Environmental Health shit Flashcards
(110 cards)
1
Q
A common pathogen found in wound infections
from dog bites.
A
Pasteurella multocida
2
Q
Antibiotic indications for dog bite
A
(1 Signs of infection
(2 Bite on face present for > 24 hours OR bite on extremity > 8 hours without irrigation
(3 Immunocompromised state for the victim
(4 Crush injury or significant contamination of wound
(5 Bite wounds of the hands or feet
3
Q
Antibiotics used for dog bites
A
Amoxicillin/Cla vulanate (Augmentin) - PCN Antibiotic with broad spectrum coverage
Dose: 875/125 mg BID or 500/125 mg TID
Clindamycin + fluoroquinolone if penicillin allergic
Dose: 300 mg PO q 6 hours for 7 days
Ciprofloxacin (Cipro)
Dose: 750mg PO BID for 4-8 weeks
4
Q
Cat bite infections are due to
A
Pasteurella
5
Q
Antibiotics that should be directed against Aeromonas hydrophila, (bodies of water excluding sea water)
A
Trimethoprim-Sulfamethaxazole (Bactrim DS)
Dose: 800mg/160mg PO q 12 hours for 7 days
Doxycycline
100mg BID for 7 days
6
Q
Antibiotics based of sea water animals (Vibrio
species)
A
Doxycycline Plus Ceftriaxone 1 gram IV daily
or
Ceftriaxone (Rocephin) 2 grams IV every 12 hours
7
Q
Mosquito-borne diseases found in the U.S. are:
A
(a) Eastern equine encephalitis
(b) Western equine encephalitis
(c) St. Louis encephalitis
(d) La Crosse encephalitis
(e) West Nile virus
8
Q
Treatment of Mosquito-borne illness starts with
A
Consulting the Centers for Disease Control and Prevention (CDC), and the local COCOM and TYCOM for the most current Force Protection recommendations when deploying of conducting field operations.
9
Q
Stings/bites in the order of insects that includes ants, bees, and wasps
A
Hymenoptera
10
Q
Clinical signs of Hymenoptera Sting
A
A local reaction is the most common reaction
Victims of multiple stings often experience:
1) Vomiting
2) Diarrhea
3) Dyspnea
4) Hypotension
5) Tachycardia
6) Syncope
7) Skin infections
In advanced stages of toxicity, the victim experiences:
1) Increased muscle activity with hyperkalemia
2) Acute tubular necrosis
3) Renal failure
4) Pancreatitis
5) Coagulopathy
6) Heart attack
7) Stroke
11
Q
Treatment for Hymenoptera Sting
A
(a) Remove the stinger
1) Scrape away the stinger in a horizontal fashion.
2) Try not to grasp the stinger sac.
3) However, if one is unable to remove the stinger in a horizontal fashion, it is
most important to remove it as soon as possible by any available means.
(b) Wash the site with soap and water.
(c) Place a cold compress or ice on the site to reduce inflammation.
(d) Give oral analgesics as needed for pain relief.
(e) Topical steroid cream can be helpful for swelling, as are oral antihistamines.
12
Q
how often can epi be used
A
The epinephrine injection can be repeated 5 to 10 minutes after the initial injection.
13
Q
Ticks transmit many diseases, including
A
a) Lyme Disease
(b) Rocky Mountain spotted fever (RMSF)
(c) Relapsing fever
(d) Colorado tick fever
(e) Ehrlichiosis
(f) Babesiosis
(g) Tularemia
(h) Southern Tick-Associated Rash Illness (STARI)
14
Q
What is Tick paralysis
A
A non-infectious ascending paralysis similar to Guillain- Barre syndrome, may occur within five days after the tick attaches. Removal of the tick is
curative.
15
Q
Coral Snake bites
A
Neurotoxins cause respiratory paralysis
(a) Signs and Symptoms: ptosis, dysphagia, diplopia, and respiratory arrest via
diaphragmatic paralysis
16
Q
Rattle Snake bites
A
Cytolytic (rattlesnakes, other pit vipers) - Cytolytic venoms cause tissue destruction by
digestion and hemorrhage due to hemolysis and destruction of the endothelial lining of
the blood vessels.
