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Environmental Flashcards

1
Q

2 types of drowning according to WHO definition (2002)

A

o Fatal drowning: any death related to drowning

o Non-fatal drowning: if victim survives

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2
Q

Poor prognostic factors in drowning patients (list 5)

A
  • duration of submersion > 10 min
  • ROSC > 25 minutes
  • degree of pulmonary damage by aspiration
  • effectiveness of resuscitation measures (delayed CPR)
  • lack of pupillary reflex
  • male gender
  • hyperglycemia
  • asystole
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3
Q

Good prognostic factors in drowning patients (list 4)

A
  • submersion < 5 minutes
  • ROSC < 10 minutes
  • pupils equal and reactive at scene
  • normal sinus rhythm at scene
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4
Q

List 4 complications of drowning

A

ARDS, pulmonary edema, pneumonia, cerebral edema leading to increase ICP, trauma, hypothermia

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5
Q

Work-up of a drowning case

A
  • Obtain chest x-ray and ABG (VBG)
  • Labs: Consider CBC, electrolytes, urea, Creatinine, ECG, ethanol level, urinalysis (Hg)
  • repeat CXR and gas in 6-12 hours
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6
Q

Management of severe drowning case

A

monitor HR/RR/BP
frequent blood gas analysis (arterial line if SaO2 less 90% on 60% oxygen)
intubation as indicated (PEEP 5-15 mmHg to maintain sat greater 90% and PaCO2 35-45 mmHg)
fluid restriction/diuretics once BP stabilized
consider antibiotics
admit to ICU

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7
Q

List 6 physical signs of smoke inhalation

A

facial burns, singed nasal hairs, pharyngeal soot, carbonaceous sputum, signs of neurological dysfunction (irritability, depression), signs respiratory dysfunction (tachypnea, cough, hoarseness, wheezing, decrease breath sounds, stridor, rhonchi, rales)

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8
Q

Management of inhalational burns

A

*early intubation for any physical signs – edema increases over first 24 hours.
100% oxygen
CXR, labs, R/O carbon monoxide/ cyanide toxicity
No role for steroids or prophylactic antibiotics

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9
Q

Pathophysiology of carbon monoxide (CO) toxicity?

A
  • Binds hemoglobin at affinity 200-300 times more than oxygen = decrease oxygen content in blood
  • Shift oxyhemoglobin dissociation curve to left = increase oxygen affinity and less being available for tissues
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10
Q

CO toxicity symptoms?

A
  • Less than or equal to 1% is normal, smokers may be as high as 5-10%
  • Mild (20% CO) = headache, mild dyspnea, visual changes, confusion
  • Moderate (20-40%) = drowsiness, faintness, N/V, tachycardia, dulled sensation, decrease awareness of danger
  • 40-60% = weakness, incoordination, cardiovascular and neurological collapse is imminent
  • greater 60% = coma, convulsions and death almost certain
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11
Q

When to consider Hyperbaric oxygen therapy in CO poisoning?

A
  1. Neurologic signs or symptoms (seizures, coma, syncope) (on presentation or despite normal oxygen) – may reduce DNS (no studies in children)
  2. Signs cardiac ischemia or metabolic acidosis
  3. Pregnancy
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12
Q

Treatment of cyanide toxicity?

A

Treat with cyanide antidote kit (Lilly kit) – caution as induced methemoglobinemia.
Correct anemia, can also use hydroxycobalamin (synthetic B12)

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13
Q

List 4 risk factors for heat-related illness?

A
  • Elderly
  • Children with CF or absent sweat glands
  • Children receiving medication that causes oligohidrosis
  • Infants left in cars on hot days
  • Young athletes
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14
Q

What are the 3 types of heat injury?

A
  1. heat cramps
  2. heat exhaustion (Neurologic status remains intact – if in doubt, treat as heat stroke!) - divided into water depletion and salt-depletion types
  3. heat stroke (Core temp > 40°C with neurologic dysfunction)
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15
Q

List 4 complications of heat stroke

A

CV collapse, rhabdomyolysis, acute tubular necrosis, DIC, liver failure, severe CNS dysfunction

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16
Q

Initial steps in management of heat stroke?

