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Clinical Disciplines- Emergency Medicine > Environmental Emergencies > Flashcards

Flashcards in Environmental Emergencies Deck (134):
1

Pathophys of hypothermia?

increased HR, vasoconstriction and increased myocardial oxygen used

hypoventilation with CO2 retention --> hypoxia

decreased mucocillary clearance

slowed mentation, motor func.

decreased platelet func.

2

In hypothermia, there is a shift of oxyhemoglobin curve to the...

left

3

When does after drop occur in hypothermia?

when cold, acidotic peripheral blood returns to the central circulation

-reason for initial decreased in temp once begin tx

4

After drop can increased the risk for...

cardiac arrhythmias

5

At what temp do we loose our shivering ability? what temp is there an increase in arrhythmias?

90 deg F

<86 deg F : Osborn J wave

6

We should withhold cardiac meds and defibrillation until temp is...

> 82.4 deg F (>28 deg C)

7

If you have an Osborn J wave in V3 and V4 on EKG, you should suspect...

hypothermia

8

Tx for hypothermia?

warmed O2 and IV fluids

active external rewarming- warm blankets

gently circulating water

active core rewarming

9

If a pt with hypothermia has an arrhythmia then you need to...

rewarm pleura w/ active core rewarming

10

What is considered hypothermia?

<95 deg F

11

Classification of hypothermia?

Mild: 89.6-95°F (32-35°C)

Moderate: 86-89.6°F (30-32°C)

Severe:<86°F (<30°C)

12

Rate of heat transfer with conduction is dependent on...

temperature gradient and size of contact area.

13

What are the different methods of heat loss?

Conduction, Convection, Radiation, Evaporation

14

Conduction heat loss?

transfer of heat by direct contact (water immersion)

15

Convection heat loss?

transfer of heat by movement of heated material (wind disrupting heat around body)

16

Radiation Heat loss?

uses electromagnetic transmission

17

Evaporation heat loss?

conversion of liquid to vapor – usually accounts for 10-15% of body heat loss

18

Pathophys of frost bite?

cold exposure > formation of EC ice crystal which damage cell membrane and their osmotic gradient > IC dehydration > IC ice crystal formation > cell death

19

1st deg frost bite?

First Degree: anesthetic central white plaque with peripheral erythema

20

2nd deg frost bite?

clear or milky-filled blisters surrounded by erythema and edema

21

3rd deg frost bite?

hemorrhagic blisters that progress to a hard black eschar

Don't drain

22

4th deg frost bite?

complete necrosis and tissue loss

23

Tx for frostbite?

elevate and splint extremity

wrap in sterile gauze, debride white/clr blisters

cover with aloe vera

update Tetanus

Analgesics

smoking cessation

24

Do abx help with frostbite?

NO

25

How do ASA and NSAIDs help with frost bite?

decrease thromboxane A2 activity

26

What is keratitis?

inflammation of the anterior chamber of the eye

27

When can ultraviolet keratitis occur?

corneal burn

w/in 1 hr of exposure

does not become sxs until 6-12 hrs later

28

Sxs of ultraviolet keratitis?

severe pain, FB sensation, tearing, conjunctival injection

29

Tx of ultraviolet keratitis?

self limited, analgesics, cold compress, polarized sunglasses

30

Pts at risk for heat exposure?

Age extremes, confusional states, limited water access, alcoholics, mental illness, chronic diseases

-1/5 of young parents believe it is okay to leave children alone in parked cars

31

When does radiation occur?

when air temp is less than body temp

32

What is hyperthermia?

rise in body temp when heat production exceeds heat loss

ex. working out

33

Fever?

rise of core temp in response to circulating cytokines

34

pathophys of heat injuries?

increased endogenous heat production, decreased heat dispersion, exercise increased MR 20-25x baseline rate

35

Is thirst a good gauge of hydration status?

no

36

What meds can increase heat production?

neuroleptics, hallucinogens, amphetamines, anesthetics, LSD, cocaine

37

What meds inhibit sweating?

