Environmental Flashcards
(146 cards)
1
Q
Describe the classic presentation of heat-related illness.
A
Typically temperature exceeds 40C
Tachycardia
Commonly normotensive, but may be hypotensive
*Severe CNS dysfunction
Pupils may be fixed, dilated, pinpoint or normal
Nystagmus or oculogyric episodes may be present
Typically hyperdynamic cardiovascular state
Hypodynamic state signifies impending CV collapse
Tachypnea and hyperventilation
*GI hemorrhage occurs frequently
Jaundice and elevated liver enzymes occurs commonly
Fulminant hepatic failure and DIC rarely occur
*Muscle tenderness and cramping are common
*Rhabdomyolysis and ARF are common complications of EHS
2
Q
Heatstroke is defined as hyperthermia usually greater than ___C associated with severe CNS dysfunction and anhidrosis (some pts maintain ability to sweat).
A
40
3
Q
Mortality rate of heat stroke is over ___%.
A
70%
4
Q
What are the 2 major types of heat stroke?
A
Classic vs. exertional
5
Q
What is “classic heat stroke”?
- What pts is it more common in?
- What CNS sx can it cause?
A
- Typically occurs during environmental heat waves as a result of the body’s failure to dissipate heat. P/w hyperthermia and an altered sensorium that develops suddenly after prolonged exposure to elevations in ambient temperature.
- It is more common in the very young, the elderly, and the chronically and mentally ill.
- Variety of CNS sx including irritability, delusions, hallucinations, seizures or coma.
6
Q
List some meds and conditions that impair the patient’s ability to tolerate heat stress.
A
Diuretics, antihypertensives, anticholinergics, and neuroleptics
Advanced age, hypotension, coagulopathy, and endotracheal intubation are poor prognostic indicators regardless of successful cooling measures.
7
Q
What is “exertional heat stroke”? What pts is it more common in?
- What sx can it cause?
A
- Usually affects young healthy individuals who are unable to dispel heat due to endogenous heat production (Athletes and military recruits)
- These patients present with hyperthermia, diaphoresis, and an altered sensorium usually during extreme physical exercise in a hot, humid environment. Abdominal cramping, nausea, vomiting, myalgias, diarrhea, headache, dizziness, dyspnea, weakness, or syncope typically precede exertional heatstroke
8
Q
What are risk factors that predispose individuals to heat related illness?
A
Obesity, poor physical fitness, precedent illness, and lack of acclimatization
- cocaine or amphetamines or prolonged seizure activity.
9
Q
Are classic or exertional heat stroke pts more likely to have rhadomyolysis, acute renal failure, coagulopathy, lactic acidosis, and hypoglycemia as a result of the illness?
A
Exertional
10
Q
Define heat cramps.
A
Heat Cramps are brief, intermittent, severe cramps in muscles fatigued by excessive exercise and occur at a time of rest. They are thought to be related to salt deficiency and usually occur in the first days of excessive work in a hot, humid environment.
11
Q
Define heat edema.
A
Heat Edema is characterized by edema of the feet and ankles in unacclimatized individuals exposed to warm tropical or subtropical climates. It is thought to be the result of increased hydrostatic pressure and vasodilation resulting in vascular leak and edema.
12
Q
Define prickly heat.
A
Prickly Heat is an acute inflammatory skin condition caused by blockage of the sweat glands and a secondary staph infection. It is initially manifested by pruritic vesicles in the clothed areas that extend producing deeper vesicles that are less pruritic.
13
Q
What sx characterize heat exhaustion?
- Is the core temp high or normal usually?
- Do they have neuro sx?
- What is the immediate initial tx?
A
- Heat Exhaustion is characterized by vague malaise, fatigue, nausea, vomiting, weakness and headache in the setting of heat stress.
- The core temperature is frequently normal or just mildly elevated. The patient is frequently water depleted from inadequate hydration, but may be salt depleted from rehydration with hypotonic solutions.
- Patients with true heat exhaustion have normal mental status, but may be tachycardic.
- Clinically heat exhaustion and heatstroke may be incredibly difficult to differentiate and if the diagnosis is unclear, cooling should be immediately initiated.
14
Q
Define heat syncope.
