Physical Med Flashcards
drowning
Nonfatal drowning –
someone gets immersed, has respiratory impairment, but doesn’t die
drowning
Water rescue –
someone gets immersed and then removed without evidence of respiratory impairment
drowning
Fatal drowning –
someone gets immersed, has respiratory impairment, and dies
Drowning
When to Discharge
if no increased work of breathing, no decreased sats, little-to-no rales
drowning
The mammalian dive reflex –
metabolism slows when immersed in cold water – more pronounced in children vs adults
Drowning
resuscitation
Aggressively resuscitate nonfatal/fatal drowning (<60 min immersed for adults, longer for kids)
Shock from water rescue or nonfatal drowning is not typical – look for other causes
Hemorrhagic
Neurogenic
Scuba- disorders of descent
Barotitis
Barotitis (pressure inflaming the ear)
Mild: pain
Mod/severe: TM rupture / vertigo / N&V / SN hearing loss
One of the squeeze syndromes – this can happen to sinuses, facemask, suit, lungs – gas in the area shrinks under pressure as you go down (Boyle’s Law)
Scuba- disorder of descent
Barotitis Tx
Treat with decongestants, pressure equalization (Valsalva), analgesics, vertigo medications (meclizine, benzodiazepines)
Inflamed, intact TM? Consider droppered lido 2% into EAC
Mod/severe: refer to ENT
Scuba- disorder of descent
Nitrogen narcosis
patho, Sx, Tx
Pathophys: neurotoxic levels of nitrogen in blood
Sx: AMS & poor coordination at depth
Tx: controlled ascent – decreases nitrogen in blood
~ at depth, partial pressure of nitrogen in lungs goes up, pushing more nitrogen from your lungs in to your bloodstream (vicious tag-team of Dalton’s Law & Henry’s Law)
disorder of ascent - Scuba
Decompression sickness
type 1 and 2, Tx
Dissolved nitrogen forms bubbles in blood, tissue during too-rapid ascent – delayed onset – 98% w/in 24h, 100% w/in 48h
Type I – skin, lymphatic, MSK
“the bends” or “caisson disease” – joint pain, rashes, itching
Type II – more serious – other organs than above (like CNS)
gradual neuro sx – paresthesias, numbness, weakness, AMS (not ALOC)
Prevention – follow dive table
Tx – hyperbaric chamber
ascent disorder
Decompression sickness
Type I – skin rash called “cutis marmorata”
scuba disorder of ascent
Pulmonary barotrauma
Rapid ascent with closed glottis
Pneumothorax, hemothorax, pneumomediastinum
Gas in the area expands as pressure
drops (Boyle’s Law strikes back!)
Prevention – exhale as you ascend
ascent disorder
Gastrointestinal barotrauma
Pathophys – diving after carbonated beverages, gas-generating foods
Rarely – intestinal perforation, diaphragm rupture
Usually – abdominal cramps, eructation, flatulence
Scuba- disorder of ascent
Arterial air/gas embolism
Sudden air in arterial circulation immediately upon surfacing or within 10 minutes
Altered LOC and not just AMS, seizures
Prevention – follow dive table
Tx – hyperbaric chamber
Altitude illness
general
Due to relative hypoxia / increased sympathetic activity / capillary leak (brain and lungs)
Can occur in anyone; being fit is not protective
Acute Mountain Sickness
general
Usually > 8k feet (Vail is 11k)
Starts early – often day 1 at altitude
HA, nausea, fatigue, insomnia
Worsened with sedatives, alcohol
Acute mountain sickness
Tx
Preventative
May be prevented by prophylactic acetazolamide
Causes a metabolic acidosis which generates a respiratory alkalosis – increased ventilation increases oxygenation
Usually self-limited (1-2 days); can treat with NSAIDs, steroids, oxygen, descent
HACE / HAPE
General
HACE = high altitude cerebral edema
Severe, life-threatening; increased ICP
Ataxia, vomiting, confusion, seizures, coma
**Descent ASAP **(+/- steroids, hyperbarics)
HAPE = high altitude pulmonary edema
