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Flashcards in Environmental Emergencies Deck (52):
1

Distribution of electrical injuries:
1. Young children?
2. Adults?

1. Young children
oral contact w/ electric cords & outlets

2. Adults
construction and electrical workers (90% men)

2

MOI
1. Direct effect of electrical current on body tissues. Severity depends on? 5

2. What results in deep and superficial burns?

3. Which is usually a larger injury: exit or entrance?

4. As current flows through the body, the greatest damage is sustained by what? 3

1. Severity depends on
-voltage,
-duration,
-type (AC or DC),
-the current path throughout the body,
-environmental factors

2. Conversion of electrical energy to thermal energy

3. Exit wounds

4.
- nerves,
- blood vessels
- muscle.

3

1. Low voltage AC current will cause muscular tetany, causing what?


2. High voltage AC and DC currents cause a single violent muscular contraction, which tend to do what to the victim?


1. the injured person to continually grasp the source, increasing contact time


2. throw the victim from the source, thus increasing the risk of blunt trauma and blast injuries.

4

1. Low voltage AC current tend to cause which arrhythmia?

2. High voltage AC and DC current tend to cause what? 2

1. V-fib.
2. asystole and respiratory arrest.

5

PE: Neuro impairment occurs in approx. 50% of high-voltage injuries. What symptoms? 4

1. Transient LOC
2. Agitation, confusion
3. Coma
4. Visual disturbances

6

Pupils: may be fixed & dilated or asymmetric due to?

autonomic dysfunction, 50-80% of those struck by lightening have ruptured eardrums

7

1. PE: Spinal cord injuries? 4


2. Peripheral nerves injuries often iinvolve what?

1. Fractures
2. The current itself
3. Ascending paralysis, spinal cord syndromes
4. Can be immediate, transient or delayed


2. Injuries often involve the hand touching a power source

8

PE: Cutaneous wound management? 4

1. Burns (entry and exit points)

2. Look for entrance and exit wounds and degree of burns.

3. Burns can be cleansed and dressed with silver sulfadizine.

4. Extremities need careful exam for neurovascular compromise, compartment syndrome.

9

Extremities need careful exam for what? 2

1. neurovascular compromise,
2. compartment syndrome.

10

1. What has the highest resistance of any body tissue, generates the greatest amount of heat when exposed to electrical current?

2. Areas of greatest destruction are often what?

3. Deep electro-thermal tissue injury can result in what? 2

1. Bone

2. deep tissue surrounding long bones.

3.
-edema &
-development of compartment syndrome.

11

Renal
1. What can occur and be complicated by pigment-induced renal failure?

2. ___________ due to extravascular extravasation of fluid can lead to what? 2

1. Rhabdomyolysis

2. Hypovolemia,
-prerenal azotemia and acute tubular necrosis.

12

Treatment
1. Considered a trauma pt ? 2

2. Dysrhythmias – management?

3. Generally need aggressive what?

4. What kind of fluid?

5. ______ mg/kg over the first hour is appropriate for most patients.

6. Acute hypotension should prompt a search for what?

1. ABC's, C-Spine….the stuff you know well by now!

2. ACLS protocol

3. fluid replacement

4. Isotonic crystalloid fluid should be given.

5. 20-40

6. thoracic or intra-abdominal bleeding secondary to blunt trauma.

13

Electrical burn labs to order? 7

1. Labs
2. Lytes
3. BUN/Creatinine
4. Creatine kinase
5. Serum and urine myoglobin
6. CBC
7. EKG

14

Electrical Burn Tx
Watch electrolytes closely.
Wound care - burn treatment as usual; may need transfer to burn unit.
1. Can cause?
2. Can cause what kind of failure?
3. If persistent and compartment syndrome has been excluded what may be necessary?

1. Myoglobinurea
2. Can cause renal failure
3. amputation may be necessary

15

Tx for electrical burns:
1. _______ prophylaxis.
2. Treat any ________ appropriately.
3. Which consults – this is trauma?
-Children with oral injuries need what?
-Pregnant women need what?

1. Tetanus

2. seizures

3. General surgeon
-ENT.
-OB consult.

16

Electrical burns: Monitoring for? 5

1. Continuous cardiovascular monitoring
-Arrhythmias do occur 15% of the time after electrical injury

2. Needs to be monitored for the development of compartment syndrome .

3. I & O followed, maintain urine output > 100mL/h as a goal;

4. monitor for rhabdomyolysis

5. renal failure.

17

Lightening strikes:
1. Pathophysiology?

2. Can result in? 4

1. Lightning is a DC current

2.
-Direct strike
-Side flash
-Ground current
-Step potential

18

Lightening strikes:
1. Extensive tissue damage and renal failure are common or rare?

2. Immediate cardiac arrest from lightning strikes result from what?
-What can this lead to?

3. Respiratory arrest from ________ and paralysis of the what?

1. rare.

2. direct current depolarization of the myocardium and
-can result in sustained asystole.