- Who should be warned to be cautious about this?
A
Heat Syncope is the temporary loss of consciousness caused by intravascular shunting to the cutaneous circulation, pooling in the lower extremities due to prolonged standing, and volume depletion. The elderly are particularly susceptible and should be warned to move often and avoid prolonged standing.
15
Q
Consider 3 initial actions to take in a heat-related illness pt.
A
- Obtain fasting blood sugar in all patients with altered mental status
- Rapidly obtain rectal temperature
- Initiate rapid cooling simultaneously with any basic resuscitation measures
16
Q
*Explain some labs/tests you might want to get with heat-related illness.
A
- Glucose (AMS)
- BMP: Hypernatremia (dehydration), hyponatremic (free water), Hypokalemia (early), hyperkalemia (muscle dmg), renal fcn tests (myoglobinuria)
- LFTs (hepatic failure)
- CK (muscle damage)
- CBC (thrombocytopenia, leukocytosis)
- BMP
- UA (hematuria)
- Chest X-ray (pulmonary infarction, edema or atelectasis)
- Head CT or LP (AMS)
- EKG (RBBB or prolonged QT, etc.)
17
Q
Hematuria on the dip stick in the absence of RBC’s on microscopic exam suggests ______________.
A
Rhabdomyolysis
18
Q
How is the dx of heat stroke or heat exhaustion made?
A
Clinical suspicion
- Caution: pt may have been cooled by EMS, so temp may be < 40C on arrival +/- anhidrosis
19
Q
Discuss the tx of heat-related illness.
A
Basic resuscitative measures and immediate, aggressive *cooling measures
20
Q
In resuscitation of heat-related illness, a __________________ should be placed in the rectum or esophagus to continuously monitor core temperature.
A
thermistor probe
21
Q
In heat-related illness, the core temperature should be rapidly lowered to ___-___ C
A
38-39 C
22
Q
Discuss ways you can cool a body in heat stroke.
A
Evaporative Techniques - Wetting body surface with continuous fanning External (Non-invasive) Conduction Techniques - Tap water immersion - Ice water immersion - Application of cold packs - Cooling blanket Internal (Invasive) Conduction Techniques - Gastric, peritoneal or bladder lavage - Cold IV fluids Pharmacologic Techniques - Dantrolene
23
Q
What technique of cooling in heat stroke is no longer suggested?
- *Are antipyretics useful??
A
- Ice water submersion is extremely effective, but is now avoided since it may induce shivering which can generate increased heat and leads to vasoconstriction of cutaneous vasculature that reduces heat transfer.
- *Antipyretics ineffective and may exacerbate the hepatic, renal and coagulopathic abnormalities
24
Q
While dantrolene use in heat stroke is controversial, explain how it works.
A
Dantrolene is a muscle relaxant that attenuates the amount of calcium released from the sarcoplastic reticulum in the skeletal muscles to the cytosol. Decreased intracellular calcium levels lead to reduced muscle metabolic activity and heat production.
- Not first-line, but can use if cooling methods fail
25
*In heat-related illness, what should you do if the pt is shivering?
Shivering leads to increased heat production and should be controlled with benzodiazepines
26
What type of shock is most similar to heat-stroke related CV collapse?
Septic
27
Rhabdomyolysis in heat stroke can cause renal failure.
- What is the major sign of AKI here?
- What is the tx?
- Dark tea colored urine and tender muscles are classic findings.
- Treatment includes infusion of large amount of IV fluids and alkalinization of the urine with IV bicarbonate infusion to prevent myoglobin precipitation in the renal tubules. Hemodialysis may be necessary for patients with ARF.
28
Hypothermia is defined as a core body temperature < ___C.
35C
29
In hypothermia, bystanders may report these changes about the patient.
a change in personality, paradoxical undressing (when cold), rocking, dysarthria, ataxia, or frank confusion.
30
What is trench foot?
Lower extremities with prolonged exposure to wet and cold conditions develop tissue damage, often presenting as paresthesias, pain, or numbness.
