PHYSICAL AND ENVIRONMENTAL AGENTS, BURNS, AND SMOKE INHALATION

Question 1

A woman comes into clinic on a chilly winter day in downtown Portland. She has red lesions on her extremities that became swollen and blistered after she rewarmed. What is this, how do you treat it?

Answer 1

Chilblains. Passively rewarm

Question 2

You are in a rain forest and your buddy complains that his feet are losing sensation. He takes off wet boots and you see pale, macerated, blistering feet. What is this and how do you treat it?

Answer 2

immersion foot. Dry, warm, treat infection.

Question 3

You go for a jog while visiting a friend who lives in the Swiss alps. Your nose and cheek become cold and very pale. What is this? TX?

Answer 3

Frost bite, first degree in epidermis, passive rewarm

Question 4

It’s winter and you get into a big snowball fight without gloves. Your hands become blue so you go inside and start to develop clear blisters. What is this? TX?

Answer 4

2nd degree frost bite, dermis, rewarm w/ warm fluid

Question 5

A man passes out from drinking and is found in a snow bank. When he starts to rewarm you notice hemorrhagic blisters. What is this?

Answer 5

3rd degree frost bite, subQ, rewarm w/ warm fluid

Question 6

A refugee had to walk through snow for 5 days in tennis shoes, his toes are swollen, black and necrotic. What is this? TX?

Answer 6

4th degree frost bite. Full thickness. splint, rewarm in warm fluid, lytics, inf. Control

Question 7

Define mild hypothermia by sx and temp. How do you treat it?

Answer 7

mild: 90-95.
confusion, tachycardic, shivering.
passive rewarm.

Question 8

Define moderate hypothermia by sx and temp. How do you treat it?

Answer 8

82-90
lethargy, brady/arrhyth, less shivering, no pupil reflx.
TX: ABC, active rewarm trunk first.

Question 9

Define severe hypothermia by sx and temp. How do you treat it?

Answer 9

<82
coma, hypotension, arrhyth, pulm ed, rigid
TX: ABC, warm IV (No LR), lavage, Extra corp. ABX, Glucose, fluids, look out for hyperK, rhabdo.

Question 10

Steve just got done with an Insanity workout video and his leg muscle is contracting uncontrollably. What now?

Answer 10

Heat cramp.
Sports drink/ NS
stretch and relax

Question 11

Betty is an older woman who shows up in the ER on a hot day. She was working in her garden when she passed out. She has a core temp of 103, is tachycardic, diaphoretic, hypotensive and has a headache. What now?

Answer 11

Heat exhaustion

Cool and treat shock by elevating legs and giving fluids

Question 12

Wayne was throwing hay bales onto his truck in the middle of August in Texas. His co-worker said he started acting strange, couldn’t walk straight, threw up and passed out. You find him in clinic hypotensive and with a core temp of >104 degrees. What now?

Answer 12

Heat stroke
rapid cooling w/ immersion or evaporation
expect rhabdo, electrolyte abnormalities and end organ damage

Question 13

A teenager was knocked unconscious after taking a spill while tubing behind a speed boat. Her friends found her apneic and performed CPR. She started breathing again and was taken to the ED. What now?

Answer 13

be suspicious for end organ dysfunction from hypoxemia, ARDS, Brain damage, Arrythmias, etc.

• Admit and give 02 by PPV per need
• keep PT until symptoms resolve
• if asymptomatic watch for 8 hours then release.

Question 14

Phil was repairing his HAM radio antenna in a lightning storm and was struck by lightning. What sort of injuries do you suspect?

Answer 14

burns that may not be evident from the surface, compartment syndrome, arrhythmias, vascular coagulation, rhabdo…

Question 15

Diver Dave sees a great white shark and shoots to the surface. Less than an hour later he feels localized joint pain in his elbow and shoulder and his chest is itchy and mottled looking. What is this?

Answer 15

DCS type 1 Musc/skel complaints

Fluids, O2 and Hyperbaric chamber

Question 16

Scuba Steve decides to try to ride a whale shark and it takes him to the surface abruptly. He is taken aboard his dive boat and he immediately loses control of his bladder, starts complaining of tingling in his legs, difficulty breathing and is behaving strangely. What is this?

Answer 16

DCS type 2 Neuro/pulm complaints

Fluids, O2 and hyperbaric chamber

Question 17

Jim decides to hike to the top of a local mountain that is about 6500 ft. He gets a severe headache with malaise. What is this and how do you treat it?