Antihistamines

Atropine

Neuroleptics

Antispasmodics

TCAs

-children also have less effective sweat mechanisms

38

How long does acclimatization take in adults? children?

7-10days

14 days

39

What is prickly heat?

heat rash

Acute inflammation of sweat ducts caused by blockage of pores

Pruritic, maculopapular erythematous rash found over clothed areas of body

40

Tx for prickly heat?

antihistamines, supportive care

41

Heat cramps?

Painful involuntary spasmodic contractions

Usually sweat profusely but replace with water only

42

Tx for heat cramps?

rest in cool environment

replace fluids/electrolytes

(fix Mg before K)

43

Heat exhaustion?

Dizzy, weak, malaise, N/V, Headache, myalgias

Syncope, orthostasis, sinus tach, tachypnea

normal mental status

44

Tx for heat exhaustion?

rest, volume and electrolyte replacement

45

Heat stoke?

MC in summer months

Triad = Hyperthermia (> 105°F), CNS dysfunction, Anhydrosis

Seizure, ↓BP, ↑HR, ↑RR

46

Abnormal labs in heat stroke?

↑ed Na and Bun -- ↓ed K, Ca, Phos, Mag (dehydration)

elevated transaminase levels

47

Tx for heat stroke?

IV fluids

diagnostics

reduce temp rapidly: remove clothes: strategic ice packs

TOC= evaporative cooling

Diazepam to inhibit shivering

48

Bad prognostic factors for heat stroke?

Delayed rapid cooling

AST > 1000

DIC

Prolonged coma

Hypotension

Renal failure in first 48 hours

49

Marine Envenomations -Jelly fish?

Pruritic pain, wheals, urticaria

50

Tx for jellyfish envenomation

vinegar to remove nematocyst

topical anesthetics

oral analgesics

no role for abx

51

Sxs of stingray envenomation

pain, bleeding

52

Tx for stingray envenomation?

irrigation, remove foreign debris, hot water immersion

NO abx

53

Catfish envenomation sxs/tx?

similar to stingray

54

Etiology of hypothermia?

Medical illnesses (DM, PVD, ASVD, Neuropathy, Psychiatric illness)

Ethanol (MCC in US)

Wind chill

Clothing (wet vs none)

Smoking

Homeless

MCly affects males 30-49 y/o

55

Hymenoptera Stings, what are the two classes?

Vespids – Yellow Jackets, Hornets, Wasps – sting multiple times

Apids – Honey and bumblebees – barbed stingers
MCC of allergic reaction secondary to insect stings = Yellow jacket

56

What is the MCC of death from envenomation for hymenoptera stings?

upper airway obstruction

57

Nest locations for bugs?

Ground – Yellow jacket

Under leaves or windowsill – Wasps

Bushes, low-lying limbs - Hornets

58

Sxs of Hymenoptera stings?

Local reaction – Pain, erythema, edema, pruritis, swelling

Systemic/anaphylactic rxn: most within 15 minutes:

Itchy eyes, facial flushing, urticaria, dry cough, dyspnea, wheezing, abdominal cramps, n/v/d, fever, arthralgias. IgE mediated histamine release

59

Hymenoptera stings tx?

clean with soap/water, remove stinger

Ice, elevate

antihistamines (Benadryl + type 2 i.e. Pepcid)

epi

steroids

Beta agonists

DC w/ auto injector epi

60

If you give a pt with a rash epi and it goes away...

you know its an allergic rxn

61

Brown Recluse Spider Bites

Loxosceles

MC in Midwestern and southern US

Woodpiles, sheds, garages, closets

light brown/tan

62

Brown Recluse Spider Bites active enzyme? sxs?

Sphingomyelinase D

Mildly erythematous lesion that becomes firm and dry over days to weeks Bluish blister then necrosis

+F/C, N/V, myalgias, petechia, seizure

63

Dx Brown Recluse Spider Bites? Tx?