31
Describe some sx of mild (32-35C) hypothermia:
- *Tachypnea
- *tachycardia w/o HDS
- *Shivering
- Neuro sx: Dysarthria, ataxia, amnesia, altered judgment, apathy, fine and gross motor impairment: “Mumbles, grumbles, stumbles, fumbles, tumbles”
- *Polyuria
32
Describe some sx of moderate (28-32C) hypothermia:
- *Bradycardia
- *Bradypnea
- *Cessation of shivering
- Hypoventilation
- Arrhythmia
- Neuro: Paradoxical undressing, Decreased responsiveness, Hyporeflexia, Dilated and sluggish pupils, Dysarthria, ataxia
33
Describe some sx of severe (< 28C) hypothermia:
- Bradycardia
- *Hypotension
- *Pulselessness
- Bradypnea/apnea
- *Rigidity
- *Pulmonary edema
- *v-fib, *v CO
- *Coma/unresponsiveness, areflexia, fixed pupils
- *Oliguria
34
Describe frostbite on physical exam.
Tissues appear pale and firm, with poor capillary refill and sensation. Severe frostbite appears purple due to blood sludging.
35
Describe trench foot on physical exam.
Skin may appear red and swollen at first, progressing to blisters and bullae and finally hemorrhage in the skin and deeper tissues.
36
Describe the initial actions to take in a pt with hypothermia.
- Minimize jerky movement of the severely hypothermic patient as movement or exercise may precipitate v-fib
- Stabilize airway
- Stabilize breathing: administer warm humidified O2
- Stabilize circulation: monitor, ECG, warm IV fluids
- Remove cold wet clothing, dry patient, cover with warm dry coverings or warming blanket (bear hugger). Initiate active rewarming measures.
- Look for signs of accompanying cold injury, trauma, or underlying illness (secondary hypothermia)
37
The best method for measuring and monitoring core body temperature is a low-reading temperature probe in the___________ or ___________.
esophagus or rectum
38
In hypothermia, can you use a rectal thermometer?
No, rectal temperature probe (5 cm in, not in feces)
39
List some lab abnormalities seen in hypothermia.
Laboratory testing may reveal hemoconcentration, hypo/hyperkalemia, hypo/hyperglycemia, or abnormal coagulation. Tests that warm blood to 37C may give false positive or false negative results, e.g. arterial blood gas, coagulation studies.
40
What CXR finding might you see in severe hypothermia?
Pulmonary edema
41
What EKG changes might you see in hypothermia?
- J (Osborne) waves in moderate-severe cases
- prolonged intervals (PR, QRS, QT)
- arrhythmias (atrial or ventricular)
42
What rewarming techniques can you use for:
- Mild hypothermia
- Mod hypothermia
- Severe hypothermia
- Mild: Passive external rewarming
Blankets (remove cold wet clothes first)
Oral hydration with sugared drinks
- Mod: Passive external rewarming + Active external rewarming
Electric or forced warm air blankets + often add noninvasive internal: warm IV fluids, warm humidified O2
- Severe: Active internal rewarming
warm IV fluids, warm humidified O2, warm bladder and gastric, or sometimes thoracic or peritoneal lavage (rarely done anymore) central arteriovenous or venovenous rewarming, cardiopulmonary bypass, dialysis
43
What medication should you give for bradycardia in hypothermia?
None, treat symptomatically
| - Atropine ineffective
44
How does CPR protocol differ in a hypothermia pt?
Not at all, except that antiarrhythmics and repeat defibrillation should be deferred until the patient is warmed to above 30C.
- Administer bretylium if available.
45
*Review some complications of rewarming.
The patient’s temperature may decrease during rewarming (called afterdrop) as peripheral vessels dilate and increase return of cool blood from extremities to the core. Rewarming shock (hypotension) may occur as rewarming causes vasodilatation. Rewarming can also drop pH, electrolyte imbalances, and coagulopathy.
46
How is frost bite treated?
- Immediately immerse the affected area in warm water (37-39C).
- Remove constricting clothing and jewelry.
- Consult surgical services
- Treatment includes ibuprofen, tetanus toxoid, elevation, and analgesia.
- New: tPA to improve perfusion and decrease the incidence of amputation.
47
What is a potential complication of frost bite to watch for?
Compartment syndrome
48
What should you treat first, hypothermia or frost bite?