A
  • Remove clothing
  • Begin active cooling (ice pack to neck, groin and axilla, spray with water and then fans, iced peritoneal lavage)
  • Transport to ER in open or air-conditioned vehicle
  • Cardiovascular support
  • Goal: cool to 38.5 degrees, monitor with rectal probe (sedation and paralysis can augment cooling process)
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17
Q

Definitions of mild, moderate and severe hypothermia and a few features of each

A

Mild: 32- 35 (normal ECG, increase HR/BP, loss shivering under 32)

Moderate: 28-32 (decrease HR/BP, flipped T waves, a fib, sluggish dilated pupils)

Severe: < 28 (absent pulse and BP, VF, coma, fixed and dilated pupils)

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18
Q

List 4 risk factors for hypothermia

A
  • Neonates (large BSA, low subcutaneous fat, unable to shiver)
  • Adolescents (less likely to take corrective steps)
  • Physical disabilities
  • Drugs/ alcohol
  • Healthy young children who work or play in cold environment
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19
Q

List 5 ECG changes seen in hypothermia

A 
sinus bradycardia
first degree AV block
T wave inversion
prolonged intervals
J (Osborn) wave
atrial fibrillation
ventricular fibrillation (less than 28 degrees)
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20
Q

What is “after drop” in rewarming?

A

active external rewarming cause peripheral vasodilation –> shunting of cold, acidemic blood to the core (therefore core temperature drops).

Minimize this if only warm head and trunk area (or use of core re-warming techniques)

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21
Q

What are some different methods of rewarming?

A
  1. Passive External Rewarming: remove from cold env’t, remove wet clothing, cover with warm blankets
  2. Active External Rewarming: Electric blankets/warmers, hot packs (anticipate “afterdrop”)
  3. Active Core Rewarming: Heated humidified oxygen, heated IV saline (40-43°C), Gastric, pleural, peritoneal, bladder lavage with warm IV saline, ECMO (for absent circulation)
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22
Q

Role for meds/ shocks in CPR in hypothermic patient?

A
  • If VF = defibrillation x3 but NO MORE until temp > 30

* No drugs until temp > 30 (ineffective)

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23
Q

List 4 indications not to resuscitate in hypothermia?

A

lethal injury, chest too stiff for CPR, avalanche burial >35 minutes, and airway obstructed by snow

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24
Q

List 4 types of cold-related skin injury

A
  • Frostbite (freezing temp -> ischemia/ necrosis)
  • Frostnip (Milder form of frostbite, paresthesias)
  • Immersion Foot (Trench foot) - non-freezing injury/wet
  • Chilblain (Pernio) - ulcers from damp cold above the freezing point
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25
Q

Treatment of frostbites?

A
  • First phase (prethaw): get patient out of cold and remove clothing, soft padding to affected areas and avoid rubbing or applying pressure
  • Second phase (active rewarming): immerse affected area in bath 40-42 degrees for 15-30 minutes; ensure adequate pain control (rewarming is painful)
  • Third phase (post-thaw): wound management and application of loose, sterile dressings, splint extremities
  • Prophylaxis with tetanus in any burn case and antibiotics if sign infection (cover for staph, strep, pseudomonas)
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26
Q

4 illnesses seen with altitude, and their characteristics?

A
  1. High altitude headache: headache only
  2. Acute mountain sickness (AMS): headache plus one of the following nausea/vomiting, fatigue, difficulty sleeping and dizziness (caused by vasogenic edema, “hangover-like”)
  3. HAPE: form of non-cardiogenic pulmonary edema
  4. HACE: Most severe form of altitude illness, occurs 2-4 days post altitude arrival. Severe vasogenic cerebral edema causing AMS + ataxia, CN palsies
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27
Q

List 3 signs and 3 symptoms of HAPE?

A

o symptoms: insidious cough, breathlessness out of proportion to work, breathlessness that does not respond to rest
o signs: production of frothy, often rusty, sputum, rapid breathing, cyanosis, elevated jugular venous pressure, diffuse crackles on auscultation of the lungs.