Cytolitic Signs and Symptoms:
(a) Local pain
(b) Redness
(c) Swelling
(d) Extravasation of blood
(e) Perioral tingling
(f) Metallic taste
(g) Nausea and vomiting
(h) Hypotension
(i) Coagulopathy
17
Q
Venomous or non venomous snake?
(a) Triangular head
(b) Keeled scales
(c) Elliptical pupils
(d) Nostrils plus IR pit
(e) Single row of subcaudal scales
A
Venomous snake
18
Q
Venomous or non venomous snake?
(a) Oval shaped head
(b) Round pupil
(c) No IR pit
(d) Double row of subcaudal scales
A
Non-Venomous
19
Q
Red touches black your OK jack. Red touches yellow you’re dead fellow
A
Identifies the appearance of the coral snake
20
Q
Black Widow Spiders signs, symptoms and treatment:
A
1) Generalized muscular pains
2) Muscle spasms,
3) Rigidity
4) Abdominal Pain
1) Pain may be relieved with pain control and muscle relaxants (benzodiazepines
and supportive care)
21
Q
Brown Recluse Spider signs, symptoms and treatment.
A
Causes progressive local necrosis as well as hemolytic reactions (rare). Bite is usually painless.
Pain management for secondary local necrosis and close monitoring initially. Consider antibiotic prophylaxis in field setting. Bites occasionally progress to extensive local necrosis and may require excision of the bite site and oral corticosteroids.
22
Q
Scorpions signs, symptoms and treatment:
A
(a) Muscle cramps
(b) Twitching and jerking
(c) Occasionally hypertension
(d) Convulsions
(e) Pulmonary edema
(a) Supportive care is appropriate for North American species.
(b) Always review the threat of local species when operating OCONUS
(c) If severe neurologic or neuromuscular dysfunction consult poison control and
discuss further management and anti-venom
(d) Suction oral secretions, airway management, cardiac monitoring, IV opioids
preferably fentanyl due to no histamine release, benzo for spasms unless getting
anti-venom
23
Q
Jelly fish signs symptoms and treatment
A
(a) Pain
(b) Erythema
(c) Edema
(d) Pruritus
(e) Vesiculations
(f) Anaphylaxis
(a) Rinse the area with seawater. Do not rinse with freshwater. Fresh water promotes Nemocyst activation.
(b) Remove tentacles with a gloved hand the scrape off any remaining nemocysts by
covering with sand/shaving cream/baking soda and scraped off with straight edge.
Sticky tape may also remove nemocysts
(c) Vinegar x 30 sec deactivates nemocysts
Antihistamines, topical corticosteroids, and pain medications
24
Q
Coneshells signs, symptoms and treatment
A
(a) Mild to severe pain
(b) Stinging or numbness
(c) Local to total paralysis
(a) Pressure Immobilization Dressing and supportive care to include close monitoring of
respiratory status
(b) MEDEVAC for advanced supportive care, possible need for ventilation if symptoms
worsen. Usually resolves in 24-72hrs
25
Stingray and stinging fish signs, symptoms and treatment
(a) Barbed spines that are a penetrating injury and envenomation.
(b) Spine commonly remains lodged in wound.
(a) Remove and irrigate to remove fragments
(b) Toxin is heat labile and immediate relief of pain can be obtained by placing the
wound in water heated to 40-45 Celsius (104-113 Fahrenheit) for 30min intervals (know both temps)
(c) Poison control useful for all envenomations
(d) Extremely painful and typically does not respond well to pain relievers
(e) Local anesthetic can be used to help with pain if hot water immersion is ineffective
(not in combination)
Prophylactic antibiotics to include coverage for Vibro are indicated:
1) Doxycycline - is in the Tetracycline family of antibiotics
a) Dose: 100mg BID for 7 days
b) Tetanus vaccine
26
The following factors increase the risk of drowning:
(a) Inadequate adult supervision.
(b) Inability to swim or overestimation of swimming capabilities.
(c) Risk-taking behavior.
(d) Use of alcohol and illicit drugs (more than 50 percent of adult drowning deaths are
believed to be alcohol-related).
(e) Hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias.
(f) Concomitant trauma, stroke, or myocardial infarction.
(g) Seizure disorder or developmental/behavioral disorders in children.
