environmental Flashcards

Question

classic heastroke: dx criteria and tx

Answer 1

-external heat stress -CNS dysfunction- HA, disorientation, AMS, seizures, delirium, coma -Vital signs abnormalities: -Hyperthermia- >104! -tachypnea -tachycarida -hypotension -hot, flushed skin, typically dry!! -multi-organ failure, shock, or ARDS may be present -TX: - Large bore IV access x 2 -Cardiac monitor -Early airway management -Core temp measurement -POC glucose -Bladder/Rectal probe continuous temp monitoring -Rapidly lower body temp to 102.2F (39C) -Tepid water mist and fans (evaporative) -Ice packs to groin, axilla, neck (conductive) -!!Cold water immersion (CWI) is standard of care -Volume resuscitation 1-2L -Avoid vasoconstrictors -!!!Antipyretics are not indicated and may be harmful

Answer 2

Thyroid storm Sympathomimetics, anti-cholinergics, PCP/LSD Serotonin syndrome Neuroleptic malignant syndrome Malignant hyperthermia Sepsis or septic shock -> differentiating sepsis from heat stroke is hard!!!!! Meningitis / Encephalitis CNS hemorrhage Status epilepticus

Answer 3

-Heat exhaustion (minor heat related illnesses): -Young and otherwise healthy -> home -Older with comorbidities -> consider admission -Consider if you are sending them back to get hyperthermic again! -Heat stroke: -Admit to critical care unit for monitoring of rebound hyperthermia, electrolyte abnormalities, and multi-organ system dysfunction

Answer 4

-exertional heatstroke Tx: -Same as classic! -!!Rapid cooling until 102F/39C -Repletion: Electrolytes, glucose -High volume urine output in rhabdomyolysis -Beware of DIC and bleeding coagulopathies -Cool patients as quickly as possible -> It does not take long to boil an egg or to cook neurons!

Answer 5

Pain medication Tetanus update Hand = burn center referral next day Do NOT unroof blisters Irrigation of wound, ±topical bacitracin, nonadherent gauze

Answer 6

-Types of burns: thermal, radiation, chemical, electrical contact, cold (frostbite) -Burns are not limited to skin! -Skin burns are classified by depth (superficial, partial thickness, full thickness) -Inhalation injuries (concomitant CO, CN), toxic gases, other related traumatic injuries -Priorities: Stabilize airway and breathing, initiate IV fluids, control pain, wound care -Large burns (>20% BSA) can provoke profound inflammatory responses including widespread tissue edema, multiorgan failure, pulmonary edema, ileus, myocardial depression -central zone of coagulation is area of max damage and will likely necrose -zone of stasis is penumbra that can be salved if perfusion restored -zone of hyperemia will most likely heal with wound care

Answer 7

-Only include 2nd and 3rd degree burns -Open hand = 1% T BSA -TBSA required to calculate fluid requirements -Parkland -4mL x TBSA % x kg -Rule of 9s for adults -Lund and Browder chart for pediatrics

Answer 8

-classified as being major, moderate, or minor in severity -“minor” criteria: -Partial thickness < 15% BSA in a patient between the ages of 10-50 -Partial thickness < 10% BSA in a patient younger than 10 or older than 50 -Full thickness < 2% BSA -No signs of assoc inhalation injury -Not from a chemical or electric burn injury -Not involving the face, hands, perineum, or feet -Not crossing any major joints -Not circumferential

Answer 9

-systemic effects once TBSA reaches 20-30% -cardiovascular: systemic hypotension and end organ hypoperfusion -respiratory: bronchospasm and ARDS -metabolic- increased metabolic rate/demand

Answer 10

-Indications for fluid resuscitation: -Adults >15% TBSA, Children >10% TBSA -Do NOT count 1st degree burns in TBSA -Crystalloids (LR or NS) -Parkland formula: -First 24hrs: 4mL x wt in kg x %TBSA -Give 1/2 in first 8hrs, other 1/2 in next 16hrs -Urine output guides management -Goal 0.5mL/kg in adults UOP -Ex: 70kg man with 25% partial thickness burns. 4mL x 70kg x 25=7000mL 3500mL in first 8 hours, 3500mL in the next 16 hours.

