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HIGHYIELD RC 2023 > ORALS - ENVIRONMENT > Flashcards

ORALS - ENVIRONMENT Flashcards

1
Q

HYPOTHERMIA ARREST

A
  1. PPE/MOVID
    resus team / RT
    monitors / cardiac pads
    2 large bore IVs, if unable to establish IOs
  2. ACLS modifications
    PALPATE pulse for 1min
    Shockable rhyhthm - defibrillate at 200J x1 (ACLS) until temp >30 is acheieved
    if bradycardia - avoid pacing until 32deg (transcut less irritating)
    => Administer medications per ACLS algorithm
    however x1 dose only until temp 30deg
    => Actively re-warm until TEMP 32 deg
  3. Ensure ongoing high quality CPR at a 30:2 ratio unless contrainidications
  4. Management considerations
    => treat other injuries (i.e. frostbite)
    => tetanus
    => consider ABX (in old / children)
    => consult CV surgery early (ECMO)
  5. ROSC (ETCO2 >40, spontaenous arterial pressure)
    repeat set of vitals
    ECG
    Hypotension with pressors with MAP >65
    appropriate sedation
    Temperature management for normothermia, monitor with rectal or esophageal probes
    foley for ins/outs

follow up questions
1. list contrainidications to CPR in hypothermic arrest
DNR
Signs of life
Obvious lethal traumatic injury (transection, decapitation)
Impossible to compress chest
Danger to rescuer
Avalanche burial with snow packed airway and >35 mins
Decomposition, rigor mortis

  1. Describe stages of hypothermia
    stage 1 (32-35) - shiver, conscious
    stage 2 (28-31) - decr shivering, AF, decr LOC
    stage 3 (24-27) - VF risk, no reflexes, pulm edema, hypotension
    stage 4 (24) - flat EEG, asystole
  2. ECG findings of hypothermia
    Osbourne J at < 32
    PR prolong
    QRS prolong
    QT prolong
    Brady
    AF
    Asystole
  3. medications that predispose to hypothermia
    ETOH
    antipsychotics
    benzos
    GA
    heroin
    barbiturates
  4. factors that contribute to hypothermia
    => Decreased heat production: Hypothyroid, Malnutrition, Hypoglycemia
    => Increased heat loss: Immersion, Tox-etoh, Burns, Skin conditions
    => Impaired thermoregulation: CVA, SAH, Parkinsons, MS
    => Sepsis
    => Trauma
    => Iatrogenic
  5. Describe indications for termination of resus
    warm + dead
    unsurvivable trauma
    K>12
    Ammonia >250
    low fibrinogen
  6. How does ABG interpretation change with hypothermia
    => blood rewarmed
    => incr partial pressure of dissolved gases
    => higher PCO2 then pt actually has
    => lower PH than patient actually has
    => higer O2 than patient actually has
  7. Describe methods of rewarming this patient
    passive external: remove clothes, warm environment, cover w blanket
    active, external: warm packs, immersion (AV rewarming), bheir hugger / forced air
    active, internal: non invasive (warmed humidified air, warm IVF), invasive (lavage - bladder, chest, peritoneal), ECMO
  8. indications for active rewarming
    Unstable
    less than 32
    Start invasive active at less than 28
    Endocrine insufficiency
    Trauma or Tox related peripheral vasodilation
    Hypothermia secondary to impaired thermoregulation
  9. what is core afterdrop
    core body temp lowers after removed from cold 2’ cold blood from periphery returning to cold (result of vasodilation when rewarming)
  10. what is rescue collapse
    cardiac arrest 2’ extrication / transportation 2’ circulatory collapse 2’
    => hypovolemia
    => arrhythmias triggered by intervention
    => further cooling
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2
Q