27
Fatal and nonfatal drowning typically begins with a period of
panic, loss of the normal
breathing pattern, breath-holding, air hunger, and a struggle by the victim to stay above the water.
Reflex inspiratory efforts eventually occur, leading to hypoxemia by means of either aspiration or reflex laryngospasm that occurs when water contacts the lower respiratory tract.
Both salt water and fresh water wash out surfactant, often producing noncardiogenic pulmonary edema and the acute respiratory distress syndrome
(ARDS)
Arrhythmias secondary to hypothermia and hypoxemia are often observed in nonfatal drowning victims.
28
Three phases of treating near drowning victim
prehospital care,
emergency department (ED) care, and inpatient care.
29
Treatment of near drowning victim
Rescue and immediate resuscitation by bystanders improve the outcome of drowning victims.
Prehospital resuscitative efforts should be continued, and the airway secured as indicated.
In the symptomatic patients who do not require immediate intubation, supplemental oxygen should be provided to maintain the SpO2 above 94 percent
May require intubation
No immersion in water, and wet clothing should be removed to avoid hypothermia
30
In the symptomatic patient, indications for intubation include the following:
1) Signs of neurological deterioration or inability to protect the airway.
2) Inability to maintain a PaO2 above 60 mmHg or oxygen saturation (SpO2) above 90 percent despite high-flow supplemental oxygen.
3) PaCO2 above 50 mmHg.
31
Near drowning presenting with the following factors at presentation have been associated with a poor
prognosis:
a) Duration of submersion > 5 minutes (most critical factor)
b) Time to effective basic life support > 10 minutes
c) Resuscitation duration > 25 minutes
d) Age > 14 years
e) Glascgow coma scale < 5 (i.e., comatose)
f) Persistent apnea requirement of cardiopulmonary resuscitation in the
emergency department.
g) Arterial blood pH<7.1 upon presentation
32
True or false? simply remaining above and not coming into contact with the sediment
may reduce the diver's potential exposure.
True
33
True or false your dry suit for swimming should be rough in order to prevent contamination.
False.
The dry suit material should have a smooth outer surface which does not trap
contaminants and is capable of being thoroughly decontaminated. Some dry suit manufacturers have had their suit materials tested against a variety of contaminants
in the laboratory using ASTM methods
34
Biological contaminants included in the tg are?
(a) Harmful algal blooms (e.g., red tide),
(b) Bacteria (e.g., fecal coliforms),
(c) Viruses and parasites which could potentially harm an unprotected diver.
(d) Biological contaminants may be present in storm water runoff and pose hazards to divers and to surface support personnel, especially when diving in near shore, urban
areas within 36 hours of a storm event.
35
five bacteria that most commonly produce soft tissue infections in association with exposure to water or water-related animals.
(a) Aeromonas species
(b) Edwardsiella tarda,
(c) Erysipelothrix rhusiopathiae,
(d) Vibrio vulnificus,
(e) Mycobacterium marinum.
36
Trauma including infection from polluted waters should be treated how?
(a) Assessment to determine whether treatment requires hospitalization
(b) Empiric antibiotic administration, assessment of tetanus vaccination status
(c) Assessment of tetanus vaccination status
(d) Surgical consultation for potential debridement in patients with necrotizing
infections
37
Recommended initial empiric therapy for trauma in polluted waters
Cephalexin (Keflex)
Clindamycin PLUS Levofloxacin + Flagyl
use if exposure to sewage – contaminated water or if soil – contaminated wound
(a) Doxycycline (100mg twice daily) for coverage of vibrio species if seawater exposure
Clindamycin plus Levofloxacin
1) Dose: 300 mg PO q 6 hours for 7 days
Levofloxacin (Levaquin) - Fluoroquinolone antibiotic
1) Dose: 500 mg PO daily x 7 days
Metronidazole (Flagyl) - is an antibiotic with cytotoxic effects towards anaerobic
organisms
1) Dose: 500mg PO TID for 7-10 day
Cephalexin (Keflex) - is a 1st generation Cephalosporin antibiotic
(a) Dose: 250mg PO four times daily (QID)
38
Once the patient is safely accessible for the IDC, the mainstay of patient treatment for toxic gas is supportive care with:
1) High-flow, 100% oxygen
2) BVM ventilation
3) Endotracheal intubation (ETI) as needed
39
Inhaled agents manifest their toxic effects by four different mechanisms:
1) Physical particulates
2) Simple asphyxiants
3) Chemical irritants
4) Chemical asphyxiants
40
Physical Particulates
Physical particulates are small, solid particles that are carried by gases or
atmospheric air into the body through inhalation (e.g., dust or combustion soot).
