Environmental Medicine Flashcards
(130 cards)
1
Q
What is a common pathogen found in wound infections from dog bites
A
Pasteurella multocida
2
Q
What are the indications of using antibiotics for dog bites
A
Signs of infection
Bite on face present for >24 hours OR bite on extremity >8 hours without irrigation
Immunocompromised state for the victim
Crush injury or significant contamination of wound
Bite wounds of the hands or feet
3
Q
What antibiotics would be given to personnel that meet the criteria for Abx treatment of a dog bite
A
1st - Amoxicillin/Clavulanate (Augmentin) 875/125 mg BID or 500/125 mg TID OR
2nd - Clindamycin 300 mg PO q 6 hours for 7 days OR
3rd - Ciprofloxacin 750 mg PO BID for 4-8 weeks
4
Q
What has a higher infection rate in comparison to other domestic animals
A
Cat bites
5
Q
Greater than 60% of cat bites are located where
A
The hand or finger; these wounds may be deep puncture wounds, which are difficult to clean
6
Q
70% of cat bite infections are due to what
A
Pasteurella
7
Q
What is the antibiotic treatment for cat bites
A
Augmentin
Clindamycin + fluoroquinolone if penicillin allergic
8
Q
In general, larger animals should raise more suspicion of blunt and penetrating trauma, including what
A
Deep arterial damage, nerve damage and internal organ damage
9
Q
When dealing with wild animal bites, antibiotics should be directed against what
A
Aeromonas hydrophilia
10
Q
What antibiotics should be used for a wild animal bite
A
Trimethoprim-sulfamethoxazole (Bactria DS) 800 mg/160mg PO q 12 hours for 7 days
OR
Doxycycline 100mg BID for 7 days
11
Q
In salt (ocean) water, where antibiotics should also be directed against what? Using what?
A
Vibrio species
Using doxycycline + Ceftriaxone 1g IV daily OR
Ceftriaxone (Rocephin) 2 gIV every 12 hours
12
Q
According to the World Health Organization in 2015 about 3.2 billion people, nearly half of the world’s population are at risk of what
A
Malaria
13
Q
What are the other mosquito-borne illnesses
A
Encephalitis
Yellow fever
Dengue
Chikungunya
Zika
Lymphatic filariasis
14
Q
What are the mosquito-borne illnesses found in the U.S.
A
Eastern equine encephalitis
Western equine encephalitis
St. Louis encephalitis
La crosse encephalitis
West Nile virus
15
Q
For the most current Force Protection recommendations when deploying or conducting field operations, who should always be consulted
A
Centers for Disease Control and Prevention (CDC), and the local COCOM and TYCOM
16
Q
Incubation period for mosquito borne diseases range from what to what
A
48 hours to one year or more
17
Q
What is the order of insects that includes ants, bees, and wasps
A
Hymenoptera
18
Q
What are the clinical signs of Hymenoptera stings
A
A local reaction is the most common reaction which consists of a small red patch that burns and itches
The generalized reaction consists of diffuse red skin, hives, swelling of lips and tongue, wheezing, abdominal cramps and diarrhea
Stings to the mouth and throat are more serious, as they may cause airway swelling
19
Q
Victims of multiple stings often experience what
A
Vomiting
Diarrhea
Dyspnea
Hypotension
Tachycardia
Syncope
Skin infections
20
Q
In advanced stages of toxicity, the victim of a Hymenoptera sting often experiences what
A
Increased muscle activity with hyperkalemia
Acute tubular necrosis
Renal failure
Pancreatitis
Coagulopathy
Heart attack
Stroke
21
Q
What is the treatment of Hymenoptera stings
A
Remove the stinger: scrape away the stinger in a horizontal fashion (try not to grasp the stinger sac)
Wash the site with soap and water
Place a cold compress or ice on the site to reduce inflammation
Give oral analgesics as needed for pain relief
Topical steroid cream can be helpful for swelling, as are oral antihistamines
22
Q
What antihistamines can be used for Hymenoptera stings
A
Antihistamines (immediate, but temporary) :
Loratadine - Claritin - 10 mg orally once daily
Desloratidine - clarinex - 5mg once daily
Fexofenadine - Allegra - 60mg twice daily or 120mg once daily
Cetirizine - Zyrtec - 10mg orally once daily
23
Q
What should be used for treatment of a Hymenoptera sting if there is wheezing and respiratory difficulty