Answer 11

-Remove loose clothing and jewelry -Irrigated with cool sterile water or normal saline -Eyes should be irrigated at least 15 minutes with warm water -Do not use ice -Cover with non-adherent dressing or cling film -TDAP, analgesics -Systemic antibiotics are not indicated -Any devitalized tissue should be debrided -1st degree burns: keep clean and dry, no special dressing since the dermis is intact. NSAIDs and topical aloe. -2nd degree partial thickness: topical ointment covered by a non-adherent dressing will promote healing and reduce the risk of infection and pain -3rd degree burns: Surgical excision by a burn surgeon

Answer 12

-skin incision to release tension caused by inelastic eschar -consider in circumferential full thickness burns to the body or chest

Answer 13

-Immediate transfer for inpatient management: -Full thickness burns of any size in any age group -Partial thickness burns >10% TBSA -Burns that involve the face, hands, feet, genitalia, major joints or genitals -Inhalation injury (singed nasal hairs, soot in mouth) -Smaller burns with high-risk comorbidities or extremes of age (all children <12months) -Referral to burn center expediently: -Burns to sensitive areas

Answer 14

-Non traumatic causes of erythroderma and skin sloughing: -SJS, TEN, SSSS -Non traumatic causes of bullae: -Pemphigus vulgaris, bullous pemphigoid, necrotizing fasciitis -Animals, insect bites

Answer 15

-Burn mechanism -Enclosed space? -Smoke inhalation? -Trauma? -Timing of burn -Suspicious history for abuse? -Medical history -Tetanus status -Vital signs -Hypovolemia -Hypothermia -Airway -Concerning findings: !carbonaceous sputum, intraoral burns, stridor, singed nasal/facial hair! -Skin: Estimate degree! of burn and TBSA! -Assess for circumferential injuries -Survey for trauma -Assess airway and consider early intubation if respiratory sx, carbonaceous sputum, perioral burns, singed nasal hairs, or were confined in burning environment -Eval of posterior pharynx is helpful in assessing airway injury -> If no evidence of posterior pharyngeal edema or erythema, airway compromise is unlikely

Answer 16

-AIRWAY: -Upper airway burn -> VERY FAST edema -> intubation early -Lower airway -> slower edema -> -½ of all fire related deaths are from inhalation injuries -Closed space >> open space -High possibility of CO or CN toxicity -100% FiO2 on non-rebreather for CO -Hydroxocobalamin for CN -BREATHING: -Direct damage to lower lung and gas exchange surface -Carbon monoxide poisoning (later) -Cyanide poisoning (later) -Circumferential chest burn requiring lifesaving escharotomy -CIRCULATION: -TBSA>15% - high risk for circulatory shock -> fluid resuscitation -> labs to assess for organ dysfunction -Circumferential burns should be checked regularly -Assess perfusion -High risk for compartment syndrome requiring escharotomy/fasciotomy -DISABILITY/DEXTROSE/EXPOSURE: -full exposure, but keep warm -clean burns with normal saline -2ndary survey -> full trauma exam

Answer 17

-Obtain labs in significant burns such as > 20% TBSA involvement, inhalation injury, persistent abnormal vital signs -CMP -CBC -Blood gas with carboxyhemoglobin testing -Lactate level -Cyanide level -T&S -Urine pregnancy testing

Answer 18

DDX Shock: Hypotension, Hemorrhage, Toxic exposure 2L IV lactated ringer’s solution Labs including lactate and blood gas with CO-oximetry Foley to measure urine output RUE: Circumferential burn, but with good distal perfusion No evidence of trauma on exam, FAST negative Carbon monoxide returned: 25% Lactate returned: 5.5 Suspected cyanide poisoning Urine pregnancy positive! Do you give 5g hydroxocobalamin IV? After 2 L of IV crystalloid fluid and treatment with 5 g IV hydroxocobalamin, the patient’s vital signs improved HR 120 beats/min; BP 115/60 mm Hg; and O2 92%. Initiate transfer to a burn center Reassessed RUE perfusion - Her radial pulse now diminished, so you performed an escharotomy prior to transfer. Continue IV crystalloid administration based on the Parkland formula, carefully monitoring urine output, until transfer