No specific dx. CBC, BMP, Coags, UA

supportive, surg once clearly demarcated

64

Black Widow Spider Bites

Latrodectus

North America except Alaska

Attics, barns, sheds, garage, firewood, hay bales

Shiny black with red hourglass on abdomen

65

Black Widow Spider Bites pathophys

alpha lactrotoxin

venom releases acetylcholine and norepinephrine at neurosynaptic junction> inhibits their reuptake > muscle contractions and fatigue

66

Hallmark of Black Widow Spider Bites? Other sxs?

muscular cramping

N/V, diaphoresis, hypertension, tachycardia, anxiety, agitation, irritability, weakness, headache, periorbital edema

HTN 10-30%, shock, coma, res failure

67

Tx for Black Widow Spider Bites?

Narcodics, Benzos, Antivenin (horse serum)

Ca Gluconate (but doesn't really help)

68

Describe lice

Intensely pruritic wheals

Waists, shoulders, axillae, neck

Eggs not easily brushed off

69

Tx for lice?

Lindane (avoid in young children and pregnant females)

fine combing of hair

sterilize clothing/bed linens

70

Scabies presentation?

Hands and feet between digits

White zigzag threadlike pattern

very pruritic

71

Tx for scabies?

Elemite or Lindane

Calamine lotion

Oral antipruritic agents (atarax)

Analgesics

72

Snake bites epidemiology?

Rattlesnakes, copperheads, moccasins account for 90-95% of bites

MC time for bites is August to October

Male: Female = 9:1

UE >LE for adults, opposite for kids

73

20-25% Crotaline bites are ...while 60% of coral snakebite are...

dry = no envenomation

74

Which is poisonous, coral snake or king snake?

coral snake

75

Pit viper characteristics?

Pit (heat sensor) between eye and nostril

Elliptical vertically-oriented pupils

Triangular-shaped head

Retractable fangs

76

What does venom do?

Venom causes local tissue injury, systemic vascular damage, hemolysis, fibrinolysis, and consumption of fibrinogen and platelets

77

Cardinal features of snake bites? other sxs?

one or more fang marks, localized pain, erythema, ecchymosis, progressive edema

N/V, weakness, paresthesias of mouth and tongue (metallic taste), tender lymphadenopathy, tachycardia, dizzy, hematuria, decreased platelets

78

Tests for snake bites?

CMC, CMP, Coags, T/S

79

Tx for snake bites?

elevate extremity,

extractor device

constriction bands (occludes venous outflow)

observe for at least 8 hrs

admit all children w/bites

"cut and suck" NOT recommended, NO abx

80

When are antivenins indicated for snake bites?

worsening swelling, coagulation abnormalities (↓ed platelets, PT > 20 seconds), systemic effects (hypotension), all copperhead bites

Rx: Polyvalent Immune Fab

old: Antivenin Crotolidea Polyvalent

81

Scorpion sting pathophys

Venom (neurotoxin) activates sodium channels which causes immediate paresthesias, tachycardia, ↑ secretions, ↑ temperature, diaphoresis, SLUDGE

82

What is pathognomonic for scorpion sting? other common sxs?

roving eye movements

fasciculations, difficultly swallowing

83

Scorpion envenomation grades?

1 – Local pain and/or paresthesias

2 - Pain and/or paresthesias remote from site of sting

3 – CN/autonomic or
somatic dysfunction: blurred vision, roving eye movements, hypersalivation, tongue fasciculations, shaking/jerking

4 – CN/autonomic and somatic nerve dysfuntion

84

Tx for scorpion sting?

Cool compress
+/- midazolam

Anascorp $$$$
-3 vials in 10 mins

85

Tx for cactus spikes?

elmer's glue

local wound care

86

Define drowning

process resulting in primary respiratory impairment from submersion/immersion in a liquid medium

87

Submersion v. immersion?

entire body covered in liquid medium

part (oral and nasal airways) covered in liquid medium

88

Risk factors for drowning?