A
Epinephrine should be given immediately
24
Q
What diseases do ticks transmit
A
Lyme disease
RMSF
Relapsing fever
Colorado tick fever
Ehrlichiosis
Babesiosis
Tularemia
Southern tick-associated rash illness (STARI)
25
What is a non-infectious ascending paralysis similar to Gillian-Barre syndrome that may occur within five days after the tick attaches
Tick paralysis - removal of the tick is curative
26
What areas are ticks found in
With weeds, shrubs, and trails - often found at forest boundaries where deer and other mammals reside (they sit on low-hanging shrubs with legs outstretched until an animal passes)
27
Which tick-borne diseases are treated with a tetracycline such as doxycycline while an evacuation is being planned
Lyme disease
RMSF
Tularemia
Ehrlichiosis
28
What is the treatment for tick paralysis
Removal of the tick
29
How do you remove a tick
Use thin-tipped tweezers or forceps to grasp the tick as close to the skin surface as possible and pull the tick straight upward with steady even pressure
Wash the bite with soap and water, then wash hands after the tick has been removed
Watch for local infection and symptoms of tick-borne illness (incubation period 3-30 days), especially headache, fever, and rash
30
What is Colorado tick fever caused by and how do you treat
It is caused by a virus and treatment is supportive
31
Which snake bite is neurotoxic and what does it cause
Coral snake - neurotoxins cause respiratory paralysis (signs and symptoms:ptosis, dysphasia, diplopia, and respiratory arrest via diaphragmatic paralysis
32
Which snake bite is cytolytic and what does it cause
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
33
What is the ditty for coral snakes
Red touches black, you’re ok jack - red touches yellow, you’re a dead fellow
34
What are the identifications of a venomous snake
Triangular head
Keeled scales
Elliptical pupils
Nostrils plus IR pit
Single row of sub causal scales
35
What are the identifications of a non venomous snake
Oval shaped head
Round pupil
No IR pit
Double row of subcaudal scales
36
What are neurotoxic signs and symptoms
Ptosis
Dysphagia
Diplopia
Respiratory arrest via diaphragmatic paralysis
37
What are cytolytic signs and symptoms
Local pain
Redness
Swelling
Extravasation of blood
Perioral tingling
Metallic taste
Nausea and vomiting
Hypotension
Coagulopathy
38
What is the treatment of snake bites
Remove from threat, try to ID snake
Immobilize the patient and maintain the bitten part in a neutral position
Remove jewelry
DO NOT apply a tourniquet or attempt to extract venom
Irrigate and clean bite
Loose dressing if he too is bite, expect swelling
Do not let patient walk, limit exertion
MEDEVAC
39
What should be avoided while treating a snake bite
Incision and oral suction
Mechanical suction devices
Cryotherapy
Surgery
Electric shock therapy
Tourniquets
40
What should be taken into consideration when treating a snake bite
Emergency management of respiratory depression and shock, followed by timely anti-venom administration whenever possible to patients with appropriate indications comprise the key initial interventions in patients with snakebites
41
What are the signs and symptoms of a black widow spider bite
Generalized muscular pain
Muscle spasms
Rigidity
Abdominal pain
42
What is the treatment of a black widow spider bite
Pain may be relieved with pain control and muscle relaxants (benzos and supportive care)
43
What are the signs and symptoms of a brown recluse spider bite
Causes progressive local necrosis as well as hemolytic reactions (rare). Bite is usually painless
44
What is the treatment for a brown recluse spider bite
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 corticosteroid
45
What are signs and symptoms of a scorpion sting
Muscle cramps
Twitching and jerking
Occasionally hypertension
Convulsions
Pulmonary edema
46
What is the treatment for a scorpion sting
Supportive care is appropriate for North American species
Always review the threat of local species when operating OCONUS
If severe neurologic or neuromuscular dysfunction, consult poison control and discuss further management and anti-venom
