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EM Test 4-Environmental emergencies*

Terms in this set (91)

Which people are more at risk for suffering frostbite?
Military personnel
Winter sports enthusiasts
Outdoor workers
Elderly
Homeless
People who use drugs or alcohol
People w/ psychotic disorders
T/F- freezing alone doesn't cause frostbite
True
Pathophysiology of frostbite?
Once area begins to thaw, arachidonic acid causes: vasoconstriction, platelet, leukocyte sludging and erythrostasis
It leads to thrombosis, ischemia, necrosis and dry gangrene.
What are the 4 degrees of frostbite?
1- Numbness, central pallor w/ surrounding erythema edema, desquamation, dysesthesia
2- Blisters of skin w/ surrounding edema and erythema
3- Tissue loss involving the entire thickness of skin, hemorrhagic blisters
4- Tissue loss involving entire thickness of body part, including deep structures, resulting in loss of the part.
Presentation of first degree (frost nip)?
Erythema
Lack of blisters
Stinging or burning followed by throbbing
Mild edema
Partial skin freezing
Occasional skin desquamation several days later
Prognosis is excellent
Presentation of second degree frost bite?
Erythema
Formation of blisters (6-24 hrs)
Numbness followed by throbbing
Full thickness skin freezing
Substantial edema
Desquamate and form eschars
Prognosis good
Presentation of third-degree frostbite?
Blue-gray discoloration of skin
Injury extends into subdermis
Hemorrhagic blister and necrosis
Involved area feels like block of wood w/ throbbing, burning, shooting pain
Prognosis is poor
Presentation of fourth-degree frostbite?
Extends into subcutaneous tissue, muscle, bones and tendon
Little edema
Skin is mottled w/ nonblanching
Eventually forms deep eschar
Aching joint paint
Dx of frostbite?
Clinical
Prehospital tx of frostbite?
Remove wet and restrictive clothing, cover w/ dry layers
Give warm drinks and provide analgesia
Do NOT heat frozen area, dry head can cause further injury
Do NOT reward if refreezing is possible
Immobilize and elevate frozen extremity
Do NOT rub w/ snow, will lead to more injury
ER management of frostbite?
Place extremity in gentle circulating water heated to 98.6-102.2°F for 20-30 mins
Treat w/ opiates
Give ibuprofen- stops arachidonic acid cascade
Aloe vera cream q6hrs (stop arachidonic acid cascade)
Faces can be thawed by warm water compress
Elevate body part
Tetanus shot
Don't perform early surgery
Separate digits w/ cotton and loosely wrap
What core temp is associated w/ hypothermia?
Core temp of <35°C or <95°F
What are secondary causes of hypothermia?
Increased heat loss:
Burns
Iatrogenic (blood transfusions/other cold transfusions, cooling blankets)
Recent birth

Impaired thermogenesis:
Impaired shivering- advanced or very young age, malnutrition, physical exhaustion

Multifactorial:
Meds and toxins- ETOH, anesthetics, narcotics, sedatives
Metabolic and endocrine disorders- DKA, hypoglycemia, hypothyroid/pituitary, lactic acidosis
Neurologic- space-occupying lesions, stroke, spinal cord injury
Sepsis
What are the stages of hypothermia?
Stage 1- Mild (HT I)- Core temp of 35-32°C
Stage 2- Mod (HT II)- core temp of <32-28°C
Stage 3- Severe (HT III)- core temp <28°C
Stage 4- HT IV
Presentation of stages of hypothermia?
HT I- conscious, shivering
HT II- Impaired consciousness, may or may not shiver
HT III- unconscious, VS present
HT IV- VS absent
Dx of hypothermia?
Rectal probe- most accurate for telling body temp
Esophageal probe
Bladder probe
Do NOT use oral or infrared thermometer
Tx of stages of hypothermia?
HT I- warm environment + clothing, warm sweet drinks, active movement if possible. Pts w/ significant trauma or comorbidities should get HT II tx

HT II- active external and minimally invasive rewarming techniques, cardiac and core temp monitoring, minimal and cautious movements to avoid arrhythmias, full body insulation, horizontal position, immobilization, warm crystalloids

HT III- HT II management +- airway management as needed, tx in ECMO/CPB center if available due to high risk of cardiac arrest, ECMO/CPB in cases w/ cardiac instability, ECMO/CPB for comorbid pts unlikely to tolerate low cardiac output associated w/ HT III, bladder lavage w/ warm saline, warm humidified oxygen.