Most lethal of the altitude illnesses
Usually second night at altitude
Shortness of breath, fever, rales, pink sputum, hypoxia; normal heart size on CXR
Descent ASAP
Usually have symptoms of Acute Mountain Sickness before HACE/HAPE
Hypothermia
general
Core temperature < 35oC (95F)
Can occur even in non-freezing temperatures
Only use accurate thermometers; rectal, bladder, esophageal
Risks include extremes of age, altered sensorium, burns, trauma; may also see in sepsis, hypoglycemia
Findings – altered mental status, bradycardia
Hypothermia
Bradycardia with an idioventricular or junctional escape rhythm
Prominent J waves in the anterior leads = Osbourne waves
(named after the fact that they occur on the “J” point of the EKG)
Hypothermia
Tx
Rewarming should start ASAP
External rewarming
Passive – remove wet clothes, give warm blanket
Active – radiant heaters, hot water bottles, warming blankets
Watch for core temperature afterdrop with passive rewarming (cold blood from the periphery goes into the central circulation)
Active core rewarming
Warm humidified oxygen, warmed IV fluids, warm lavage (NG tube, foley)
Frostbite
general
degrees, Tx
Think of it as burns caused by cold (local tissue freezing)
First degree – superficial
Second degree – full thickness, clear blisters
Third degree – hemorrhagic blisters (blood = deeper)
Fourth degree – to bone
Rapid rewarming with warm circulating water
Do not allow refreezing
Do not debride bloody blisters
Types of Heat Illness
Heat edema
Do not treat with
swelling of feet/hands, transient, do not treat with diuretics
Types of Heat Illness
Heat cramps
after exertion in hot climates / usually after cooling / resolves without treatment
Types of Heat Illness
Heat syncope
– pooling of blood in extremities / treat by lying patient down in cool place
Types of heat illness
Heat exhaustion
– “summer flu” / nausea, vomiting, due to salt and water depletion / treat by moving to cooler environment, PO hydration with fluids with electrolytes/sugar
Heat Stroke
general
A true emergency – must cool ASAP
Multiorgan failure / brain, liver and endothelium at highest risk, but all systems affected
Core temperature usually ≥ 40oC (104F)
Two types, classic and exertional
Heat stroke
S/Sx
Altered mental status, tachycardia, tachypnea, may be hypotensive
May see acidosis, rhabdomyolysis, ARDS, renal failure, hyperkalemia
Heat Stroke
Classic
Epidemic (with heat wave)
Non-exertional
Elderly with chronic disease, very young, chronic illnesses
Dry skin
Rare to see acute tubular necrosis (ATN), rhabdomyolysis
Heat Stroke
Exertional
Isolated
Exertional
Healthy, active
Profuse sweating
May have diarrhea
DIC, ATN, rhabdomyolysis common
Heat stroke
Tx
Cooling is crucial – change “ABCs” to “C-ABCs”
Resuscitate as usual, but cool simultaneously
Methods of cooling
External – strip patient / tepid mist plus fans / wet sheets plus fans; ice packs to groin, axillae, neck
Internal – iced water gastric lavage / iced water bladder lavage
May need chlorpromazine to control shivering
Goal is to decrease temperature by 0.1-0.2oC per minute to 38.5oC (101.3F), then stop; watch for overshoot (hypothermia)
Burns
1st degree
(superficial) – epidermis only, painful, red and dry, hypersensitive. Heals in 3-7 days.
burns
2nd degree
Superficial partial thickness –to dermis, painful, red and wet, thin-walled blisters, hypersensitive. Heals in 7-14 days without scarring (called “second degree”)
Burns
3rd degree
Deep partial thickness: To dermis, painful, red and white (mottled), thick-walled blisters, slight decrease in sensation. Heals in weeks-months with scarring and pigment changes.
burns
4th degree
Full thickness: To deeper tissues, painless, white and brown and dry. No sensation. Needs grafting.