Hypothermia
49
What is the initial tx of trench foot?
Keep feet warm, clean, and dry.
| Elevate the extremity.
50
Why do rewarmed hypothermic pts need to be observed?
For the development of DIC, rhabdomyolysis, pancreatitis, seizures, and other complications
51
True or false:
Providing aggressive rewarming and resuscitation efforts to patients in cardiac arrest due to hypothermia often leads to a full neurologic recovery.
True
52
The largest family of venomous snakes is ___________, which includes the subfamily of Crotalinae, or pit vipers.
Viperidae
| - Rattlesnakes, copperheads, and cottonmouths are examples
53
Describe what viperidae look like.
- What is the most important characteristic that ID's them?
- triangular head, elliptical pupils, fangs, and a characteristic ‘single row’ arrangement of their caudal plates.
- There may be a rattle
- The most important characteristic is the presence of bilateral “pits,” or heat-sensing organs, located between the eye and the nostril on each side
54
_________, the other venomous snake family besides viperidae, is comprised of cobras, and coral snakes, as well as many species of Australian snakes
Elapidae
55
How do you differentiate a harmless milk snake from a venomous Texas coral snake (elapidae)?
A Texas coral snake (“Red on yellow, kill a fellow”).
A harmless milk snake (“Red on black, venom lack” or “friend of Jack”)
56
What parts of the US have brown recluses?
South and Midwest
57
How do you ID brown recluses?
Referred to as 'fiddleback spiders’ due to the dark fiddle (or violin) shaped marking on their dorsal aspect.
58
Most species of scorpians are not dangerous to humans, however, the __________ scorpion (C. exilicauda formerly sculpturatus) found in Arizona and New Mexico harbors a poisonous venom.
Bark scorpion
59
What is a poisonous jellyfish found along the New England coast in the Summer months?
Cyanea jellyfish
60
Do jellyfish and sting rays have venom?
Yes
61
How does coral (elapidae) snake venom work, mechanistically?
*What sx might you see?
Blocks ACh R sites
- See ptosis (first, often), neuromuscular weakness, slurred speech, fasiculations, drowsiness, weakness, and trouble breathing --> paralysis
62
*What sx might you see in a pit viper (viperidae) bite?
- localized edema and pain, which usually spreads proximally and involves the entire extremity.
- After a few hours, vesicular lesions and bullae, often hemorrhagic, may develop.
- --> nausea, weakness, muscle fasiculations, changes in taste sensation (metallic), and sensory changes, involving the mouth, fingers, and toes.
- Sometimes neurotoxicity, resp failure
63
*Describe the typical sx of black widow bite.
- Pain (local, radiating, regional) that increases over the course of an hour and may radiate proximally along the affected limb to the trunk.
- Muscle spasm may occur
- Systemic effects are less common: HTN, agitation, fever, paresthesias, fasiculations and cardiac effects
64
*Describe the typical sx of a brown recluse bite.
- Bites can vary from mild, self-limiting erythema to large, necrotic ulcerations.
- Local pain and burning are common.
- Systemic symptoms are rare, but may include hemolysis, DIC, and renal failure.
65
Describe the common and *more severe sx of an AZ Bark scorpion envenomation.
- Often burning pain, pruritus and paresthesias at the site of the sting.
- Severe systemic symptoms of the Arizona bark scorpion include catecholamine (restlessness, coma, and convulsions) and cholinergic effects (bradycardia, hypotension, salivation, lacrimation, and diarrhea)
66
What can occur from marine life stings?
In addition to localized pain, bleeding, and erythema, systemic symptoms such as hypotension and shock may occur
67
With puncture wounds from animal stings/bites, besides the effects of envenomation and deposited foreign body, what's another thing that could occur which could influence tx?
Prone to infections from bacterial flora that may enter the wound, such as anaerobes and tetanus.
68
Are ice water immersion, suction, and incision of the wound useful in envenomation?
No!! contraindicated
69
Are there serum tests to determine the type of snake venom in a bite?
No (clinical dx)
70
*What labs should be drawn in suspected envenomation?
A CBC, chemistry, coagulation profile (including fibrinogen, PT, aPTT) and CPK should be drawn.