FROSTBITE CASE

A
  1. PPE/MOVID
  2. MGMT
    stabilize core temp
    administer volume replacement
    dry and elevate frostbite limb
    immersion into warm water (37-39deg), no massage
    debride broken vesicles and non hematologic vesicles over joints
  3. Medications
    ibuprofen 600mg
    apply topical antibiotics
    TDAP
  4. Consider:
    CTA/imaging
    consider TPA
    consider iloprost

follow up questions

  1. How to adivse EMS to care for frostbite pre-ER
    => Remove from cold
    => Prevent re-freeze injury, do not rewarm unless sure will not refreeze
    => Analgesia
    => Remove wet or constricting clothing
    => Don’t rub/massage
    =. Don’t used forced air
    => Don’t use fire or dry heat (=burns)
    => Protect part (consider splinting)
  2. Describe sequelae of frostbite
    Phantom pain
    CRPS, Chronic pain
    paresthesia
    Heat sensitivity
    Hyperhidrosis
    Raynauds
    Compartment syndrome
    OA
    Amputation
    Sepsis
  3. Prognostication factors for frostbite
    good => normal sensation, warmth, early blister formation
    bad => delayed / late bleb formation, residual violaceous hue, hemorrhagic vesicles
    => lac of edema, eschar
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3
Q

HEAT ILLNESS CASE

A

STROKE presentation = seizure, pulm edema/ARDS, hypotension ,DIC, rhabdo/ATN, hypocalcemia, LFT (>1000 exhaust / >10 000 stroke)

  1. PPE/MOVID
    BW: LFTs, CK/Myo, trop, coagulation panel, fibrinogen/INR
    CT head - punctate hemorrhages (3rd/4th ventricle)
  2. Management
    => treat complications - DIC, seizure, rhabdo, hypoglycemia
    => treat volume: hypotension, Na concentration
    => cool (internal + external)

follow up questions
1. Methods of cooling
**External **:
=> Remove from env
=> Misting with fans for evaporative cooling
=> Ice water immersion
=> Ice packs
=> Cooling blanket
Internal
=> Cool IVF
=> Lavage- rectal and gastric
=> CV bypass
=> Disable warming circuits on vent

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4
Q

ELECTRICAL INJURY CASE

A
  1. PPE/MOVID
    BW: Ck/Myo, LFT, lipase, T+S, Coags
    ECG
  2. Do they require investigation?
    => >1000 volts
    => Syncope or LOC
    => Entry or exit wound
    => Burns
    => symptomatic
  3. Telemetry if:
    Have cardiac arrest
    LOC
    Abnormal ECG
    Dysrhythmia
    Hx of cardiac disease
    Concomitant injury requiring admission
    Hypoxia
    CP
    + RF for cardiac disease
  4. MGMT
    CT / XR for trauma
    compartment syndrome
    BURNS - parkland 2cc/kg X TBSA (50% / 8HR then 50% / 16H)
    tetanus

follow up questions
1. Severity of injury from electrocution
Voltage
Amperage
Resistance (high resistance seen in bones)
Current pathway
Circuit type (AC in your house- causes grasping vs DC- throws patients )
Contact duration

  1. mechanism of injury from lightning strike
    Direct strike- conduction
    Indirect- touching an object that is strike
    Side flash- lightning jumps
    Ground current/stride injury- lightning spreads through the ground and goes up the leg
    Thermal burn
    Blunt trauma- barotrauma, blunt trauma
    Shrapnel
  2. Findings of lightning strike
    Wet clothing
    Disintegrated clothing
    Multiple victims
    Lictenberg figures- flashover effect
    TM rupture
    Cataracts
    Magnetization of metallic objects
    ECG changes
    Burns where there was metal touching the skin
  3. Complications of lightening strike
    Cardiac arrest
    Burns
    Delayed hemorrhage
    Rhabdo
    Compartment syndrome
    Clostridial myositis
    Amputation
    Spinal cord syndromes
    Keraunoparalysis- temporary paralysis due to vascular spasm and sympathetic instability, lower extremities mottled and blue
    Seizure do
    Psych issues
  4. Discharge criteria for patients struck by lightening
    no LOC
    normal ECG
    no symptoms
    no evidence of direct strike
  5. ECG changes in pt struck by lightening
    STE
    QTprolong
    AF
    TWI or flattening
    MI
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5
Q