HT IV-CPR and 3 doses of epinephrine and defibrillation, airway management, ECMO/CPB

CPB- cardiopulmonary bypass
ECMO- extracorporeal membrane oxygenation
Complications from hypothermia?
Pulmonary edema and infx
Hypotension or arrhythmias
Seizure disorders, peripheral neuropathy, impaired cognitive function
Multi-organ failure possible
What are heat cramps?
Painful, involuntary spasm of skeletal muscles
What is the cause of heat cramps?
Those that sweat and only drink water (no electrolytes)
It is due to deficiency in Na, K, Mg or fluids
Presentation of heat cramps?
Occurs several hours after exercise
Tx of heat cramps?
Sports drinks work great
Salt replacement and resting in a cool place
Self limiting
What is the cause of heat stress/heat exhaustion?
Occurs after being exposed to high temps and accompanied by dehydration and electrolyte imbalance
Presentation of heat stress/heat exhaustion?
Sweating profusely
Pale skin
Tachycardia
HA
N/V
Malaise
Dizziness
Muscle cramps
Near syncope
Hypotension
Temp will be elevated to <40°C (104°F)
Tx of heat stress/heat exhaustion?
Volume and electrolyte replacement and rest
Remove from hot environment
Rapid IV normal saline (1-2L)
Heat stress can progress to heat stroke even if removed from hot environment, cool pt until temp is 39°C (102°F)
What temp is the body w/ heat stroke?
>40°C (104°C)
Presentation of heat stroke?
High body temp + altered mental status
Red, hot, dry
Irritable, confusion
Hallucinations
Decorticate or decerebrate posturing
Hemiplegia
Seizure
Coma
Athletes won't present classically
Pathophys of heat stroke?
Cerebellum is sensitive to heat, thats why ataxia is an early sign
Prehospital care of heat stroke?
Rapid cooling <30 mins (cool water immersion)
Remove from heat
Alternatives- remove clothing, spray pt w/ water and provide air flow, place wet towels on pt
ED management of heat stroke?
IV fluids
Check glucose levels
Monitor core temp
Reduce temp to 39°C (102.2°F)
Evaporative cooling
Immersion cooling
Invasive colling measures
What is hymenoptera?
Bee stings
Tx of hymenoptera?
Remove stinger immediately if possible
Ice
Ibuprofen, Tylenol for pain
ER tx of hymenoptera?
Epinephrine 0.01 mg/kg (peds dose)
Steroid IV/IM
Benadryl IV/IM
What is the clinical criteria for anaphylaxis?
1. Acute onset of illness w/ involvement of skin or mucosal tissue (hives, urticaria, pruritus, flushing, swollen lips, tongue
Respiratory compromise Reduced BP
Associated sxs of organ dysfunction

2. Two or more of the following that occur rapidly after exposure to allergen
Involvement of skin or mucosal tissue
Resp compromise
Reduced BP
Persistent GI sxs