Answer 19

What is the MCC of death in fires? -Volume depletion and hypovolemic shock -Sepsis -Carbon monoxide (CO) poisoning -Renal failure -Hyperkalemia and arrhythmia -Respiratory burn - Reports: ABG: pH 7.32 (↓) PCO2 28 mm Hg PO2 90 mm Hg 98% saturation COHb level: 42% BMP: normal ECG: ST depression in V2 to V4 -What is the mechanism of metabolic acidosis? Decreased perfusion of tissues Lactate from tissue hypoxia Rhabdomyolysis Sepsis Which of the following is the strongest indication to use hyperbaric oxygen in this patient? pH 7.32 ST depression on the ECG Confusion COHb level 42%

Answer 20

-CO binds to Hgb with a higher affinity than oxygen -Leading cause of toxic death. Common successful suicides. -Silent killer: Colorless, odorless -Sources: Incomplete combustion of fuel (charcoal, kerosene, wood, gas, open stoves) with poor ventilation -RF: Smoke inhalation, poorly functioning heating systems, no smoke alarms -Vague initial sx:

Answer 21

-!100% oxygen on non-rebreather -!Hyperbaric oxygen therapy (HBO) is indicated in the following: -Loss of consciousness, coma, seizures -CO levels >25% regardless of symptoms -Pregnancy -Myocardial ischemia or life-threatening dysrhythmias* -Evidence of end organ damage -Persistent symptoms even with high flow oxygen

Answer 22

a. Decreased affinity of hemoglobin for oxygen. b. Decreased oxygen carrying capacity of hemoglobin. c. Oxidative phosphorylation uncoupling. d. Methemoglobinemia. e. Stimulation of the tissue cytochrome oxidase system.

Answer 23

-Cyanide inhibits mitochondrial cytochrome complex so cells switch to anaerobic metabolism -> lactic metabolic acidosis -Cyanide can have a bitter almond smell -Found in: Burning plastic in a fire, jewelers, chemical labs -If inhaled, symptoms are immediate (sudden collapse!!) -If ingested or dermal exposure, usually delayed symptoms: Abd, nausea, coma, bradycardia, AMS, sudden CV collapse , death -Normal PaO2 and O2 sat; severe lactic acidosis!!!!! -Labs with lactic acidosis with anion gap (don’t need cyanide lab test) -Tx: intubate early 100% oxygen Hydroxocobalamin!!! (cyanokit) is a b12 precursor combines with cyanide to form B12 which is cleared renally -*Both CO and CN poisoning can occur in fires* Suspect CN more if sudden collapse at the scene of the fire, if there is metabolic acidosis, serum lactate >8, or carbonaceous material in the oropharynx

Answer 24

-Raised, pruritic, erythematous plaques -Release of histamine and bradykinin -Infections, medications (PCNs, NSAIDs, sulfa), insects, latex, foods, allergens, idiopathic -Clinical diagnosis -1st line treatment: H1 antihistamines -Diphenhydramine, Cetirizine, Loratadine, Fexofenadine -Steroids can be given if symptoms persist for more than a few days

Answer 25

-Allergic reaction = body reacting to a previously sensitized allergen. These are IgE mediated. -Peanuts, shellfish, pollen, bee stings etc. -Non-IgE mediated can trigger a cascade on first exposure -Vancomycin, opioids, radiocontrast media -Both can range from a mild allergic reaction to severe allergic reaction (anaphylaxis) -Anaphylaxis = multi-system involvement -Medical emergency! -The average time to anaphylaxis is: -5 minutes for iatrogenic reactions (anesthesia, contrast, abx) -15 minutes for venom (bee stings) -30 minutes for food (peanuts)

Answer 26

-tight throat, swollen lips, swollen tongue, stomach pain, syncope, hives -Dx Criteria #1: -Acute onset of sx (mins–hrs) involving mucocutaneous regions AND either sx of respiratory compromise or reduced BP/end organ dysfunction. -Dx Criteria #2: -After a likely allergen exposure, with involvement of 2 or more of: (1) mucocutaneous involvement, (2) respiratory compromise, (3) reduced BP or assoc sx, and/or (4) persistent GI sx -Dx Criteria #3: -After a known allergen exposure, having evidence of reduced BP -Infants and children: low systolic BP (age specific) or > 30% decreased in SBP -Adults: SBP <90mmHg or > 30% decrease from baseline