Suction oral secretions, airway management, cardiac monitoring, IV opioids preferably fentanyl due to no histamine release, benzodiazepines for spasms unless getting anti-venom
47
What are the signs and symptoms of a jellyfish sting
Pain
Erythema
Edema
Pruritus
Vesiculations
Anaphylaxis
48
What is the treatment for a jellyfish sting
Rinse the area with seawater. Do not rinse with fresh water - freshwater promotes nemocyst activation
Remove tentacles with a gloved hand and scrape off any remaining nemocytsts by covering with sand/shaving cream/baking soda and scrape off with straight edge - sticky tape may also remove nemocysts
Vinegar x30 seconds deactivates nemocysts
49
What are signs and symptoms of coneshell stings
Mild to severe pain
Stinging or numbness
Local to total paralysis
50
What is the treatment for coneshell stings
Pressure immobilization dressing and supportive care to include close monitoring of respiratory status
MEDEVAC for advanced supportive care, possible need for ventilation if symptoms worsen. Usually resolves in 24-72 hours
51
What are signs and symptoms of a stingray or stinging fish
Barbed spines that are a penetrating injury and envenomation
Spine commonly remains lodged in wound
52
What is the treatment of a stingray/stinging fish injury
Remove and irrigate to remove fragments
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
Poison control useful for all envenomations
Extremely painful and typically does not respond well to pain relievers
Local anesthetic can be used to help with pain if hot water immersion is ineffective (NOT in combination)
53
Stonefish stings not responsive to hot water immersion should receive what
Antivenom and patient should be closely monitored for anaphylaxis
54
What should be taken into consideration for treatment of stingray/stinging fish injuries
Prophylactic antibiotics to include coverage for Vibrio: Doxycycline
Tetanus vaccine
Treatment for scorpion and catfish envenomation should be treated in similar manner
55
What are the risk factors of near drowning
Inadequate adult supervision
Inability to swim or overestimation of swimming capabilities
Risk-taking behavior
Use of alcohol and illicit drugs
Hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias
Concomitant trauma, stroke, or myocardial infarction
Seizure disorder or developmental/behavioral disorders in children
56
What is the pathophysiology of near drowning
Fatal and non fatal 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
57
What are some important physical pulmonary finding of near drowning
Fluid aspiration results in varying degrees of hypoxemia
Both salt water and fresh water wash out surfactant, often producing non radiogenic pulmonary edema and the acute respiratory distress syndrome (ARDS)
58
What are the primary physical finings of near drowning
Pulmonary conditions
Neurologic findings
Cardiovascular findings
Abnormal acid-base and electrolytes
Renal issues
59
What is the treatment for near drowning
Management of drowning victims can be divided into three phases:
Prehospital care
Emergency department (ED) care
Inpatient care
60
In a patient who is symptomatic for near drowning, what are the indications for intubation
Signs of neurological deterioration or inability to protect the airway
Inability to maintain a PaO2 above 60 mmHg or oxygen saturation (SpO2) above 90% despite high-flow supplemental oxygen
PaCO2 above 50 mmHg
61
What presentations have been associated with a poor prognosis for near drowning
Duration of submission >5 minutes (most critical factor)
Time to effective basic life support >10 minutes
Resuscitation duration >25 minutes
Age >14 years
Glascgow come scale <5
Persistent apnea requirement of cardiopulmonary resuscitation in the emergency department
Arterial blood pH <7.1 upon presentation
62
What is contaminated water defined as
Any body of water that is suspected of containing chemical or biological agents in concentrations that could potentially harm an unprotected diver and/or surface support personnel
63
True or false: unless a body of water is known to be clean, some degree of contamination must be assumed
True