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28
Q

List the symptoms/ signs of HACE?

A

Encephalopathic symptoms and signs, including ataxic gait, severe lassitude, and progressive decline of mental function and consciousness (irritability, confusion, impaired mentation, drowsiness, stupor, and finally coma)

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29
Q

List 4 factors that affect the severity of high altitude illness

A

rate of ascent, altitude itself, altitude where sleeping occurs, and child’s physiology

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30
Q

What is the treatment for severe AMS or HACE? For HAPE?

A

o Oxygen
o acetazolamide and/or dexamethasone
o either HBO therapy (portable) or immediate descent

For HAPE: same but add nifedipine to reduce pulmonary pressure

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31
Q

What medication is given for prophylaxis at high altitude? How does it work?

A

Acetazolamide - works by creating metabolic acidosis to allow RR to remain high – improved oxygenation

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32
Q

What is the pathophysiology of decompression sickness (“the bends”)?

A

SCUBA diving and rapid ascent – as the diver descends, breathing air under increased pressure – increased oxygen and nitrogen in their blood (Henry’s Law).

With rapid ascent - liberation of free gas from the tissues in the form of bubbles; The liberated gas bubbles can alter organ function by blocking vessels, rupturing or compressing tissue, or activating clotting and inflammatory cascades.

think of it like opening a bottle of carbonated beverage –> decompression sickness if opened too rapidly

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33
Q

What are the symptoms of DCS (decompression sickness)?

A

Type 1 DCS (mild): MSK system (joint pain – “bent over”), skin (pruritis), lymphatics (pain, localized edema)

Type 2 DCS (severe): CNS (paresthesia, weakness, paralysis), ear, lungs, heart

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34
Q

What is the most severe form of decompression sickness?

A

Arterial gas embolism (AGE) = severe form of decompression sickness (#1 cause of death in divers)
• Sudden onset
• cerebral symptoms
• Loss of consciousness
• h/a, confusion, convulsions, motor/sensory loss, alteration of normal consciousness, seizures, visual changes, ataxia
• Cardiac arrhythmias / arrest

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35
Q

Treatment of DCS? List 4

A
  • Hydration
  • 100% O2
  • Trendelenburg (head down) - to restore forward blood flow by placing the right ventricular outflow tract inferior to the right ventricular cavity → allows air to migrate superiorly to a non-obstructing position
  • positioning the patient in the left lateral decubitus (Durant’s maneuver)
  • ALL types of decompression illnesses require recompression (hyperbaric therapy)
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36
Q

What is “Rapture of the deep”?

A
  • Intoxicating effects of increased tissue nitrogen concentration
  • Signs and Symptoms: Euphoria, false well-being, confusion, poor judgement/skill, disorientation, laughter, diminished motor control, paresthesias/numbness in lips/gums/legs.
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37
Q

6 factors that determine the severity of electrical injuries?

A
  1. Resistance of skin, mucosa or internal structures
  2. Type of current (alternating or DC)
  3. Frequency of current
  4. Intensity of current (voltage)
  5. Duration of contact
  6. Pathway taken by current
38
Q

Which is more dangerous, AC or DC?

A

AC more dangerous = tetanic muscle contractions ex. “Locking-on” state

39
Q

What is the relationship between tissue resistance and electrical damage?

A
  • Externally: Lower resistance - more internal damage possible (passes easily) Moist oral mucosa < dry skin < thick palms
  • Internal tissues: high resistance ie. bone = high damage
40
Q

How does the pathway taken by electrical current predict injuries?

A
  • Did the current pass through the thorax? — Think dysrhythmias
  • Through the head or neck? — Think damage to the CNS and risk for later central respiratory arrest; acoustic nerve damage; cataract formation.
  • Did the current pass along an extremity? — Think compartment syndrome and rhabdomyolysis.
41
Q

List 3 ways that electrical injuries can induce arrest?

A
  1. V.fib
  2. Brainstem paralysis or tetanic contractions of thoracic muscles –> respiratory arrest
  3. Lightning injury –> asystole
42
Q

List 4 cardiac side effects of electrical injuries?

