Occupational and Environmental

Question 1

What are the features of Hydrogen Sulfide poisoning?

Answer 1

Exposures: petroleum industry, enclosed areas where organic matter is being broken down (sewers/swamps)
Buzzwords: odor of rotten eggs, “knock down gas”, discolored nail beds
Symptoms: immediate loss of consciousness, can cause asphyxiation. Lower exposures (10-500ppm) cause respiratory symptoms like rhinitis to respiratory failure and can affect cardiovascular, renal, hepatic, hematologic systems.

Question 2

What are the features of carbon monoxide poisoning?

Answer 2

Exposures: incomplete combustion of natural gas or other carbonaceous material (gasoline, kerosene, oil, propane, coal, wood)
Buzzwords: odorless, cherry red skin color, retinal hemorrhages
Symptoms: headache, fatigue, dizziness, drowsiness, nausea–> vomiting, confusion, collapse–> LOC, muscle weakness, death
Dx: 10+% carboxyhemoglobin
Tx: HF oxygen or hyperbaric oxygen

Question 3

What are the features of toluene diisocyanate (TDI) poisoning?

Answer 3

Exposures: production of polyurethanes and consumer products like coatings, elastomer, adhesives, paints, sealants
Symptoms: asthma, lung damage, rarely fatal reactions. Usually subacute and chronic

Question 4

What are the features of cadmium poisoning?

Answer 4

Exposures: air, water, soil, food
Symptoms: can lead to cancer, affects skeletal/urinary/reproductive/cardiovascular/central/peripheral nerves/respiratory. Can develop COPD and emphysema

Question 5

What are the features of metal fume fever?

Answer 5

Exposures: inhalation of metal oxides from welding, particularly zinc oxide.
Symptoms: fever, cough, wheezing, chest tightness, fatigue, chills, myalgias, dyspnea. 4-10hrs after exposure

OTC analgesics may help

Question 6

What are the guidelines for smoking cessation?

Answer 6

Combination of behavioral and pharmacotherapy be used, regardless of readiness to quit.

Psych/substance use issues are not a contraindication for varenacline, but should monitor for changes in behavioral changes and psych symptoms

Question 7

How does high flow oxygen support help decompression sickness?

Answer 7

The oxygen rich/nitrogen poor gradient helps resorb the nitrogen gas that has bubbled out

Question 8

What are the low, miderate, and high risk factors for developing acute mountain sickness?

Answer 8

Low: no Hx, less than 2800m (9186ft), taking more than 2 days to arrive at 2500-3000m with subsequent increases in sleeping elevation less than 500m/day and an extra day for acclimatization every 1000m

Moderate: PHx and ascending to 2500-28000 or no PHx and 2800+ in 1 day or more than 500m per day above 3000m with extra day of acclimatization every 1000m

High: PHx, going higher than 2800 in 1 day, Hx HACE, 3500m in 1 day, more than 500m per day above 3000m without extra days for acclimatization, or very rapid ascends

Question 9

What are the features of domestically acquired particulate lung disease (hut lung)?

Answer 9

Pneumoconiosis of inhalation of smoke from biomass fuels in poorly ventilated huts or domestic settings

Anthracotic pigment-laden macrophages on biopsy. Mid/upper zone reticulation, bronchial wall thickening, GGO, mosaicism (more closely resembles chronic HP)

Question 10

What are the features of chronic simple nodular silicosis?

Answer 10

Histo: silicotic nodule (acellular well demarcated fibrotic lesion), birefringent polyhedral particles 1-2 um in maximal dimension interspersed with needle like crystals
Features:
Imaging: innumerable centrilobular rounded micronodules

Question 11

In evaluating EVALI, what can be seen in BAL samples?

Answer 11

Tetrahydrocannabinol and/or vitamin E acetate (the latter with more severe respiratory compromise)

Question 12

What are the features of berylliosis?

Answer 12

Exposure: heat-resistant/lightweight parts in aerospace industry
Buzzwords: radiographic features of sarcoid
Symptoms: acute pneumonitis in acute exposures. Chronic–> like sarcoid without extrapulmonary problems. Latency months to years. Cough, fever, night sweats, fatigue
Dx: beryllium lymphocyte transformation test showing sensitization

Question 13

What are the features of “building related illness”

Answer 13

Exposure: poor ventilation in building or a specific identified contaminant
Buzzword: sick building syndrome
Symptoms: worsens at work, resolves at home, 10-20% of cohort with vague symptoms.

Question 14

What is the difference between work-exacerbated asthma and occupational asthma?

Answer 14

Work-exacerbated: Asthma triggered by work with patients with pre-existing asthma (can diagnose with specific inhalation challenge)

Occupational asthma: asthma triggered de novo by sensitization to a specific substance at work

Question 15

What are some common antigens for immune mediated work related asthma?

Answer 15

High molecular weight antigens:
flour/grain dust for bakers, animal protein for lab workers like murine urine, natural rubber latex in healthcare

Low molecular weight antigens:
metal salts, isocyanates (TDI, HDI), red cedar dust, acid anhydrides in epoxy, colophony in soderers

Question 16

What are the features of nitrogen narcosis?

Answer 16

Exposure: divers, may be precipitated by rapid descent
Symptom: intoxicating effect of compressed nitrogen

Limit dives to less than 30-40m

Question 17

What are the indications for hyperbaric oxygen therapy?

Answer 17

Non healing wounds and compromised skin grafts, radiation injury, acute traumatic/thermal injury, arterial gas embolisms, decompression sickness, CO or cyanide poisoning, certain complex infections

Question 18

What are the features of coal workers pneumoconiosis?

Answer 18

Histo: coal laden macrophages
Features: exposure to coal dust, graphite and other forms of carbon, asymptomatic to cor pulmonale. Not associated with cancer unlike silicosis
Buzzword: black nodules
Imaging: centrilobular emphysema

Caplan’s syndrome: conglomerate masses that cavitate, associated with RA

Question 19

What are the features of asbestosis?

Answer 19

Histo: ferrunginous bodies (small brown nodules in septum)
Features: mining, ship building, pipe cutters, textiles. Can have benign pleural effusions (L>R, often asymptomatic), pleural plaques (not a sign of cancer but if present in cancer portends worse outcomes)

Question 20

What are the features of cobalt-associated disease?

Answer 20

Airway obstruction, AIP (HP-like), or chronic giant cell interstitial pneumonitis in a metal worker

Question 21

Rattle off some buzzword associations with occupational/environmental

Answer 21

Question 22

Rattle off some buzzword associations with occupational/environmental

Answer 22