In general, these small particles cause physical irritation to the upper airways. In some cases, extremely small particles may even be carried down to the alveolar
level and cause mechanical problems, such as impairing proper gas exchange.
Physical particulates may act as vehicles that carry toxic chemicals, such as organic acids, throughout the respiratory system.
41
Physical findings of physical particulates
Irritation of the respiratory system.
Excessive coughing and shortness of breath.
Dyspnea that might not
caused by significantly impair airway diameter.
productive cough
burns to the face,
signed nasal vibrissae
Presence of soot in places like the oro and nasopharynx
42
Treatment of exposure to physical particulates
1) Remove the patient from the source of the physical particulates and
administer oxygen.
2) Patients with signs of reactive airway disease (e.g., wheezing and poor air flow) should be treated with nebulized Albuterol.
43
Simple Asphyxiants
gas agents that include:
1) Carbon dioxide (CO2)
2) Nitrogen
3) Methane
4) Natural gas
Simple asphyxiants have no inherent toxic or metabolic effect on the body's cells, other than causing hypoxia by default due to lack of adequate oxygen
44
Which simple asphyxiant causes a narcotic-like
sleepiness as the initial effect of exposure.
CO2
45
Treatment of simple asphyxiant
get out of area, administer o2 and cardiopulmonary support as indicated
46
Chemical Irritants
Two general classes of chemical irritants are those that react readily with water and those that do not.
Chemical irritants are those that reacte with the mucus membranes of the eyes and respiratory system
I.e Hydrochloric acid and ammonia
47
Treatment of chemical irritants
Irrigation of eyes with water or saline
As with particulate irritants, patients with underlying asthma or COPD will likely benefit from nebulized albuterol treatments if bronchospasm is evident during physical examination.
48
Chemical Asphyxiants
chemical asphyxiants cause injury by asphyxiating patients at the cellular level by massively deranging normal cellular utilization of oxygen.
example is carbon monoxide, cyanide gas (HCN),
and Hydrogen Sulfide (H2S).
49
produced by Industrial activities that include
petroleum/natural gas drilling and refining, wastewater treatment, coke ovens, tanneries, and Kraft paper mills.
Hydrogen sulfide gas
Both HCN and H2S block the effective use of oxygen within the
cell. This causes rapid body-wide ischemia, which results in a
severe metabolic acidosis.
50
Physical findings of CO poisoning
CO poisoning often has a gradual, even insidious, onset of symptoms, which may
include headache, chest pain and decreasing mental status. Frequently, the patient
progresses to coma and death.
51
CO-exposure patients with high blood levels of COHgb or those who are pregnant, have signs of cardiac ischemia or have a loss consciousness are
all candidates for
Hyperbaric oxygen therapy.
52
Treatment of cyanide poisining
The kit contains three drugs designed to be administered in the
following sequence:
(1 Inhaled amyl nitrite
(2 IV sodium nitrite and
(3 IV sodium thiosulfate
More recently, a safer cyanide antidote has become available in the
U.S. IV hydroxocobalamin, combined with sodium thiosulfate
53
In regards to overdose Thorough physical examination is essential - with a special emphasis on:
(a) Mental status
(b) Pupil size and reactivity
(c) Skin temp
(d) Presence or absence of sweat
(e) Muscular tone
(f) GI motility and mucus membrane moisture
54
The term “toxidrome” refers to
the collection of signs and symptoms that are observed after an exposure to a substance “toxic fingerprint”.