DIVE CASE

A
  1. PPE/MOVID
  2. Dive hx
    dive depth, length
    fly post dive (2H = 12h, days = 24H, DCS1 = no fly, ACE/DCS2 = no fly 4wks)
    dive at altitude
    decompression stops
    type of gas
    med hx (RF: fatigue, obesity, fever, dehydration, strenous activity, ETOH, cold ambient temp)
    contraindications (PFO, PTX, sinus/ear pathology)
  3. MGMT
    100% FiO2
    IVF - judicious if AGE, pulm edema, cerebral edema
    DCS1 - BP cuff on joint = decompress gas
    arrange HBOT
    r/o other causes
  4. HBOT goals
    reduce mechanical obstruction of bubbles
    100% O2 displaces N from lungs = N removal
    increased O2 delivery to ischemic tissues

follow up questions
1. ddx for descent injuries
middle ear barotrauma (Transient CN7, decongestant, antihistamine, perf-abx, ENT)
IET (perm, rupture of round window, neural hearing loss, supportive, no valsalva, ENT)
EET, facial, sinus barotrauma

  1. What law explains diving injuries
    volume = 1/P (gas in body decreases as pressure increases - on descent)
  2. ddx for at depth injuries
    nitrogen narcosis (disorientation, impaired judgement)
    O2 toxicity (pneumonitis, burn w inspiration, tunnel vision, dizzy)
    contam gas (CO2/CO/CaOH)
  3. DDX for ascent injuries (rapid ascent, acute onset)
    alternobaric vertigo (decongestants)
    barodontalgia
    pulmonary barotrauma
    AGE (air gas embolism - forced across capillaries into arterial system => MI, CA, PE, neuro)
  4. DDX for ascent injuries (long dive, near limit)
    DCS (nitrogen bubbles as pressure decr)
    DCS1 - MSK, skin, lymphatics // DCS2 - ear, lungs - chokes, heart, spinal cord, brain
  5. How to transport ACE/DCS
    AGE - ground prefererred, if flying only => fixed wing (pressurized to sea level)
    Instruct balloons are filled NS (ETT, foley) - altitude will cause bubbles to expand
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6
Q

HIGH ALTITUDE MEDICINE CASE

A
  1. AMS CASE (HA, anorexia, fatigue, insomnia)
    PPE/MOVID
    rest 1-4d
    descend 1500-3000 ft if not resolving
    HBOT, 100% FiO2
    Symptom mgmt (NSAIDs - HA, prochlorperazine for NV)
    acetazolamide 250mg
    dex 8mg IV
    tx contributing factors - hypotherm, trauma, CO tox
  2. HAPE CASE(cough, SOB, fatigue, cyanosis, rales - B/L infiltrates, no bat wing)
    PPE/MOVID
    Consider descent, rest, warm, ABCs
    HBOT (or portable HB chamber to temporize)
    100% FiO2
    Acetazolamide 250mg BID
    Nifedipine 30mg BID (pulm vasodilator)
    Dex 8mg PO BID
    Ventolin 125mcg BID
    Tadalafil 10mg BID (pulm vasodilator)
    PPV => intubate
    r/o other ddx - CO, PNA, PTX, PE, ACS, CHF, AECODE,
  3. HACE CASE (ataxia, dysarthria, HA)
    PPE/MOVID
    immediate descent
    HBOT (portable hyperbaric bag to temporize)
    high flow FiO2
    acetazolamide (post recovery)
    dex 8mg => 4mg Q4-6H
    prochlorperazine 10mg
    ICP mgmt (hypervent, mannitol (1g/kg), 3% saline (100cc or 3cc/kg), HOBE)
    CT brain
    r/o ddx - CVA, hypoglycemia, CO, hypothermia, seizure, tox, vert dissection

follow up questions

  1. Describe the HVR
    carotid bodies - sense low PaO2 => signal resp to incr MV
    resp alkalosis = negative feedback for response
  2. Absolute contraindications to high altitude exposure
    SCD
    Pulm HTN
    uncompensated CHF
    Severe COPD
  3. Strategies to prevent AMS / HACE
    Gradual ascent
    hydration
    mild exercise
    acetazolamide (acclimatization)
    high carb diet
    avoid ETOH / drugs
  4. RF for altitude related illnesses
    rate of ascent
    sleep at altitude
    final altitude
    duration of stay
    individual susceptibility
    use of sedatives
  5. How does acetazolamide work
    renal diuresis of HCO3 = decreased ph = increased minute ventilation
    also decr overal volume (from diuresis)
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7
Q