64
True or false: since a river or a large body of water has flow or circulation allowing for removal or dilution of suspected contaminants, these are generally of less concern than diving in a closed body of water which has no flow and significantly less potential for dilution of contaminants
True
65
What biological contaminants may be present polluted waters
Harmful algal blooms (red tide)
Bacteria (fecal coliforms)
Viruses and parasites which could potentially harm an unprotected diver
**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**
66
What are some microorganisms that can produce soft tissue infections following water exposure
Aeromonas species
Edwardsiella tarda
Erysipelothrix rhusiopathiae
Vibrio vulnificus
Mycobacterium marinum
67
What is the recommended initial empiric therapy for exposure to polluted water
Cephalexin (Keflex) - 250mg PO QID
OR
Clindamycin PLUS Levofloxacin
+ Flagyl
68
What medication should be given if exposure to sewage, contaminated water or soil, contaminated wound
Doxycycline (100 mg twice daily) for coverage of vibrio species if seawater exposure
69
What is an antibiotic with cytotoxic effects towards anaerobic organisms (exposure to polluted water)
Metronidazole (Flagyl) - 500mg TID for 7-10 days
70
What is the pathophysiology for inhaled agents that manifest their toxic effects by different mechanisms
Physical particulates
Simple asphyxiants
Chemical irritants
Chemical asphyxiants
71
What are the clinical symptoms of inhaling physical particulates
Upper airway injury, such as difficulty breathing, might not be immediately obvious until edema is severe enough to significantly impair airway diameter
72
What are the physical findings of inhaling physical particulates
Includes burns to the face, signed nasal vibrissae, soot in the oropharynx, nasal passages, proximal airways, and carbonaceous sputum
73
What is the treatment for inhaling physical particulates
Management is supportive - remove patient from source and give oxygen; if signs of reactive airway disease are present, treat with nebulized albuterol
74
What is the pathophysiology of inhaling simple asphyxiants
They cause injury by merely being present in an environment and displacing the normal levels of atmospheric oxygen
75
What gas agents are included in simple asphyxiants
Carbon dioxide (CO2)
Nitrogen
Methane
Natural gas
76
What is the most common example of a chemical asphyxiants
Carbon monoxide
77
What are other examples of inhaled chemical asphyxiants besides carbon monoxide
Cyanide gas (HCN)
Hydrogen sulfide (H2S)
78
What is the treatment for H2S exposure
Includes supportive care with high-concentration oxygen and ETI if indicated
79
The typical cyanide antidote contains what drugs designed to be administered in what order
Inhaled amyl nitrite
IV sodium nitrite and
IV sodium thiosulfate
80
What is a more recent and safer cyanide antidote
IV hydroxocobalamin, combined with sodium thiosulfate
81
The term “toxidrome” refers to the collection of signs and symptoms that are observed after an exposure to a substance “toxic fingerprint” that includes what
Grouped abnormalities of vitals, appearance, skin, eyes, mucus membranes, lungs, heart, abdomen, and neurological examinations
82
What should be administered if altered mental status, obtundation, or coma is present
Nalaxone:
0.2mg IV/IM/SQ every 2-3 minutes. 15mg max
30-90 minute (has shorter half-life than most opioids which usually requires redosing)
83
What are the contraindications of using nalaxone
No absolute contraindications
84
What is the disposition of a patient that is poisoned/overdosed
MEDEVAC/MEDADVICE - observation for patients is variable and should be done in consultation with supervising MO and poison control
85
Where should a patient be referred to if poisoning or overdose is/was intentional
Referred for psychiatric evaluation once STABLE
86
What is the toxidrome of an anticholinergic patient
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
Unable to sweat, red in color, hot skin, visual disturbances, altered mental status, and urinary retention
87
What is the pathophysiology of an anticholinergic overdose