3. depolarization
-medullary respiratory center.

19

Lightening strikes: Minor injuries? 7



Most minor injuries have a gradual improvement and no long term sequelae.

1. Stunned patient
2. Confusion, amnesia
3. Short term memory problems
4. Headache
5. Muscle pain
6. Parasthesias
7. Temporary visual or auditory problems

20

Lightening Strike:
1. A diagnosis of lightning injury is based on history and should be considered in which patients?

2. What may occur and have no prognostic value? 2

3. What should alert the provider to potential lightning injury? 2

1. found unconscious or in arrest who was outside during appropriate weather conditions.

2.
-Pupil dilatation
-anisocoria

3.
-Ruptured tympanic membranes or
-fern-like erythematous skin marking

21

Lightening strikes:
Treatment? 5

Secondary survey for occult injuries? 4

1. Aggressive resuscitation
2. ACLS and CPR
3. Cardiac monitoring, SA02, BP
4. Two large bore IV’s
5. High flow 02

1. Cutaneous burns
2. Ocular involvement
3. Auditory involvement
4. Musculoskeletal fractures

22

Lightening Strike Labs 3

1. Tetanus
2. Moderate to severe injuries – admit to critical care unit
3. Minor – admit, closely monitor cardiac and neuro status

23

Near-Drowning—Risk Factors
7

1. Inability to swim or overestimation of swimming capabilities
2. Risk-taking behavior
3. Use of alcohol and/or illicit drugs
4. Inadequate adult supervision
5. Hypothermia which can lead to rapid exhaustion or cardiac arrhythmias
6. Concomitant trauma, CVA or MI
7. Hyperventilation prior to a shallow dive

24

PP of Drowning
1. After submersion, the degree of what determine the ultimate outcome? 2

2. Drowning begins w/ period of what?

3. Loss of?
-How does it change?
-After a while?

4. Leading to hypoxemia by: 2

1.
-pulmonary and
-in particular CNS insult

2. Panis

3. Loss of normal breathing pattern
-Breath-holding, air hunger and struggle to stay above water
-Reflex inspiratory efforts occur

4.
-Aspiration
-Reflex laryngospasm

25

PP: Dry drowning
10-20% of submersion injuries
1. Cause by what?
-followed by? 2

2. Wet drowning
What happens? 5

1. laryngospasm,
-followed by hypoxia and LOC

2.
-Aspiration of water
-Dilution and washout of the pulmonary surfactant
-Diminished gas transfer
-Atelectasis
-Ventilation-perfusion mismatch

26

PP
Fresh water drowning
1. Transient hemodilution causing what?
2. If large enough volume are what?
-Leads to?

1. causing blood cells to swell and burst
2. If large enough volumes are aspirated,
-significant hemolysis is possible

27

PP
Salt water drowning
1. Lungs fill with salt water which draws blood where?

2. Build up of what?

3. stops what? from reaching the blood.

1. out of the bloodstream and into the lungs

2. sodium in the alveoli

3. oxygen

28

End Organ Effects of drowing
1. Pulmonary? 4
2. Neurologic? 3

1. Pulmonary:
-Fluid aspiration
-Both salt and fresh water wash out surfactant
-Producing noncardiogenic edema & acute respiratory distress syndrome (ARDS)‏
-S/S of ARDS: SOB, rales, wheezing

2. Neurologic:
-Hypoxemia & ischemia cause neuronal damage
-Can produce cerebral edema & elevated ICP
-20% near-drowning victims sustain neurologic damage limiting functional recovery

29

End Organ Effects of drowning
1. CV? 2
2. Acid base and electrolytes? 2

1. CV:
-Arrhythmias secondary to hypothermia & hyoxemia often occur
-Sinus bradycardia & fibrillation are more common

2. Acid-base & electrolytes:
-Metabolic and/or respiratory acidosis often occurs
-Significant electrolyte imbalances do not generally occur except those submerged in unusual media such as the Dead Sea

30

Drowning Management—Prehospital Care
3

1. Assess the need for CPR—pulses may be weak
2. Support the neck in a neutral position.
3. Hypothermic patients should be rewarmed.


Heimlich maneuver or other postural drainage techniques are NOT proven to benefit—therefore rescue breathing should not be delayed.