Answer 17

Acute mountain sickness

avoid abrupt ascents above 6500 ft. TX: Analgesia, antiemetic, 02, acetazolamide, dex, descent

Question 18

Ed and his climbing party just reached a mountain pass at 9500 feet. Ed notices his friend starts walking and behaving almost as though he’s drunk. What is this?

Answer 18

HACE

Descent, Dex, O2

Question 19

Gena is back country skiing in a range that sits at about 8000 feet. It’s been 4 days since she started her trip and she has developed a cough, sob and feels fatigued. What is going on?

Answer 19

HAPE

O2, descent.

Question 20

what’s a first degree burn?

Answer 20

epidermal (red, blanches), touch/air causes pain, heals in 3-6d. Not counted in burn eval

Question 21

what’s a second degree burn?

Answer 21

partial/dermal (blisters, blanches)/ deep partial (blisters, non blanch), touch/air causes pain, heals in 7-21d/>+surg.

Question 22

what’s a third degree burn?

Answer 22

full/subQ (waxy white, grey, black, non blanch), deep pressure can be felt , full healing is rare, needs surg.

Question 23

what’s a fourth degree burn?

Answer 23

(fascia, muscle inv.), can feel deep pressure, never heals, need surg.

Question 24

When evaluating burn size what percentage is….

• an arm
• a leg
• the anterior trunk
• the posterior trunk
• the head
• genitals

Answer 24

• an arm=9
• a leg=18
• the anterior trunk=18
• the posterior trunk=18
• the head=9
• genitals=1

Question 25

John a 35 year old man who was playing with a flame thrower and sustained 2nd burns to one arm. Is this considered major or minor?

Answer 25

Minor: <2% full thickness

Question 26

What is the general treatment plan for minor burns?

Answer 26

Cool (H2O + gauze),
Pain (Tylenol/NSAID/Opioid),
Remove clothes/debris,
Clean (Soap + H2O),
debride (leave small, blisters if intact),
Prophylaxis (topical ABX if skin broke),
Dress (non-adherent, then dry, then elastic),
Itching (H1 blocker)

Question 27

What constitutes a moderate burn?

Answer 27

Moderate >10<20%

B/t 2-5% full

Question 28

What constitutes a major burn? What are some specific burn sites that need special attention?

Answer 28

Severe (>20 2nd / >10 3rd )

inhalation, face, hands, feet, genitals, joints, circumferential

Question 29

What is the general treatment plan for major burns?

Answer 29

Stop burn (cool with H2O)
ABC O2 IV
Tx hypothermia,
Pain mgt.
Tetanus
Fluid (LR)
Wound mgt.
Check for CO poisoning

Question 30

A pregnant woman comes into the ED with burns near her eyes. She has a sulfa allergy what burn cream should you use for wound management: bacitracin, silver sulfadiazine or mafenide?

Answer 30

• Bacitracin
• Silver sulfadiazine is contraindicated in pregnancy, infants, breastfeeding and sulfa allergies
• mafenide is contraindicated for sulfa allergy

Question 31

How long do sunburns generally last and how are they treated?

Answer 31

72 hours

TX: cool compress, calamine, aloe, NSAID, fluids.

Question 32

How what is the main treatment of chemical burns and when is it contraindicated?

Answer 32

30 minutes of irrigation or until pH is physiologic

contraindicated w/ Dry Lyme, elemental metals, phenol

Question 33

When should you consider intubation with burn patients?

Answer 33

stridor, access muscle use, dysp, hypoxemia, deep burns to face/neck. Edema/blisters in mouth

Question 34

Name a few of the major complications of burn injuries

Answer 34

Infection(Pneumonia/cellulitis/UTI), 
resp failure, 
MODs, 
SIRS, 
rhabdo, 
compartment syndrome,
 gastroparesis, 
GI ulcers, 
keloids, 
Depression, 
PTSD

Question 35

Justin is an 8 year old patient in your practice. He lives at home with his single mother. He comes in today for immunizations required for school and you notice burns on both of his arms that look like the outline of some sort of object. What is going on?

Answer 35

Abusive burns:
single parent, burns to both hands/legs, Brands (clear outline of object), Cig. burns(face, back of hands/feet), immersion (butt, legs, stocking/glove).