55
If overdose and altered mental status, obtundation, or coma is present then administer
Naloxone Dosage IV 0.2mg IV/IM/SQ every 2 to 3 minutes. 15 mg max
Duration 30-90 minutes
Glucose Dosage - 50ml bolus (25gm glucose)
Thiamine dosage - 250mg IV/IM once daily
56
With overdose how do you treat hypotension, dysrthythmias, seizures, ocular exposure and gi decontamination
(3) Hypotension is first treated with fluid bolus
(4) Dysrhythmias are treated per ACLS guidelines
(5) Benzodiazepines are first line treatment for seizures
(6) Ocular exposure - copious irrigation
(7) GI decontamination - various methods including
(a) Orogastric lavage (following placement of an NG tube)
(b) Activated charcoal - most commonly used
57
Activated Charcoal dosage
1) Dosage - 1gm/kg (awake patients can drink, alternatively can be administered to NG tube)
58
Dry as a bone, red as a beet, hot as a hare, blind as a bat, mad as a hatter and stuffed as a pipe. indicts what type of overdose
Anticholinergic
59
Anticholinergic overdose is caused by
Antihistamines (primarily diphenhydramine), phenothiazines, muscle
relaxers, antidepressants, and Jimson weed
60
Common EKG finding with anticholinergic overdose
Most common EKG finding is sinus tachycardia. Also wide complex
tachycardia and prolonged QT interval can be seen. If available get an EKG on
all Tox patients.
61
Anticholinergic overdose treatment
Activated charcoal
hyperthermia, seizures and agitation use benzos
62
Effects of barbiturates
Barbiturates depress CNS activity by enhancing the action of Gamma aminobutyric acid (GABA)
sedation, dizziness, slurred speech,
confusion, ataxia.
Respiratory depression is the most common vital sign abnormality in severe overdoses.
63
Treatment of barbiturates overdose
(a) Assess and stabilize ABC's
(b) Airways management and ventilator support may be required in the obtunded
patient
(c) Activated charcoal may decrease absorption and should be administered to the
cooperative patient presenting within 1 hour of ingestion
(d)Flumazenil/ Romazicon - limited role
(e) Call MO/Poison control 1-800-222-1222
(f) MEDEVAC
64
a benzodiazepine antagonist - not routinely used and many contraindication exist
Flumazenil
65
Most frequently ingested intoxicant in the US. Contributes to 100,000 deaths per
year.
Ethanol
66
Alcohol intoxication treatment
(a) Mainstay is observation and supportive care
(b) Exclude hypoglycemia with glucose level
- if low administer glucose agent
(c) IV fluids do not alter the alcohol elimination and are generally not required unless patient appears clinically dehydrated
(d) Observe until sobriety is reached and patient is not a harm to self
(e) Complicating injuries must be excluded and a deterioration or worsening
condition through observation should prompt an evaluation for further causes
67
refers to all opium related compounds that possess analgesic and sedative
properties
Opioids
68
Opioids Pathophysiology
(a) Work on nerves in the CNS, PNS and GI tract
(b) Agonist on three primary receptors (Mu, kappa, delta)
1) Mu receptors - responsible for analgesia, sedation, respiratory depression
and cough suppression
69
Treatment of opioids
(a) Airway and ventilator support are most important considerations
(b) Activated charcoal - considered if ingestion is less than 1 hour
(c) Naloxone (Narcan) - competitive agonist at all opioid receptors
Opioid dependent patients should receive a smaller dose to prevent acute withdrawal
70
Overdose of Salicylates cause what?
ASA toxicity causes respiratory alkalosis due to a direct effect on the medullary
respiratory center
Symptoms include:
1) Tachypnea
2) Tinnitus
3) N/V
4) Acid base abnormalities
5) AMS
6) Pulmonary edema
7) Arrhythmia
8) Hypovolemia
71
Salicylates
Clinical diagnosis made in conjunction with acid base status. (blood levels may
correlate poorly with toxicity) Ingestion less than:
1) 150mg/kg - mild - N/V GI irritation
2) 150-300mg/kg moderate - vomiting, tachypnea, tinnitus, sweating
3) > 300mg/kg - severe
72
Clinical features - APAP toxicity presents in 4 stages
(a) Stage 1 first 24 hours - nonspecific. N/V, malaise, anorexia
(b) Stage 2 - day 2-3 - N/V may improve and evidence of toxicity may develop. RUQ pain, elevated bilirubin/jaundice
(c) Stage 3 - day 3-4 - progression to hepatic failure. Lactic acidosis, coagulopathy,
renal failure, encephalopathy, N/V
(d) Stage 4 - those who survive will begin to recover
73
Toxicity occurs at what level with APAP
> 140mg/kg or > 7.5 gm over 24 hours.