African Americans (except 0-4 y/o), unsupervised pool/bath time, bath seat use, seizure, alcohol use

89

Pathophys of drowning

percived risk of drowning>

last inhalation effort>

submersion/immersion> (LOC)

tissue hypoxia, acidosis, hypercapnia>

laryngospasm or aspiration>

respiratory failure/death

-surfactant can be washed out, most victims will ingest water

90

What determines prognosis of drown?

duration of submersion/immersion

Good: age <14, CPR in field, CPR <25 mins, detectable pulses on arrival

Poor: submersion >5 mins, no resuscitation for > 10 mins, fixed/dilated pupils, GCS <5, ph < 7.1

91

How long should asxs drowning pts be observed? those who required resuscitation?

4-6 hrs

eval in hospital

92

drowning tx?

o2 if o2 <92%

admit 24 hrs

postural drainage/heimlich -unproven efficacy

93

What are the zones of thermal burns?

Zone of coagulation

Zone of stasis

Zone of hyperemia or inflammation

94

Rule of nines? What is this used for?

Head/neck – 9
Each UE – 9 (9x2)
Each thigh – 9 (9x2)
Each lower leg/foot – 9 (9x2)
Clavicle to pubis – 18
Root of neck thru buttocks – 18
Perineum – 1
ROT = back of hand = 1% BSA

to determine total body area burned

95

First deg burn

epidermis only – painful, red, no blisters – sunburn

96

Second deg burn

partial: partly thru dermis – blisters, painful – hot liquids

deep: thru hair follicles and sweat glands – hot steam or oil

97

Should you drain blister from second deg burn?

NO

98

Third deg burn

skin to fat – charred, pale, painless, leathery feel

99

What is included in the major burn criteria?

Partial thickness > 25% BSA in 10-50yo, > 20% if < 10yo or > 50yo,
Full thickness > 10% in anyone,
Any burn to hands, face, feet, perineum
Any burn crossing major joint,
Circumferential limb burn,
Inhalational or electrical injury,
Burn with fractures,
Burns in infants and elderly

100

Tx for burns

update tetanus

NG tube

LR via 2 large bore peripheral IVs
"2-4 in 24, 1/2 in 8 the rest can wait"

keep UO 0.5-1cc/kg/hr for adults

IV narcotics

sharply debride OPEN blisters

cover with sterile moist dressings w/out abx if transferring

If DC, 24 hr FU

101

What is more lethal carbon monoxide or cyanide?

cyanide

CO is more common

102

When should you suspect smoke inhalation?

Facial, intraoral, or pharyngeal burns,
Singed nasal hairs,
Soot in mouth or nose,
Hoarseness
Carbonaceous sputum, Wheezing

103

CO pathophys

CO binds to hgb --> carboxyhemoglobin

CO has affinity for Hgb 200x that of O2 --> leftward shift of hgb oxygen dissociation curve

104

When should you suspect CO poisoning?

if have multiple family members with nonspecific symptoms, which resolve in the ED

normal CO-Hgb: 2-5%

105

CO-Hgb level and sxs

< 10% = asymptomatic

10-30% = H/A, N/V, Loss of dexterity

30-40% = Confusion, Lethargy, ST segment depression

40-60% = Coma

>60% = Death

106

When is hyperbaric tx for CO indicated?

CO-Hgb >25-30%

Cardiac involvement

Severe acidosis

Transient or prolonged
unconsciousness

Neurological impairment

Age >36 years old

Pregnancy

107

cherry red skin is indicative of?