MOA involves cholinergic blockade of muscarinic receptors (primarily in the brain), nicotine receptors, or both
88
What medication(s) is commonly seen in the ED due to high use causing an anticholinergic overdose
Antihistamines (primarily Benadryl), phenothiazines, muscle relaxers, antidepressants, and Jimson weed
89
What are the clinical effects of an anticholinergic overdose
Findings associated with inhibition of the PNS
Absent bowel sounds
Mydriasis
Hyperthermia
Dry skin/mucus membranes
Urinary retention
Confusion/agitation
Tachycardia
Flushed skin
90
What is the emergency care of an anticholinergic overdose
Mostly supportive: IV, O2, monitor
GI decontamination with activated charcoal
Treat hyperthermia and seizures (benzos)
If acutely agitated (benzos)
MEDADVICE/MEDEVAC
91
What are adverse effects of an SSRI overdose
Serotonin syndrome - most serious adverse effect
Headache
Sedation
Insomnia
Dizziness
Nausea/vomiting
Fatigue
Tremor
Nervousness
Diarrhea/anorexia
92
What is the emergency care of a patient with SSRI overdose
Supportive care generally all that is required (IV, O2, Monitors, MEDEVAC/MEDADVICE)
If symptomatic, gain IV access and place monitors and discuss with higher echelon
Treat seizures with benzos and MEDEVAC
93
What is serotonin syndrome
Potentially fatal adverse drug reaction to seroteninergic medication, characterized by autonomic and neuromuscular dysfunction
94
What are the clinical features of serotonin syndrome
Cognitive and behavioral - confusion, agitation, coma, anxiety, Hypomania, lethargy, seizures
Autonomic - hyperthermia, diphoresis, tachycardia, hyper/hypo tension, dilated pupils, salivation
Neuromuscular - MYOCLONUS, hyperreflexia, rigidity, tremor, ataxia, shivering, nystagmus
Dx is made clinically after excluding other psychiatric or medical conditions
95
What is the main inhibitory neurotransmitter in the CNS
Gamma aminobutyric acid (GABA)
96
What enhances the action of GABA
Barbiturates depress CNS activity by enhancing the action of GABA
97
Ingestion of what drugs can lead to sedation, dizziness, slurred speech, confusion, ataxia
Barbiturates
Benzodiazepines
98
What is the most common vital sign abnormality in severe overdoses
Respiratory depression
99
What is the emergency care of a sedative/hypnotic overdose
Assess and stabilize ABCs
Airway management and ventilator support may be required
Activated charcoal may decrease absorption and should be given to patient within 1 hour of ingestion
Flumazenil/romazicon - limited role
MEDEVAC
100
What refers to all opium related compounds that possess analgesics and sedative properties
Opioids
101
What is the pathophysiology of opioids
Work on nerves in the CNS, PNS and GI tract
102
Opioids is an agonist on what primary receptors
Mu
Kappa
Delta
103
What is responsible for analgesia, sedation, respiratory depression and cough suppression
Mu receptors
104
What are the clinical features of an opioid overdose
CNS depression
Miosis
Respiratory depression
Bradycardia
Hypothermia
Death may result from respiratory arrest
105
What is the emergency care of a patient with opioid overdose
Can be given IV, IM and SC
Onset 1-2 minutes
Duration of 20-90 minutes
0.4-2mg, max 15 mg
**opioid dependent patients should receive a smaller dose to prevent acute withdrawal
106
What causes sympathetic nervous system activation which causes typical mydriasis, tachycardia, hypertension and diaphoresis
Cocaine
107
What has a similar effect to cocaine, blocks re-uptake of catecholamines, also have effect on serotonin release which causes hallucinogenic effect
Amphetamines
108
What are the clinical features of cocaine, amphetamines, stimulants (sympathomimetic)
May demonstrate psychomotor agitation
Mydriasis
Diaphoresis
Tachycardia
Tachypnea
Hypertension
Hyperthermia
AMS
Watch for seizures and rhabdomyolosis
May present with chest pain, headache, dyspnea, or focal neuro complaints
109
What is the emergency care for a sympathomimetic overdose
Adequate sedation and continuous monitoring of vital signs
Obtain EKG
Benzos will improve tachycardia, hypertension and agitation
Active cooling
Treat seizures with benzos