- A Foley catheter may be placed to monitor urine output and to obtain a urinalysis for myoglobin.
71
What envenomation should prompt serial CPKs?
Black widow bite
72
Why might you order x-rays in marine life injuries?
To look for spine remnants from stingrays, scorpion fish or sea urchins (otherwise x-rays not useful in bites/stings)
73
Who is a candidate for anti-venom tx?
Anyone w/mod or severe sx.
74
*What is the tx of most bites/stings?
Appropriate *first aid is the mainstay of treatment.
- Removal of spines, stingers, tentacles and fangs.
- Washing the affected site, local wound care and applying ice to reduce swelling are essential.
- The affected extremity should be closely examined for edema and signs of compartment syndrome
75
*What type of bite, if suspected, should always receive antivenom immediately?
Coral snake
76
Once you decide to administer antivenom, what should you do?
Call poison control if you haven't already 1800 222 1222
the patient must be closely monitored for anaphylaxis. Two IV lines should be established. Oxygen, ECG monitor, and resuscitation equipment should be in the room.
77
True or false:
| Spider bites from U.S. species are likely to cause envenomation that requires urgent administration of antivenom.
False
- However, children, the elderly and patients with serious co-morbidities bitten by black widow spiders may benefit from early antivenom therapy.
78
*Antivenom is not used routinely for spider envenomations in the United States because of concern for ___________.
anaphylaxis
79
Stings from the Arizona bark scorpion may require antivenom therapy if there are signs of systemic _______________.
neurotoxicity
80
What should you do right away with sting ray envenomations? (1)
Soak in hot water ASAP
81
*Most jellyfish stings should first be treated by inactivating the nematocysts with _____________ or ____________.
* vinegar or acetic acid
| - Soaking in hot water provides effective analgesia as well
82
If a pt requires antivenom, what is there dispo from the ED?
ICU (watch for shock; may require ventilatory supprt, IV vasopressors, etc)
83
How long should an asymptomatic bite/sting pt be observed?
8 hrs (prior to d/c)
84
*Most scorpion stings are minor and local wound care is sufficient. However, if an Arizona bark scorpion sting is suspected, what is the pt's dispo?
The patient should be monitored in an ICU setting regardless of the administration of antivenom.
85
Following envenomations, is immobilization and splinting of the extremity indicated?
Yes
86
Following envenomations, are arterial tourniquets, incision and/or suction of the wound, venom extraction devices, cryotherapy, oxidizing substances or proteases helpful?
No
87
*In ruling out acute abdomen in black widow bite, while both have rigidity, how can you tell the difference?
Black widow bite will have no tenderness/pain.
88
What infection is commonly mistaken for spider bite?
MRSA
89
In coral snakes, antivenin may require repeat doses due to ___________________ phenomenon.
recurrence
90
In cholinergic crisis from a scorpion, what tx may be helpful?
Atropine
| - The benefits of atropine must be weighed against the risk of tachycardia and dysrhythmias.
91
Why is informed consent important for venomous scorpion stings?
It is important for the patient to understand that scorpion envenomation is unlikely to be a fatal disease process. Therefore, antivenom is not lifesaving. However, without antivenom, the patient will likely have a prolonged period of distressing symptoms, and of all available treatments, current evidence indicates antivenom is likely to be effective and may significantly reduce the duration of suffering and hospitalization.
92
Describe the MoA of scorpion venom.
Centruroides exilicauda venom contains neurotoxin that increases Na+ channel permeability resulting in na+ channel activation and cell membrane depolarization --> over-stimulation of sympathetic and parasympathetic nervous systems, causing excessive ACh and catecholamine release.
93
____________ ____________ (previously known as Centruroides sculpturatus) is the only scorpion in the United States with venom potent enough to produce a life-threatening illness.
Centruroides exilicauda
| - Known as bark scorpion (lives near trees)
94
Where are bark scorpions found?
Southwestern US, CA, TX, Mexico
95
List the 3 zones of a burn injury.
1. Zone of Coagulation.
2. Zone of Stasis.
3. Zone of Hyperemia.
(increasing injury severity)
96
What is the Zone of Coagulation in a burn injury?