DROWNING CASE

A
  1. PPE/MOVID
  2. ABCs
  3. treat hypothermia
  4. treat causes for drowning - hypoglycemia, ACS, drug OD, seizure, C spine injury
  5. Intubation
    => ARDS lung protection (RR10-15, VT 4-6, peep 5)
    => frothing (2’ surfactant washout) = needs PEEP, not suction (BIPAP vs intubation)

follow up questions
1. ddx for a non cardiogenic pulmonary edema
WATER BATHS
water submersion
aspiration
toxic ingestion (ASA)
embolism
re-expansion pulm edema
brain bleed
ARDS
toxin inhalation
HAPE
strangulation

  1. List risk factors for drowning
    ETOH
    race
    summer months
    seizure d/o
    prolonged QT syndrome
    developmental delay
  2. List poor prognostic factors post drowning
    less than 3yrs
    10min submierssion / CPR time
    GCS 3
    asystole
    hypothermia
    severe acidosis
    unreactive pupils
  3. List admission criteria post drowning
    symptomatic
    hx of apnea
    LOC
    dysrryhthmia
    abnormal CXR
    dc if normal O2 sat, ABG, no symptoms x6H, normal CXR
  4. Describe immersion syndrome
    arryhtmia (massive catecholamine surge) or syncope (vagal) on contact with water that is 5 deg colder than body, then drown
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8
Q

RADIATION CASE

describe mgmt plan for radiation exposure

A
  1. PRE-RESUS
    contact radiation control (cdn nuclear safety commission)
    ensure decontamination area (clothing placed in sealed bag)
    separate ED entrance
  2. PPE/MOVID
    dosimeter
    BW: Q6h X24h then daily, ALC (500 @ 48H = bad)
    treat life threats
    wash patient
    => soap + water
    => trim nails
    => collect water as radioactive waste
    continue decontam until no radiation picked up
  3. MGMT
    record time of vomit (1H = >6.5Gy - DEADLY, 4H = 3.5Gy)
    neuro symptoms within 24H (comfort care)

follow up questions
1. What are the stages of acute radiation sickness
prodromal - non specific, N/V, fatigue
latent - S/S stop
Heme - first sub syndrome => hematopoietic cells most sensitive
GI - >6Gy, NVD
Neurovascular - lethal, seizure, AMS, ataxia, coma

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9
Q

CHEMICAL INURY CASE

brick cleaner, glass etching, rust cleaner, rim cleaner (HF)

A
  1. PPE/MOVID
    decontamination => irrigate copiously, debride blisters
    ECG = hypocalcemia (prolonged QTC)
  2. MGMT: antidote = calcium
    CaGlc topical gel
    intradermal Caglc 0.5cc
    refractory = 10cc of 10% caclcium gluconate in 40cc NS arterial injection
    IV with beir block
  3. Consults
    plastics

follow up questions
1. Consequences of HF toxicity
electrolytes - HyperK, hypoMg, hypoCa
QT prolongation, hypotension, ventricular dysrhythmias
MSK - tetany, cramps
CNS - seizures, confusion
DERM - burn, liquefaction, coagulation necrosis
resp - distress if inhaled

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10
Q

EXPOSURE - NO/NO2/N2O

Trapped in a grain silo (methemoglobinemia case)

A
  1. PPE/MOVID
  2. Methylene blue 1-2mg IV / 5min if >25% Q15min
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HIGHYIELD RC 2023 (20 decks)

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