A 
SVT
atrial and ventricular extra systole
RBBB
complete heart block
myocardial damage
ventricular wall perforation
asystole
ventricular fibrillation
43
Q

What are the effects of an “arcing” electrical current?

A 
across joints (elbow, axilla, wrist) – entry and exit wounds are poor predictors of internal damage. 
*risk of compartment syndrome (edema, ischemia, thrombosis)
44
Q

List 2 complications of oral commisure burns

A
  1. Eschar separates in 2-3 weeks –> risk of severe hemorrhage from lingual artery
  2. Acute edema
  3. later scarring/ contractures
45
Q

Work-up of high voltage electrical injuries?

A

need ECG, labs (CBC, CPK, BUN, creatinine, urine myoglobin)

46
Q

What skin finding is seen with lightning strikes?

A

Lichtenberg sign

47
Q

What is the timing of greatest risk for whole-body radiation injuries?

A

3-4 weeks after exposure when bone marrow suppression reaches nadir

48
Q

List 3 methods from protecting from radiation exposure (in hospital xrays)

A
  • minimize time of exposure
  • maximize distance (most effective - dose decreases by square of the distance)
  • shielding
49
Q

List 5 types of radiation injuries?

A
  1. Perceived (need reassurance)
  2. Exposure to radiation (whole body or local)
    - whole body high dose exposure –> acute radiation syndrome
    - small part of body –> local radiation injury
  3. contamination (external or internal) *requires medical staff to take precautions
  4. metal fragment
  5. hot particle
  6. terrorist event
50
Q

Which 2 body systems are most affected by acute radiation syndrome?

A

GI tract and bone marrow are most susceptible (rapidly dividing cells)

51
Q

Management of external contamination in radiation injuries?

A

o wear glove/gown/shoe covers/mask (contact precautions)
o staff to wear Geiger counter to measure radiation exposure to themselves
o cover the floor
o keep isolated from other patients
o remove patients clothing** (eliminates 90% of external contamination)
o place contaminated articles in plastic bag
o cover clean wounds to prevent contamination
o prevent external water from becoming internal
o pay attention to skin folds and finger nails
o clean hands/face/body/hair/wounds with damp washcloths, avoid excessive rubbing

52
Q

Signs and symptoms of Portuguese man-of-war envenomation?

A

local pain and irritation
systemic: headache, myalgias, fever, abdominal rigidity, arthralgia, N/V, pallor, respiratory distress, hemolysis, renal failure, coma, death if large area relative to victim size

53
Q

Treatment of Portuguese man-of-war stings?

A
  • Man-of-war responds to salt water (avoid vinegar – ineffective and may activate nematocysts), no anti-venom available
  • Supportive care with oral steroids, oral antihistamines, opiates for pain
  • Tx muscle spasms with IV calcium gluconate
  • Tx local dermatitis with steroids creams
54
Q

What is sea bathers eruption (SBE)

A
  • Stinging or a hypersensitivity reaction to Cnidaria larva
  • Erythematous rash underneath the bathing suit of swimmers
  • Only 50% report stinging while in the water
  • Skin lesions - discrete papules with pustules, vesicle and urticaria
55
Q

General scene management for jellyfish stings

A

• Inactivate nematocysts remaining on the skin with vinegar
(Stings from the American sea nettle, Portuguese man-of-war, little mauve stinger jellyfish, and “lion’s mane” jellyfish may worsen with the use of vinegar; use sea water) - Application of fresh water will cause discharge of nematocysts
• Remove inactivated nematocysts by scraping gently with a hard object (e.g., credit card)

56
Q

Which bacteria to worry about in infection after jellyfish stings?

A

Vibrio - Use a third generation cephalosporin if there is any suspicion for infection

57
Q

Treatment for stingray stings?

A

irrigate at scene with cold salt water, place extremity in hot water 30-90 minutes, then debride wound, tetanus prophylaxis, antibiotics for secondary infections

58
Q

Scromboid vs. ciguatera?