Serum levels should be drawn on all patients with APAP ingestion and
levels at 4 hours evaluated. Levels above 150mcg/dl at 4 hours are considered toxic.
74
Emergency care of APAP
Priorities remain Airway, Breathing and Circulation, cardiac monitoring and IV
access
NAC (N-acetylcysteine) - specific antidote for APAP toxicity. Can prevent toxicity in administered within 8 hours of ingestion. However, still beneficial if given after this timeframe.
1) Oral, NG tube 140mg/kg loading dose, followed by 70mg/kg Q4 hours for 17 additional doses.
75
Insecticides (malathion, parathion) Nerve agents (VX, sarin) Pathophysiology
Bind irreversibly to and inhibit cholinesterases in the nervous system and skeletal muscle. Leads to the accumulation of acetyl-choline at synapse and NMJ.
76
Insecticides (malathion, parathion) Nerve agents (VX, sarin) Toxidrome/clinical features
(a) SLUDGE
1) Salivation
2) Lacrimation
3) Urinary incontinence
4) Defecation
5) GI pain/dismotility
6) Emesis
77
Insecticides (malathion, parathion) Nerve agents (VX, sarin) Toxidrome/clinical features treatment
Atropine** 1 mg in adult. Repeat Q 5 min until respiratory secretions improve
Pralidoxine – 2-PAM. Should NOT be administered without concurrent Atropine.
Treats neuromuscular dysfunction.
78
Self-limited process manifested by the mild swelling of the feet, ankles, and hands that appears within the first few days of exposure to a hot environment.
Heat edema
79
a skin rash caused by trapped sweat travels to the surface become clogged. tends to be more common in
warmer, more humid climates.
Prickly heat
Treatment:
1) Chlorhexidine in a light cream or lotion
2) Talc or baby powder is of no benefit
80
Painful, involuntary, spasmodic contractions of skeletal muscles, usually those of the calves, although they may involve the thighs and shoulders.
Heat Cramps
Treatment:
1) Fluid and salt replacement (Commercial Sport drinks)
2) Rest in a cool environment.
3) Cases of heat cramps will respond to intravenous rehydration with NS
81
Differentiated from heat cramps by:
1) The fact there is very little pain or cramps in the muscle compartments
2) Paresthesia of the extremities and perioral region are more prominent.
Heat Tetany
82
Postural hypotension resulting from the cumulative effect of relative volume
depletion, peripheral vasodilatation, and decreased vasomotor tone
Heat Syncope
Treatment:
1) Removal from the heat source,
2) Oral or intravenous rehydration,
3) Rest
83
Temperature is variable and can range from normal to 104°F (40°C)
1) Malaise
2) Lightheadedness
3) Fatigue
4) Dizziness
5) Nausea and vomiting
6) Frontal headache
Heat Exhaustion
Treatment
1) Volume and electrolyte replacement and rest.
2) Mild cases may be treated with oral electrolyte solutions.
3) Rapid infusion of moderate amounts of intravenous fluids (1 to 2 L of saline solution) may be necessary in some patients who demonstrate
significant tissue hypoperfusion
4) Move patient to a shaded area or air conditioned area
5) Place patient in supine position with their feet elevated abode the level of
their head.
6) Remove excess clothing and equipmen
t
7) Cool the patient until their core temperature is approximately 101F
(38.3C)
8) Hydrate
9) Transport to ED if patient is not responsive to treatment
84
Signs and Symptoms
1) Irritability,
2) Confusion,
3) Bizarre behavior,
4) Combativeness,
5) Hallucinations,
6) Seizures,
7) Coma
8) Core temperature higher than 104°F (40°C),
9) CNS dysfunction,
10) Anhidrosis.
11) Any neurologic deficit
Heat Stroke
Treatment:
1) ABC's;
2) High-flow oxygen;
3) Continuous cardiac monitoring
4) Pulse oximetry;
5) Intravenous access; NS solution at a rate of 250 mL/h
6) Actively cool the patient with evaporation or immersion in cold ice bath
7) May add cold packs to axilla, groin, and neck
8) May consider placing a foley catheter to measure urine output
9) Stop active cooling once temperature reaches 102 F
10) Serial monitoring of the patient's core temperature
85
1) Patients may complain of pruritus and burning paresthesia.