31

Drowning Management—ER
3

1. Prehospital resuscitative efforts should be continued
2. Head and spinal cord injuries should be sought: often precipitate near-drowning
3. Re-warming initiated in hypothermic patients

32

Drowning: How should you go about rewarming? 4

1. Blankets
2. Bair hugger
3. Overhead warmers
4. Resuscitative efforts should be continued until the patient’s temperature is 32-35C (90-95F)

33

Drowning Management—ER
Patients with GCS > or = to 13 4

1. O2
2. Observation for 4-6 hours
3. If pulmonary exam and room air SA02 remain normal….discharge home with someone to watch
4. If not better….. reassess and admit

34

Drowning Management—ER

Patients with GCS less than 13? 3

1. O2 – ventilation support if needed
2. Chest xray
3. Labs

35

Drowning: Which labs for Patients with GCS less than 13?
9

1. ABG’s
2. CBC,
3. CMP
4. Could develop dilutional hyponatramia and have seizures
5. PT/PTT,
6. UA,
7. CK,
8. urine myoglobin,
9. urine drug screen

36

Management--Inpatient
Neurologic - major determinants of neurologic outcome are:
3

1. Duration of LOC
2. Neurologic state of the patient at presentation
3. Goal of management…..prevent secondary injury

37

Management--Inpatient

Goal of management…..prevent secondary injury such as? 5

1. Cerebral edema
2. Hypoxemia
3. Fluid and electrolyte imbalances
4. Acidosis
5. Seizure activity

38

Management—Inpatient
Pulmonary? 4

1. May need intubation for PEEP delivery: ARDS
2. CXR's should be performed only when indicated
3. Bronchospasm is often seen and responds to beta agonists
4. Glucocorticoids or prophylatic antibiotics are not helpful

39

Factors Associated with a Poor Prognosis
9

1. Duration of submersion > 10 min
2. Time to effective basic life support > 10 min
3. Resuscitation duration > 25 min
4. Hypothermia w/ core temp less than 33C (92F)
5. Glasgow coma scale of 5 (comatose)
6. Age less than 3YO
7. Persistent apnea and requirement of CPR in the ER
8. Arterial blood pH 10C (50F)‏

40

Hypothermia
1. Defined as?
2. Mild?
3. Moderate?
4. Severe?

1. Defined as a core temperature of less than 35C (95F).

2. Mild hypothermia - core temp 90-95F
3. Mod hypothermia - core temp 82-90F
4. Severe Hypothermia - core temp less than 82F

While mostly seem in cold climates, can develop without exposure to extreme environmental conditions.


41

Hypothermia at risk population? 4

1. Elderly lose their ability to sense cold.
2. Neonates have large surface-to-volume ratio.
3. Both groups have limited ability to increase heat production and conserve body heat.
4. Individuals with an altered sensorium.

42

PP of hypothermia:
1. Heat is generated by cellular metabolism (prominently what? 2)

2. Loss by the skin and lungs though?
4

1. (heart & liver)‏

2.
-Evaporation
-Radiation
-Conduction
-Convection

43

Hypothermia
Heat is preserved by? 3

1. Peripheral vasoconstriction
2. Shivering
3. Non-shivering thermogenesis

44

What is non-shivering thermogenesis?

Increase in metabolic rate from thyroid and adrenal glands

45

Presentation of Hypothermia

-Mild? 7

-Moderate? 9

Mild:
1. Tachypnea,
2. tachycardia,
3. hyperventilation
4. Ataxia,
5. dysarthria,
6. impaired judgement
7. Shivering and “cold diuresis”

Moderate:
1. Reductions in pulse rate & cardiac output…
2. hypoventilation…
3. A fib….
4. junctional bradycardia & other arrhythmias can occur
5. CNS depression,
6. hyporeflexia
7. Decreased renal blood flow and
8. loss of shivering
9. Paradoxical undressing

46

Hypothermia Presentation
Severe? 7

1. Pulmonary edema
2. Oliguria
3. Areflexia
4. Coma
5. Hypotension,
6. bradycardia,
7. ventricular arrhythmias and asytole

47

Dx of Hypothermia
1. Must use what kind of thermometer?
2. Labs to ID potential complications? 5

1. Must use low-reading thermometer.

2. Labs to ID potential complications:
-Electrolytes
-Hematocrit
-Coagulation studies
-ABGs
-EKG: elevation of the J point—J or Osborne wave

48

EKG reading for hypothermia?

J waves

49

Managment of ABC’s
Initiation of rewarming
2

1. Passive external rewarming
2. Active external rewarming

50

Active external rewarming:
1. Ways to do this? 4
2. Risk is what?
3. Warm what part of the body first?

1. Combination of
-warm blankets,
-radiant heat,
-warm baths or
-forced warm air.

2. Risk is core temperature afterdrop—occurs when trunk and extremities warmed simultaneously.

3. Warm trunk 1st and minimize use of peripheral muscles .

51

Active internal rewarming:
Can be used alone or with active external rewarming.

Ways you can do this? 4

1. Pleural and peritoneal irrigation with warm saline.

2. Hemodialysis and cardiopulmonary bypass.

3. Warm humidified oxygen.

4. Warm IV fluids and bladder or GI irrigation with warm saline may be used.

52

Treatment of Arrhythmias

1. Hypothermic heart very sensitive to what?

2. Which usually resolve with rewarming? 2

3. Management of V-fib and asystole can be difficult—they may be refractory to therapy until the patient has been what?

1. movement & rough handling of the patient may precipitate arrhythmias.

2. A fib and flutter

3. rewarmed (core temp of 86-90F).