A

Scromboid: high concentration of histidine –> histamine. Min-hours after ingestion: numbness, tingling, burning sensation of the mouth, flushed/ erythema of the skin (look sunburnt).

Ciguatera: ingestion of neurotoxin (ciguatoxin) – onset 2-24 hours after ingestion, diaphoresis, headache, abdo pain + neuro symptoms (neuro symptoms can persist days-weeks). Sensation of loose, painful teeth, metallic taste, reversal of temperature discrimination.

59
Q

Which 2 types of spiders in the USA are deadly?

A

brown recluse and black widow spiders

60
Q

Skin findings with brown recluse spider bite?

A

pustule or blister –> leads to local ulcer /necrosis

61
Q

Manifestations of black widow spider bite?

A

Generalized pain and rigidity 1-8 hours post-bite with cramping in abdomen, flanks, thighs and chest

62
Q

Timing of tick paralysis? Treatment?

A

4-7 days post bite can get restlessness, irritability, ascending flaccid paralysis, may lead to respiratory paralysis and death

Treatment: remove the tick. Once removed the paralysis is reversible

63
Q

List 4 tick-borne illnesses?

A

Lyme, RMSF, tularemia, ehrlichiosis, babesiosis

64
Q

Most common venomous snakes in USA?

A

Pit vipers (rattlesnake, water moccasin, copper head) = 99% of venomous snakebites in USA

65
Q

How to differentiate coral snake (venomous) vs. king snake (not venomous)

A

Pattern of colored stripes:
• Coral snakes (red on yellow, kill a fellow)
• King snake not venomous (red on black venom lack)

66
Q

Appearance of venomous snakes?

A

Triangular head, elliptical pupil (not round), rattles

67
Q

List 5 systemic signs of pit viper envenomation?

A 
CV - tachycardia, hypotension, shock
Pulmonary - pulmonary edema, resp failure
Renal dysfunction
Neuromuscular - paralysis, seizures
Bleeding diathesis
68
Q

Prehospital care of venomous snake bite

A

Keep patient calm, at rest, limb below heart, constriction band if long transport anticipated (need to allow some blood flow – don’t use a tourniquet)

Incision and suction NOT recommended. Tourniquet NOT recommended

69
Q

Specific hospital management of venomous snake bites?

A
  • Give antivenin (CroFab) within 4 hours of the bite
  • Wound care included cleaning the wound, debridement of blebs, irrigation, tetanus prophylaxis, neurovascular checks, measure circumference for edema
  • Labs every 6 hours
70
Q

Which infectious organisms are seen in cat/ dog bites?

A

o Pasteurella in the 1st 24 hours (fulminant infection)

o Other organisms after 24 hours (staph aureus, strep, coag neg staph)

71
Q

Bacterial infection seen only in human bites?

A

Eikenella corrodens

72
Q

Which bite wounds NOT to suture?

A

puncture wounds, minor hand or foot wounds, wounds given initial care after 12 hours, cat or human bites, wounds in immunocompromised patients

73
Q

Indications for antibiotic prophylaxis in bite wounds? Which Abx to use?

A

crush wound, puncture wound, bones/tendons/joints involved, face, hands, feet, genitalia, immunocompromised, obvious signs of infection, ALL human bites, cat bites. Dog bites if primary closure

Use clavulin for 5 days (for P.multocida, Streptococcus and anaerobes, MSSA)

74
Q

List 3 examples of agents used in chemical attacks?

A

nerve gases, nitrogen mustard, cyanide

75
Q

List 3 examples of agents used in biologic attacks?

A

anthrax, plague, smallpox, botulism, tularemia

76
Q

List 5 clues to biologic terrorism attack?

A

epidemic number of patients, common exposure, history, exotic disease presentation, high infection rates among exposed persons, high rates atypical pneumonia, high morbidity and mortality, attack rates lowered by persons sheltered, presence of infected or dying animals

77
Q

Features of anthrax inhalation?

A

Fever, ARDS, widened mediastinum on CXR
Start with fever, headache, myalgia and cough; second phase is high fever, dyspnea, cyanosis and shock; hemorrhagic meningitis (50%)
Incubation period 1-5 days

78
Q

Features of cutaneous anthrax?