3. anaphylaxis should be suspected when pts are exposed to a known allergen
Tx of black widow bite?
IV calcium gluconate (10%)
Muscle relaxants
Analgesics
BZDs
Tx for scorpion sting?
Ice
Analgesics
Presentation of pit viper bite?
25% don't develop sxs
1-2 fang marks
Edema, localized pain
N/V
Weakness
Oral numbness/tingling
Tachypnea
Tachycardia
Hypotension
Altered LOC
It causes local tissue destruction
Dx of pit viper (crotalinae envenomation)?
Fang marks plus evidence of tissue injury
First aid management of pit viper bite?
Do NOT use snake bike kits
Do NOT use suction or incision
Ice water worsens venom injury
Immobilize extremity below heart
Do NOT use tourniquets
Stay calm
Prehospital care of pit viper bite?
Immobilize limb
Establish IV access
O2
Don't remove constriction band until antivenom is available
ED management of pit viper bites?
Antivenom- crotalinae polyvalent, crofab
Monitor for edema and systemic sxs for 6-8 hrs
How to tell if a bite is from a coral snake or not?
Red on yellow, kill a fellow
Red on black, venom lack
Presentation of elapid (coral snake) bites?
Venom has powerful neurotoxin, doesn't cause much local injury
N/V
HA
Abd pain
Diplopia
Muscle weakness
Discolored urine
Seizures
Sxs may occur several hrs after bite
Management of coral snake bite?
Admit potential victims
Give 3-5 vials of antivenom
May not be possible to prevent effects or reverse effects once they start
Presentation of jellyfish sting?
Skin rxn
Stinging pain
Erythema
Wheal formation
Tx of jellyfish sting?
Irrigation w/ salt water and hot water immersion apply topical lidocaine gel
May scrape out sharp tubes or needles that you got stung with
T/F- it is good to pee on a jellyfish sting
False. You'll just have pee on your body.
What barotrauma can result from descent?
Middle ear- TM retracts in, may rupture TM
Sinus- pressure increases, may cause pain, mucosal edema, submucosal hemorrhage
Inner ear- poss vestibular or cochlear structures rupture
Face squeeze- mask causes bruising around face
Tooth squeeze- tooth pain with fillings or abscess
Dry suit squeeze- causes painful red streaks
S/sxs of barotrauma descent?
Sinus- bleeding into mask
Inner ear- unilateral roaring tinnitus and profound vertigo
Face squeeze- conjunctival hemorrhage
Tx of barotrauma of descent?
Middle ear- Clearing ears may help
Sinus- Decongestants and abx
Inner ear- rest, symptomatic care, poss surgery
Examples of barotrauma of ascent?
Alternobaric vertigo- gas in air containing organs expands
Pulmonary barotrauma- air expands in lungs
Arterial gas embolism- air enters the pulmonary venous circulation, may lead to embolism and death.
Presentation of barotrauma ascent?
Alternobaric vertigo- air trapped in middle ear will cause transient vertigo. No tx
Pulm barotrauma- holding breath leads to pneumomediastinum or pneumothorax. Problem if gas gets into circulation
Decompression and arterial embolism tx?
100% O2
IV fluids
Rapid recompression w/ hyperbaric chamber
IV lidocaine
At what elevation does it become a hypoxic environment?
>8000 ft
At which altitude does acute mountain sickness occur?
7000-8000 ft
Presentation of high altitude sickness?
8000-14000ft- associated w/ decreased arterial oxygen saturation, hypoxia
Presentation of very high altitude sickness?
14000-18000ft- severe hypoxemia, hypocapnia, progressive physiological deterioration
When is the risk of hypoxemia the greatest at high altitude?
During sleep
S/sxs of acute hypoxia?
Dizziness
Lightheaded
Dimmed vision
Unconsciousness
Reverses w/ immediate oxygen
S/sxs of acute mountain sickness?
HA
GI disturbance
Dizziness
Fatigue or sleep disturbances
Tx of acute mountain sickness?
Acetaxolamide- decreased reabsorption of bicarbonate and metabolic acidosis
What is high altitude cerebral edema?
(HACE)
A medical condition in which the brain swells with fluid because of the physiological effects of traveling to a high altitude. It generally appears in patients who have acute mountain sickness and involves disorientation, lethargy, and nausea among other symptoms
Associated w/ pulmonary edema
What is the most lethal altitude illness?
High-altitude pulmonary edema
Presentation of high-altitude pulmonary edema?
Starts as dry cough, decreased exercise performance, dyspnea on exertion
Later- tachycardia, tachypnea, dyspnea at rest, marked weakness, productive cough, cyanosis, rales
Hypoxemia worsens, altered mental status and eventually coma
Prehospital care for near drowning?
Remove from water
Rapid resuscitation (CPR)
High flow O2 by facemask
Transport pts to ER if: amnesia, loss of consciousness, period of apnea
Warm and monitor during transport
What are factors associated w/ poor resuscitation in near drowning?
Need for bystander CPR at scene