CO poisoning

108

Etiology of cyanide poisoning?

smoke inhalation, byproduct burning (wool, silk), fruit pits containing amygdalin, cassava root, jewelry and textile industries, sodium nitroprusside

109

cyanide pathophys

Cyanide disrupts mitochondrial production of ATP by binding to and inhibiting cytochrome oxidase --> cessation of aerobic cellular metabolism

110

Cyanide sxs

Mild: HA, N, vertigo, tachypnea, HTN, AMS

severe: dyspnea, bradycardia, hypotension, arrhythmia, LOC, convulsions, CV collapse

111

findings for cyanide poisoning?

severe metabolic acidosis, usually not cyanotic, smells like bitter almonds

112

Cyanide tx

O2, amyl nitrate, sodium nitrite, sodium thiosulfate

113

Acid chemical burns causes...

coagulation necrosis which limits penetration of chemical

114

Alkalis chemical burns cause...

liquefactions necrosis

115

Would you rather get burned by acid or alkalis?

acid

but both suck

116

Therapy for chemical burns?

hydrotherapy

117

In electrical injuries, what is more dangerous alternating current or direct current?

alternating current

118

Pathophys of electrical injuries?

Cell membrane disruption, edema, coagulation necrosis, ischemia, release of myoglobin (renal failure from rhabdomyolysis

AC may precipitate V fib

119

Possible sxs of electrical injuries

cardiopulmonary arrest, LOC, seizure, amnesia, HA, compartment syndrome

120

Electrical burn tx

CBC, CMP, CK =, myoglobins

IV fluids

myoglobinuria

update tetanus

121

What are the dif. ways lightning strike injuries can occur?

direct strike

side flash/side splash

ground current

conduction

streamer

122

MCC of death from lightening injuries? sxs?

asystole

fatality rate 20-30%

res arrest, "stunned" HA, myalgias, paresthesias, temporary LOC, vision & hearing loss-usually gradually resolves

123

fern like rash pattern is pathognomonic for

lightening injuries

124

Lightening injuring dx? Tx?

CBC, CMP, CK, EKG +/- or CT braine

Tx: aggressive fluids not needed

if survive to ER, admit

125

Your neighbor knows you have just completed PA School and comes over to ask you “some medical advice”. He was in the backyard cleaning his storage shed about 45 minutes ago when he was bitten by something. He now complains of severe abdominal pain and nauseous and hypertensive. What most likely bit him?

A. Black widow spider.
B. Brown recluse spider.
C. Granddaddy long leg spider.
D. Scorpion

A

126

What treatment do you suggest to him?
A. Scorpion antivenin.
B. Dapsone.
C. Black widow antivenin.
D. Amoxicillin

C

127

While climbing Camelback Mountain with your friends, you are bitten by a rattlesnake on the leg. What is the preferred treatment of your injury in the field?

a. Apply tourniquet to the involved extremity.
b. Apply constriction band to the involved extremity.
c. “Cut and Suck” the venom from the wound.
d. Apply warm compresses to the wound

B

128

Your friends transport you to the hospital for further evaluation. While in the ED, you are noticed to have progressive swelling of your leg, hypotension, platelet count of 50K, and a PT of 25 seconds. Should you be given antivenin?

a. Yes.
b. No.

A

129

What is the treatment of choice for an anaphylactic reaction to a bee sting?

Epinephrine

130

What is the pathognomonic physical exam finding in scorpion sting?

Roving eye movements

131

58 year old gentleman presents with hypothermia. Core temperature is 85.5°F. Which of the following is the most accurate?

A. Shivering is common
B. Osborne J wave is pathognomic
C. Rough handling can produce dysrhythmias
D. NG tube should be inserted

C + B

132

Patient presents after being bitten while outside. Bite has target area with muscle cramps. What is the most likely cause?
A. Black widow spider
B. Hobo spider
C. Brown recluse spider
D. Tarantula
E. Scorpion

A

133

What is the most lethal form of acute mountain illness?

HAPE

134

What is the most important treatment option for acute mountain sickness?
A. Oxygen
B. Dexamethasone
C. Hyperbaric therapy
D. Acetazolamide
E. Immediate descent

E