A

Papule at inoculation site which changes to a vesicle then ulcer and finally depressed, black eschar; swelling surrounding tissue; not tender to touch

79
Q

Pathophysiology of botulism?

A

Botulinum toxin functions at peripheral nerves (neuromuscular junction) – prevents release of acetylcholine –> flaccid paralysis

80
Q

Signs and symptoms of botulism?

A

cranial nerve dysfunction - bulbar palsy, ptosis, photophobia, blurred vision
then dysarthria, dysphonia, dysphagia; descending symmetric flaccid paralysis

81
Q

How to decontaminate patients after a chemical attack?

A
  • Patients go from “hot zone” (pre hospital care) to “warm zone” in hospital corridor/tent on hospital grounds, to “cold zone” after being thoroughly decontaminated
  • In warm zone: ABC’s, spot decontamination (remove all clothing, wash/shower) and drugs (anticonvulsants and antidotes)
  • Use level C PPE – non encapsulated chemically resistant body suit, gloves and boots with full face air purifying mask containing filter for chemical gases and HEPA filter
82
Q

How do nerve agents (ie. sarin gas) work?

A

They are organophosphate esters and irreversibly inhibit acetylcholinesterase

Increased Ach in cholinergic synapses, neuromuscular junctions and smooth muscle = Cholinergic syndrome

83
Q

Signs and symptoms of nerve gas toxicity?

A
  1. CNS effects: altered mental status, lethargy, coma, ataxia, convulsions, respiratory depression
  2. Nicotonic effects: muscle fasciculation, twitching –> weakness, flaccid paralysis; Sympathetic effects: tachycardia, HTN, hyperglycemia, hypokalemia, metabolic acidosis
  3. Muscarinic (“SLUDGE”)
84
Q

List 4 treatments for nerve gas toxicity?

A
  1. Decontamination
  2. Atropine for muscarinic effects
  3. Pralidoxime(2-PAM) for neuromuscular effects – reactivates acetylcholinesterase
  4. benzodiazepine prophylaxis for seizures in large exposures.
85
Q

Signs of cyanide toxicity?

A

severe dyspnea without cyanosis, flushing, bitter almond odour to breath and body fluids

86
Q

Lab abnormalities in drowning

A

respiratory and metabolic acidosis

87
Q

10mo male with temp 45C, what 3 things would you do (Not ABC’s).

A

active cooling (ice baths, cooling blankets), remove warm clothing, fluid resuscitation.

88
Q

List 6 complications of heat stroke

A
  • Cardiac failure secondary to direct thermal damage to myocardium
  • Pulmonary hypertension
  • ATN
  • Electrolyte disturbances (especially hypocalcemia), Hypoglycemia
  • Rhabdomyolysis
  • Permanent neurologic damage is more commonly seen in patients with core temperatures >42ºC (107.6ºF) and consist of spasticity, ataxia, dysarthria, poor coordination, impaired memory, and behavioral changes
  • Heat intolerance: disorder in temperature homeostasis that is seen in heat stroke victims and that places them at greater risk for repeated heat illness
89
Q

List 4 metabolic alterations in hypothermia

A 
Metabolic acidosis
Increased CK/renal failure
Hypoglycemia
Hypocalcemia
Coagulopathy 
Hypokalemia 
Hypercarbia
90
Q

Radiation emergency - list the 7 things needed to decontaminate children assuming personal protective equipment and resuscitation is taken care of.

A

· Plastic bag (for contaminated clothing) + gown to wear after
· Water source
· Mild soap & sponge
· Warming blanket to prevent hypothermia
· Identification tag
· For non-ambulatory patients: conveyer belt with restraining belt/seat for young children
· Chaperones or parents
· Stretcher pre and post decontamination
· Radiation detecting device

91
Q

List 2 mechanisms of how electrical injuries damage tissues?

A
  1. Direct effect of electrical current on body tissues
  2. Conversion of electrical energy to thermal energy → deep and superficial burns
  3. Blunt mechanical injury from lightning strike, muscle contraction, or as a complication of a fall after electrocution

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