Need for CPR in ED
Asystole at scene or in ED after warming
ED management of near drowning?
Assess and secure airway
Provide O2
Determine core temp
Spinal injury is rare if no hx of diving, routine CT scan not needed
GCS >13 and SpO2 >95% at low risk- observe for 4-6 hrs
GCS <13 maintained on O2 and ventilatory support- xray, cardiac monitoring, temp
What is the half life of CO?
About 5 hrs
Presentation of CO poisoning?
HA
Vomiting
Ataxia
Seizure
Syncope
Chest pain
Focal neurologic deficit
Visual disturbance
Dyspnea/tachypnea
ECG
Retinal hemorrhage
Bullous skin lesions
Dx of CO poisoning?
Co-oximetry measures total Hgb, oxyhemoglobin, methemoglobin, and carboxyhemoglobin saturation, it is the only accurate tool
Standard SpO2 is unreliable.
Tx of CO poisoning?
Give pt highest concentration of O2 possible
Discharge if minimal exposure
If sxs but no high risk features, observe 4 hrs and release if sxs resolve
High risk hyperbaric chamber should be initiated
Indications for hyperbaric oxygen tx?
Pregs w/ carboxyhemoglobin level >15%
Carboxyhemoglobin >25%
Sycope
Evidence of acute myocardial ischemia
Confusion/altered mental status
Seizure, coma or focal neurologic deficit
At what voltage does serious or fatal injury occur?
>600V
Most homes are 120V
What are the 3 ways electricity can cause damage?
1. Direct tissue damage from electrical energy
2. Tissue damage from thermal energy
3. Mechanical injury from trauma induced by fall or muscle contraction
S/sxs of electrical injury?
Cardiac dysrhythmias- V-Fib
CNS- LOC common followed by seizures, confusion, agitation, or comatose
Spinal cord injury- Compression fx, cellular or vascular injury from electricity
Peripheral nerve injury- often in hands, paresthesias may be immediate or delayed (poss 2 yrs)
Cutaneous burns- entry and exit areas. Burns are painless, grey-yellow, depressed area
Ortho injury- caused by muscle contractions or falls. Fx's to wrist, forearm, humerus, femoral necks, shoulders and scapulae
Vascular/muscle injury- at risk of compartment syndrome.
Dx of electrical injuries?
MRI to assess electrical damage of CNS
US and CT if suspected GI injury
T/F- if a pt has suffered an electrical injury, it is important to immediately respond to them and pull them from the area
False. Victims may transmit electric current
How far should you stay from downed powerlines?
32 ft
Prehospital care of electrical injuries?
Turn off power ASAP
Begin CPR immediately
Maintain spinal immobilization
ED Tx of electrical injuries?
ABCs
Treat cardiac arrhythmias
IV fluid resuscitation- parkland formula to start
Observe for compartment syndrome, rhabdomyolysis, and renal failure
Ileus- NG tube
Stress- ulcer prophylaxis, H2 blockers, antacids, PPIs
Monitor for ileus, bowel perf, hemorrhage
What is the Parkland formula for IV resuscitation?
4 ml/kg x % of BSA burned administered over 24 hrs
What is the rule of 9's for calculating total BSA burned?
1%- Genitalia/perineum, front of neck, back of neck
1.5%- each hand,
9%- head and neck, each arm, each leg,
18%- anterior trunk, posterior trunk
T/F- lightening is more likely to cause internal, cardiac or muscle injury than other electrical injuries
False. It travels over the body's surface
How does lightning cause internal injury?
Through blunt mechanical force
How does a lightning strike affect cardiac and respiratory systems?
Lightning causes depolarization of myocardium
May cause cardiac and resp arrest w/o evidence of external injury
What are the types of lightning strikes?
Direct- pt is directly hit...
Side flash- nearby objects are hit and current travels through air to strike victim
Contact strike- hits object pt is holding and is transferred to pt
Ground current- hits ground and travels through ground to pt
What are the types of cutaneous manifestations of lightning strikes?
Lichtenberg figures- looks like branching in a leaf or of a pine tree across the skin.
Punctate burns- look like little stab wounds that are concentrated in the middle and the spread outward.
Clinical presentation of lightning strikes?
Most victims lose consciousness and have LE paralysis
Ruptured tympanic membranes is common
Fx's seen from blunt force injury or secondary to falls.
Spinal fx's
Prehospital care of lightning strikes?
Pts in cardiac arrest should be tx'd first- defibrillators w/ CPR
ED management of lightning strikes?
Cutaneous burn may help identify current course and potential internal injuries
EKG may show injury, ST elevation
Brain CT indicated in coma, altered mental status, HA or confusion
Lightning injury prevention?
Safe shelter
Avoid trees or tall structures, open fields, open vehicles
Avoid nearby water
Avoid contact w/ metal or wire fences
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