In this area, cell death is complete. This is usually nearest to the energy source and forms the eschar of the burn wound
97
What is the Zone of Stasis in a burn injury?
In this area, cells are viable but circulation is impaired. If the injury continues, then increased damage and tissue ischemia may result
98
What is the Zone of Hyperemia in a burn injury?
In this area, there is minimal cellular injury but there is increased blood flow due to vasodilatation. This tissue usually recovers without intervention
99
True or false:
| Burn pts should be assessed as trauma pts.
True
100
What are 2 signs to look for when assessing the airway of a burn pt?
Is there carbonaceous sputum?
| Soot Hair singed?
101
What are questions to ask about the breathing of a burn pt?
Are there burns to lung or chest wall?
| Gas/toxin inhalation?
102
What tests should you order if the pt was exposed to gases/toxin inhalation in a burn injury?
ABG to check pH
a CO level
a methemoglobinemia level
103
What is an escharotomy for?
A procedure to release tension due to scar formation.
104
*How does the "Palm Estimate" of burn injuries work?
The burned patient's palm (ventral surface of the hand excluding the fingers) is estimated to be equal to 1% of the TBSA and then used to measure the size of the burn.
105
*What is the "Rule of 9's" in a burn injury?
- entire head and each arm are estimated at 9% of the TBSA
| - each entire leg, the anterior thorax plus abdomen & back is each estimated at 18% of the TBSA
106
In contradiction to the Rule of 9's in adults, what % of a burn does a child's head comprise?
18% (larger head size)
107
The classic presentation of a burn patient is not related to the source of injury (i.e. heat, chemical, electrical, etc.) but instead depends on the ________ and ________ of the injury.
extent and depth
108
Classify a first-degree burn (layer and sx)
superficial, limited to the epidermis
| - wound is red, *painful, and well demarcated
109
Classify a second-degree burn (layer and sx)
partial thickness, involves the epidermis and part of the dermis.
- May involve hair + glands. Wounds are *painful, blister, + blanch with pressure. Tends to be wet + slippery to touch.
110
Classify a third-degree burn (layer and sx)
Full thickness. Involves all epithelial and dermal elements.
- Painless (but will often be surrounded by painful tissue so patients may report pain). It is depressed, non-edematous, and *leathery. May be white, brown, or black
111
Classify a fourth-degree burn (layer and sx)
Deep tissue. Extends through all layers of skin and involves underlying tissue.
- Wound is painless but injury is extensive and often requires amputation
112
How do electrical burns differ from thermal burns?
| Why does this matter?
Electrical energy is converted to heat which causes thermal injury and burns. However, unlike conventional thermal burns, the electricity may flow in unpredictable pattern and significant injury may not be evident at site of entry.
- Therefore, a detailed skin exam, including evaluation of the palms and soles is essential.
113
What serious finding is often seen in electrical burns?
Cardiac arrhythmias
114
Extent of electrical burn injury is determined by:
voltage type, voltage strength, the resistance of tissue, and the duration of contact.
115
Since inhalation injuries are difficult to spot, what additional tests should you consider in the burn pt?
CXR, detailed oropharyngeal exam, nasopharyngeal laryngoscopy, or bronchoscopy
116
List the 3 categories on inhalation injuries.
1. temperature-related
2. smoke-related
3. gas-related
117
Do temperature-related inhalation injuries tend to affect the upper or lower airways?
- What sx may develop?
Upper
| - edema, erythema, and ulcerations of lips, tongue, posterior oropharynx, and upper airway.
118
In temperature-related inhalation injuries, when do sx set on, and when to they resolve by?
24 hrs
| 5 days
119
Do smoke-related inhalation injuries tend to affect the upper or lower airways?
- What mechanism is disrupted, and what dz may result?
Lower
| - reduced mucociliary function, may develop PNA
120
*In gas-related inhalation injuries, what are signs of CO poisoning?
Sx range from a slight headache or confusion to chest pain, stroke, or seizure, coma, + death.
121
What can cause cyanide gas-related inhalation injury?
Burning of home furnishings and other synthetic materials release various toxins into the environment such as plastics releasing cyanide.