Treat cardiac chest pain with ASA. Nitro or benzo
**beta blockers are contraindicated in cocaine use**
110
What has an ASA toxicity that causes respiratory alkalosis due to a direct effect on the medullary respiratory center
Salicylate overdose
111
Clinical diagnosis of salicylate overdose is made in conjunction with acid base status of ingestion less than what
150mg/kg - mild - N/V, GI irritation
150-300mg/kg - moderate - vomiting, tachypnea, tinnitus, sweating
>300mg/kg - severe
112
What are the symptoms included in salicylate overdose
Tachypnea
Tinnitus
N/V
Acid base abnormalities
AMS
Pulmonary edema
Arrhythmia
Hypovolemia
Thrombocytopenia
Hepatic effects
113
What has a maximum recommended daily dose in adults of 4g - however, toxicity is possible to occur with single ingestion > 140mg/kg or greater than 7.5pm/24 hours
Acetaminophen (APAP)
114
What is the pathophysiology of APAP
It is rapidly absorbed from the GI tract
Primarily metabolized by the liver, however a small fraction undergoes renal elimination
115
APAP toxicity presents in what stages for clinical features
Stage 1 - first 24 hours - nonspecific. N/V, malaise, anorexia
Stage 2 - 2-3 days - N/V may improve and evidence of toxicity may develop. RUQ pain, elevated bilirubin/jaundice
Stage 3 - days 3-4 - progression to hepatic failure. Lactic acidosis, coagulopathy, renal failure, encephalopathy, N/V
Stage 4 - those who survive will begin to recover
116
What is the emergency care for APAP
NAC (N-acetylcysteine):
Oral, NG tube - 140mg/kg loading dose followed by 70mg/kg Q4 hours for additional 17 doses
IV - 150mg/kg loading dose followed by 50mg/kg over next 4 hours, then 100mg/kg over next 16 hours
MOA: hepato-protective agent by restoring hepatic glutathione
May induce N/V - administer Zofran
117
What is the pathophysiology of organophosphate/insecticides (cholinergic toxidrome)
Bind irreversibly to and inhibit cholinesterase in the nervous system and skeletal muscle
118
What is the toxidrome/clinical features of insecticides/nerve agents
Salivation
Lacrimation
Urinary incontinence
Defecation
GI pain
Emesis
Pt is usually symptomatic within 8 hours of dermal exposure to organophosphates - other sx: weakness, bradycardia, muscle spasms/fasiculation’s, miosis, bronchorrhea
119
What is the emergency care of a patient exposed to insecticides or nerve agents
Decontamination: PPE, wash patient with soap/water, handle and dispose of runoff/hazardous waste, monitoring VS, cardiac monitoring
Atropine - 1mg in adult and repeat every 5 minutes until respiratory improvement
Pralidoxine - 2-PAM: should NOT be administered without concurrent atropine (treats neuromuscular dysfunction)
120
What is a 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 - usually resolves spontaneously in a few days but my take up to 6 weeks
121
What is the treatment for heat edema
No special treatment necessary - if patient is insistent on treatment, elevate the legs
122
What is a skin rash caused by trapped sweat that travels to the surface becoming clogged
Prickly heat also known as miliaria
123
What is the treatment for prickly heat
Chlorhexidine in a light cream or lotion
124
What is painful, involuntary, spasmodic contractions of skeletal muscles, usually those of the calves, although they may involve the thighs and shoulders
Heat cramps
125
What is the treatment of heat cramps
Fluid and salt replacement
Rest in cool environment’
Cases of heat cramps will respond to intravenous rehydration with NS
126
What is hyperventilation resulting in respiratory alkalosis, parenthesis of the extremities, circumpolar paresthesia, carpopedal spasm
Heat tetany
127
How is heat tetany differentiated from heat cramps
The fact there is very little pain or cramps in the muscle compartments
Paresthesia of the extremities and perioral region are more prominent
128
What is the treatment of heat tetany
Removal from the heat and decreasing the respiratory rate
129
What is most commonly in non-acclimatized individuals during the early stages of heat exposure
Heat syncope
130
What is the treatment for heat syncope
Removal from the heat source
Oral or intravenous rehydration
Rest