2) Localized edema,
3) Erythema,
4) Cyanosis,
5) Plaques,
6) Nodules,
7) In rare cases, ulcerations, vesicles, and bullae.
Chilblains
The skin is pale, mottled, anesthetic, pulseless, and immobile, which initially does not change after rewarming.
1) Management of chilblains is supportive.
2) The affected skin should be rewarmed gently.
3) To soothing lotions can relive itching
4) Nifedipine 30 to 60 mg PO QD x 7 days
86
Four classifications of frost bit
First Degree
a) Transient stinging and burning, followed by throbbing.
b) Partial skin freezing, erythema, mild edema, lack of blisters, and
occasional skin desquamation several days later.
Second Degree
a) Recognized by large blisters containing clear fluid surrounded by
edema and erythema, developing within 24 hours and extending
to or nearly to the tips of digits. The blisters may form an eschar,
but this later sloughs off, revealing healthy granulation tissue.
There is no tissue loss.
Third Degree
a) The patient may complain that the involved extremity feels like a
"block of wood," followed later by burning, throbbing, and shooting
pains.
b) Hemorrhagic blisters form and are associated with skin necrosis and a
blue- gray discoloration of the skin.
c) Prognosis is often poor.
Fourth Degree
a) The patient may complain of a deep, aching joint pain.
b) Extends to muscle and bone, involves complete tissue necrosis.
c) Vesicles often present late, if at all, and may be small, bloody blebs
that do not extend to the digit tips.
d) Prognosis is extremely poor. Mummification occurs in 4 to 10 days.
87
Clinical management of frost bite
a) Rapid rewarming is the core of frostbite therapy and should be
initiated a soon as possible.
b) The injured extremity should be placed in gently circulating water at a temperature of 104°-107.6°F (40° to 42°C) for approximately 10 to 30 min, until the distal extremity is pliable and erythematous.
c) Clear blisters should be debrided or at least aspirated
d) Hemorrhagic blisters should not be debrided because this often results in tissue desiccation.
e) Blister types should be treated with topical aloe vera cream every
6hrs.
f) Digits should be separated with cotton and wrapped with sterile, dry
gauze.
g) Elevation of the involved extremities helps decrease edema and pain.
88
Temperature stages of hypothermia
Temperature stages
b) Mild – 90-95
c) Moderate – 82-90
d) Severe below 82
89
Mild hypothermia symptoms
1) Alert, but mental status may be altered.
2) Shivering present.
3) Not functioning normally.
4) Not able to care for self.
Demonstrates tachypnea, tachycardia, initial hyperventilation, ataxia, dysarthria, impaired judgment, shivering, and so-called "cold diuresis
90
Moderate hypothermia symptoms
1) Decreased level of consciousness.
2) Conscious or unconscious, with or without shivering.
At lower ends of temp, loss of shivering, dysryhtmias (A fib), and dilated pupils below 29oC
Pulmonary edema, oliguria, hypotension, bradycardia, ventricular
dysrhythmias. (V fib/tach/asystole)
Loss of oculocephalic reflexes
91
Severe hypothermia
1) Unconscious.
2) Not shivering.
92
Treatment of hypothermia
ABCS Efforts should be continued (occasionally for several hours) until the patient's core temperature reaches 32 to 35°C (90 to 95°F)
93
HACE usually occurs at what level of elevation
Usually occurs at elevations above 2500 meters (8250 feet) and is more common in
unacclimated individuals.
Treatment
(a) Immediate descent for at least 610 meters (2000 feet), continuing until
symptoms improve.
1) Oxygen (100% 2-4 L/min) should be administered by mask.
2) Acetazolamide (250 mg orally every 8-12 hours)
3) Dexamethasone, 4-8 mg orally every 6 hours, is recommended
thereafter.
4) If immediate descent is impossible, a portable hyperbaric chamber
should be used until.