122
In gas-related inhalation injuries, water soluble chemicals (ammonia, chlorine, etc.) can lead to what sx?.
bronchospams, edema
123
In gas-related inhalation injuries, lipid soluble chemicals (phosgene, nitrous oxide, etc) direct cell damage, impairing _________________.
ciliary clearance
124
*When treating minor burns, what should you focus on doing? (4-5)
1. Remove clothing
2. Run water over burns
3. Pain control
4. Topical ointment + sterile dressing
5. Maybe tetanus ppx
125
What are some ointments you can use for minor burns?
- Bacitracin is used for burns on the face.
- A combination of Bacitracin and Xeroform dressings are used for many areas of the body.
- Silvadene (SSD) or newer silver based products may also be used
126
Do you give PO abx for minor burns?
No
127
*In severe burns, what part of tx is of paramount importance?
Fluid resuscitation
128
*What is the fluid of choice for severe burns?
LR
129
*How is LR given in severe burns?
Parkland formula: %TBSA burn x wt in kg x 4cc/kg = volume of LR that should be administered over the first 24 hours
- Half should be given in the 8 hours following the burn and the remaining half should be given over next 16 hrs (24hrs total). Remember, this is extra fluid in addition to the patient’s baseline fluid requirements.
130
Review adequate urine output in adults and peds (cc/kg/hr)
Adult urine output: 0.5cc/kg/hour
Pediatric urine output: 1-2cc/kg/hour
131
___________ is the leading cause of death in patients with large burns, accounting for up to 75% of deaths.
Sepsis
Why? Loss of barrier, eschar is favorable growth environment, and hypermetabolic/catabolic state leads to cytokine release and global immune system impairment.
132
The prevention and control of infection in the burned patient takes three main forms:
1. Debridement of devitalized tissue
2. Wound management: antibiotic dressings and early wound closure with skin grafting and/or commercial products.
3. Preventing the delayed development of pneumonia and sepsis: universal precautions and general infection control practices. Aggressively evaluate fevers by pan-culturing and initiating broad-spectrum abx.
133
Adult patients with >___% TBSA burns are generally transferred to a regional burn center for evaluation.
Pediatric patients with >___% TBSA burns are generally transferred to a regional pediatric burn center for evaluation.
20%
10%
134
True or false:
| You can go through burned skin for IV access, chest tubes, and other essential procedures
True
135
Which is better for burn tx:
1. Placing moist towels or gauze of burned areas
2. Covering burns with Xeroform or silver sulfadiazene (SSD) dressings and gauze
Zeroform or SSD dressings + gauze
| - Do not place moist towels or gauze of burned areas as this will contribute to hypothermia
136
Define drowning, via WHO definition.
“the process of experiencing respiratory impairment from submersion/immersion in a liquid”
137
What demo's are more susceptible to drowning?
- Toddlers/teenage
- M x4 vs. F
- Black 1.3x vs. White
138
True or false:
Healthy patients who have been rescued from drowning and have no respiratory symptoms, clear lungs and normal mental status may not need any further care.
True
139
What are some sx of the drowning pt?
- Respiratory distress
- Tachypnea
- Hypoxia
- Coughing
- Foaming at mouth/nose
- Rhonchi/rales on exam
- Vomiting
- Hypothermia
- Trauma
140
Describe the pathophysiologic sequence of drowning.
1. Breath holding
2. Water aspiration +/- laryngospasm
3. Brain hypoxia
4. Tachycardia --> bradycardia --> cardiac arrest
141
What is the rhythm typically seen during cardiac arrest of drowning pts?
PEA followed by asystole
142
Is CXR useful in drowning pts?
Yes - check for aspiration
143
Is EKG useful in drowning pts?
Yes (also cardiac monitoring)
144
What is the initial tx of drowning?
ABCs
Don't need to correct hypothermia if prolonged ROSC
Watch for PNA development (no ppx abx)
145
If d/c'ing a drowning pt, what should you warn them about?
Respiratory symptoms may be delayed. Ensure they have appropriate return precautions and the ability to access care.
146
Which type of burn tends to be wet + slippery, 2nd or 3rd degree?
2nd degree (painful)
- 3rd degree is leather-like and painless, not wet