Burns
Body Surface Area
Body surface area (BSA)
Patient’s palm = 1% of patient’s BSA
Adults – rule of 9’s
Children – Lund/Browder chart
Minor burns
Tx
Minor burns
Cool ASAP
Treat pain with NSAIDs, opiates
Leave blisters intact if unruptured and not tense
Debride if blisters broken, tense, across joints
Update tetanus
Can manage ”open” (topical antimicrobials) or “closed” (occlusive dressings)
Major burns
Tx
Major burns
Cool > watch for hypothermia
Assess airway > look for singed nasal hairs, oral burns; intubate early for respiratory distress, concern for airway edema
Enclosed space? Think carbon monoxide, cyanide toxicity.
Fluid resuscitation crucial – Parkland formula
4 mL x kg x %BSA per day of Ringers lactate
Half of volume given over first 8 hours
Watch urine output – goal is > 1ml/kg/hr
electrical injuries
general
Tissue damage caused by electrical current
Injuries common (falls)
AC 3X worse than DC at same voltage
Degree of injury determined by
Type of current
Duration of contact
Tissue in path of current
Biggest risk of death is either trauma or cardiac arrhythmia – treat them as a trauma patient
Mouth burns in children usually from biting electric cord; risk of arterial bleeding at 7-10 days after burn
electrical injuries
Tx
Examine carefully – look for entrance and exit sites
Resuscitation and ABCs
Household current exposure generally requires no specific treatment, testing or monitoring
If more than minor electric shock, consider labs – CMP, CBC, CK (risk of rhabdomyolysis), coag studies if seriously injured
Monitor urine output / admit to monitored bed
mammalian bites
human, dog, cat
Human bite is the worst “mammal” bite
“Fight bite” – wound over MCP joint
High risk; may need to go to OR
Dog bites
< infection rate, > crush injury rate
Cat bites
Puncture wounds > risk of infection
animal bite
Tx
1st line: amoxicillin/clavulanate
2nd line: doxycycline OR TMP/SMX
PLUS
clindamycin OR metronidazole
Rabies
general
Rare in US; most cases imported in developing countries (often dog bites)
Bites at risk – fox, skunk, raccoon, bats (most common risk animal) / rodents, rabbits and squirrels do not pose risk
A bat in an occupied room – assume bite
rabies
Tx
Early post-exposure prophylaxis is key
Passive human rabies immune globulin (HRIG); give as much as possible around and into wound, remainder give IM
Active human diploid cell vaccine (HDCV) – 4 doses (days 0-3-7-14)
Bites and stings
general, Sx, Tx
Bees, wasps and ants
Usually only cause local symptoms – burning, pain, swelling
Treatment usually ice to area, OTC meds (NSAIDs, acetaminophen, nonsedating antihistamine)
About 10-15% of those stung will have unusually large areas of swelling lasting up to a week with a sting
black widow spider bite
general Sx, Tx
Black with red hourglass, aggressive
Immediate pain
N/V, cramps, rigid abdomen (appy mimic)
Treat with ice, opioids/benzos, antivenom (?)
brown recluse
general
Brown with “violin,” reclusive
Delayed pain, “volcano” lesion
Systemic symptoms including hemolysis, necrosis
Treat with analgesics, debridement if needed
Rattlesnake bite
Envenomation – amount of venom in bite / up to one quarter are “dry bites”
Local effects – swelling, ecchymosis, pain
Systemic effect – DIC, capillary leak
Males, teens-twenties, intoxicated – highest risk
Ooze at site of bite suggests envenomation
Do not I&D, tourniquet or try to extract venom
If ecchymosis, blisters, systemic effects – treat with antivenom – look up doses, side effects