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HAPE usually occurs at what levels
Usually occurs at levels above 3000 meters (9840 feet)
SAME TREATMENT AS HACE
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Types of shock
Hypovolemic,
Cardiogenic, Distributive, Obstructive
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What do these usually cause?
a) Trauma
b) Massive hemorrhage
c) GI Bleed
d) Burns
e) Vomiting or Diarrhea
f) Excessive sweating
g) Hyperosmolar states (DKA)
Hypovolemic Shock
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Whats cardiac output
Stroke volume x Heart rate.
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Physical findings of hypovolemic shock
Tachycardia, and later bradycardia when body can no longer keep up :(
Hypotension
Mental status changes
Oliguria
Cool extremities
Weak pulse
Low JVP
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Treatment of hypovolemic shock
a) If loosing fluids then give LR 1-2 Liter bolus (if giving unwarmed fluid then this can lead to hypothermia)
b) If loosing blood then need to give blood transfusion (remember
that they are losing whole blood so need to give PRBC, FFP, and
Platelets)
c) For every 1 unit PRBC you give your hematocrit should increase 3%
(1 Norepinephrine 0.02 - mcg/kg/min IV infusion
(2 Epinephrine 0.014 - 0.5 mcg/kg/min IV infusion
(3 Dopamine 1-20 mcg/kg/min IV infusion
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What is cardiogenic shock
Pump failure secondary to AMI, Cardiac contusion, Arrhythmia,
Valvular incompetence or stenosis
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Physical Findings of cardiogenic shock
similar to hypovolemic shock but with JVD Tachypnea pulmonary edema and arrhythmias
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Treatment of cardiogenic shock
1) Initial management focuses on airway stability and improving pump function, until definitive treatment re-establishes adequate cardiac output
2) Follow ACLS if go into cardiac arrest
3) Fluid replacement requires smaller fluid challenges (250 ml)
4) Vasopressors
a) Epinephrine 0.014 – 0.5 mcg/kg/min IV infusion
b) Dopamine 1-20 mcg/kg/min IV infusion
c) Dobutamine 2-20 mcg/kg/min IV infusion
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Three types of distributive shock
Sepsis, Anaphylaxis, Neurogenic
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Most common cause of distributive shock
Sepsis
Commonly caused by gram negative bacteremia
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Caused by massive release of histamine and other vasoactive
substances cause systemic vasodilation, potential airway
compromise due to airway edema and bronchospasm
Anaphylaxis
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Caused by spinal cord injury resulting in loss of sympathetic
stimulation and reduction in systemic vascular resistance.
Neurogenic
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Physical Findings
of the three distributive types of shock
1) Sepsis
a) Evidence of infection (fever, tachycardia) in the setting of
persistent hypoperfusion despite volume resuscitation.
b) Check CBC (will reveal elevated WBC)
c) History should help point you to the source of infection
2) Anaphylaxis
a) Evidence of diffuse urticaria, angioedema, bronchospasm, SOB,
fullness of the throat, hoarseness.
b) History of an insect bite, exposure to certain food, etc.
3) Neurogenic
a) Evidence of acute traumatic spinal cord injury and
hypotension without compensatory tachycardia.
b) Unresponsive to fluid resuscitation, Bradycardia
c) Warm, dry skin
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Treatment of sepsis
ABC’s, O2 if saturation <92%, IV, Monitor
Primary treatment is to treat underlying infection with early initiation
of broad spectrum antibiotics:
Ertapenem 1 gram IV Daily
Fluid resuscitation, start with 1 L LR
If does not respond to 2 Liters of IVFL then start pressors to keep
MAP > 60
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Treatment of anaphylaxis
a) ABCs (secure airway), O2 to keep saturation > 92%, IV, Monitor
b) Epinephrine (Epipen): 0.1 – 0.5 mg SC/IM repeat q 10-15 minutes
(Epipen delivers 0.3 mg per dose)
c) IV fluids with LR or NS
d) Ancillary Treatments
(1 Benadryl 50 mg IV q6 hours prn
(2 Zantac 50 mg IV q 6 hours prn or 150mg PO BID
(3 Solumedrol 125mg IM/IV q 4 hours prn
(a Corticosteroid
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Causes of obstructive shock
Massive PE
Tension pneumothorax
Pericardial Tamponade
Restrictive
cardiomyopathy
abdominal compartment syndrome