Answer 27

-EPINEPHRINE saves lives -Adult: 0.3-0.5mg!! of 1mg/mL IM q5-10 min x 3 -Peds: 0.01mg/kg IM q5-10 min, max dose 0.5mg per dose -Anterolateral thigh > deltoid -1st line tx (even in mild cases) = ↓ mortality -Immediately stops histamine release from mast cells, ↑ blood pressure, Promotes bronchodilation and ↓ mucosal edema -No absolute CI! -blue to sky, orange to thigh -Other adjuncts to give -!Antihistamine (Diphenhydramine) (25-50mg IV/IM/PO q4h) – blocks further histamine release -!H2 blocker (Famotidine) (20mg IV) – blocks bradykinin -!Corticosteroids: Prednisone or methylprednisolone (125mg IV) – block rebound anaphylaxis -IV fluids – improves hypotension -Glucagon (1-5mg IV over 5 minutes)– to patients on beta-blockers, because BB prevents epinephrine effectiveness -ABCs: -Check the oropharynx for swelling of lips, tongue, mucous membranes -Assess for difficulty swallowing / throat tightness / listen for stridor -EPINEPHRINE- No improvement requires definitive airway with ET tube or crich -Check for wheezing from bronchoconstriction -Assess for respiratory distress (tripoding, abdominal breathing, tracheal tug, intercostal retractions) -Bronchoconstriction present: -Bronchodilators!!! (albuterol 2.5-5mg nebulizer, in addition to the epinephrine) -Oxygen if hypoxic -Check for tachy and hypotension -Syncope is common 2ndary to hypotension -Cardiac monitor, IV access, ECG -Place in recumbent position with legs elevated if no edematous upper airway -Circulatory compromise: -!!!1-2L of IV fluids for distributive shock -No improvement --> vasopressor such as epinephrine 0.5-1cc 1:10,000 epinephrine IV infusion over 10-15 minutes

Answer 28

-Observe for at least 6-8 hours from time of IMPROVEMENT -Biphasic reactions occur in 5% of cases -RX: EPI pen, 3 days of antihistamines and steroids -CLEAR instructions on epi pen use -CLEAR return precautions -Follow up appointment and plan

Answer 29

# 4 - place foot in as hot water as you can tolerate for 30 minutes 1 - kick yourself for not wearing water shoes #2 - pull out spikes with tweezers #3 - apply vinegar to kill the little parts that are poisonous # 5 - apply vinegar again # 6 watch out for signs of infection - may need antibiotics -Remove tentacles with a tweezer Do not scrape with a credit card - this releases more nematocysts Apply vinegar or acetic acid and soak for 30 minutes Hot water after vinegar soak reduces pain Avoid rinsing with fresh water, urine, ethanol, ammonia - these can increase nematocyst discharge and cause more pain

Answer 30

Rays often sting when stepped on Death occur from hemorrhagic, abdominal trauma, organ puncture, or tetanus Pain out of proportion to wound Can progress to hemorrhagic necrosis and necrotizing fasciitis Venom can cause weakness, vomiting, diarrhea, syncope, seizures, muscle cramps, hypotension, dysrhythmias -tx: -Management: Plain radiograph r/o retained spine Clean the wound Tetanus prophylaxis Hot water immersion relieves pain and inactivates venom Observe for 3-4 hours

Answer 31

Loxosoeles reclusa Sphingomyelinase D Mild erythematous lesion in most cases Severe reaction: immediate pain, blister, pale discoloration --> blue or violet blotchy colors with hard and depressed center --> necrosis and central eschar will form over 3-4 days Bite may not be witnessed, painLESS Rare systemic reaction 1-2 days after the bite Fever chills vomiting myalgias, hemolysis, renal failure, DIC - called LOXOSCELISM Treatment is supportive immobilization, ice, elevation, wound care, nsaids, tetanus prophylaxis Debride any necrosed areas No anti-venom available currently

Answer 32

-AKA Lacrodectus mactans -Venom is neurotoxin (more potent than pit viper venom) that can cause calcium chelation and tetany Immediate pinprick sensation , Symptom onset is fast Erythematous target-shaped lesion within one hour! Myalgias, diaphoresis, abdominal wall cramping, nausea, vomiting and even respiratory failure Treatment is supportive: Analgesics and benzos for cramps Calcium repletion Hospitalization and anti-venom (LYOVAC) in severe cases

environmental Flashcards

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