil, 10 milligrams PO every 12 h if no oxygen or descent*
Hyperbaric therapy if patient cannot descend
Measures to minimize patient exertion and keep patient warm
Dexamethasone if cerebral signs present, 4 milligrams PO every 6 h
Moderate/severe AMS treatment
Immediate descent for worsening symptoms
Low-flow oxygen if available
Acetazolamide, 250 milligrams PO twice a day, and/or dexamethasone, 4 milligrams PO every 6 h
Hyperbaric therapy
Mild AMS treatment
No further ascent
Descent to lower altitude or acclimatization at same altitude
Acetazolamide, 125–250 milligrams PO twice a day, to speed acclimatization
Symptomatic treatment as necessary with analgesics and antiemetics
syndrome characterized by headache along with some combination of nausea or vomiting, dizziness, fatigue, or sleep disturbance
AMS
ACUTE MOUNTAIN SICKNESS
