Module 4 Flashcards
(95 cards)
1
Q
Heat Stress
A
- Heat Exhaustion
- Heat Stroke
2
Q
Fluids and Salts
A
- Hyponatremia
- Dehydration
3
Q
Exertion
A
-Rhabdomyolysis
4
Q
Challenges with Exertion and Heat Illnesses
A
-Vague Symptoms ~Nausea ~Vomiting ~Weakness ~Dizziness ~Syncope -Big differential diagnosis can make management priorities challenging
5
Q
Narrowing it Down
A
- Detailed History
- Especially regarding fluid and nutritional intake, and urination
- Consider the environment and activities leading up to the illness
6
Q
Hyperthermia and Heat Related Illness
A
-Hyperthermia is not a fever
-Heat Gained > Heat Lost
~Production over accumulation
~Exercise
~Metabolism
~Environment
~Respiration
~Vasodilation
*Blood vessels opening up
~Perspiration
7
Q
Body’s Response to Heat
A
-Vasodilation ~Increased blood flow to skin ~Flushed appearance -Increased Cardiac Output ~Faster heart rate -Increased Sweating ~Depletes salt and water -Increased Anti-Diuretic hormone (ADH) ~Prevents urination
8
Q
Risk Factors
A
Obese ~70% relative risk for heat illness among US army recruits -Unfit -Dehydrated -Previous Hx of Heat stroke -Cardiovascular disease, diabetes, etc. -Not acclimated to heat -Medication ~Diuretics ~Anticholinergics ~Vasodilators ~Antihistamines ~Sedatives ~B-blockers
9
Q
Heat-related Illness (Occur at Normothermia)
A
-Heat Edema
-Heat Rash (miliaria rubra)
-Heat Cramps
-Heat Syncope
~All Non-emergent
*Oral rehydration
*Passive Cooling
*Remove from heat
*Elevate extremities
*Electrolyte Replacement
-Heat Exhaustion
~Possible risk for progression
10
Q
Heat Stroke
-True Emergency!!
A
-Core body temp. greater than 104F
-Presents with CNS abnormalities
-Altered mentation, seizures, coma
-Sweating?
~DO NOT use the presence of sweating to argue against heat stroke
-Prognosis
-Directly related to magnitude and duration of heat stroke
-Mortality 10%
-Up to 33% if associated with hypotension
11
Q
Management of Hyperthermia
A
-ABCs
-Remove from heat source
-Begin active cooling
~Cold water immersion
~Cold pack
~Convective cooling
-Hydration
12
Q
Heat Conditioning
A
-Good for heath
-Prevents heat illness
~Increases plasma volumes
~Increases sweating with reduced salt depletion
~Promotes heat shock proteins
13
Q
Exercise Associated Hyponatremia (EAH)
A
-Low sodium in the blood
-Less a problem of salt than it is water
~Dilutional hyponatremia
~Water Toxicity
-“If you’re thirsty, you’re already dehydrated”
~Is not exactly true can cause hyponatremia if over hydrated
14
Q
Pathophysiology of EAH
A
-Behavioral Factors ~Drinking too much water ~Afraid of becoming dehydrated -Environmental/Physical Factors ~Heat and physical stress increase ADH ~Accumulation for free water
15
Q
Recognition of hyponatremia
A
-History of drinking excessive water
-Mild Symptoms
~Headache, agitation, thousand yard stare, nausea& vomiting, little or no urine output, lethargy, thirsty, paranola, impeding doom
-Severe Signs and Symptoms
~Seizure
~Altered Mentation
~Coma/death
16
Q
Treatment of Hyponatremia
A
-Remove from heat and cool them down
-Calm them down
-Consider oral hypertonic solution
~No group difference was noted in the primary outcome measure of change in blood {Na+} over 60 min of observation following a 100mL bolus of either oral or IV 3% saline
-For mild, be patient
-For severe, immediate evacuation & ALS care
17
Q
Dehydration
A
-Fluid intake < fluid loss
-Most fluid loss results from thermoregulatory sweating
~Insensible loss = respiration, can be as much as 1-1.5 liters/hour at high altitudes
-Dehydration has a significant impact on exercise performance and thermoregulation
~2% or greater of body weight
-During exercise, sweat rates vary from 0.5 to 2 liters/hour
18
Q
Complications of Dehydration
A
- Decreased renal blood flow = prerenal injury
- Decreased blood flow to muscles
- Decreased cardiac output
- Decreased cutaneous blood flow and decreased sweating = greater heat accumulation
- Increased osmolality = cellular dehydration
19
Q
Signs and Symptoms of Dehydration
A
- Weakness/Dizziness
- Nausea and Vomiting
- Increased Thirst
- Dry oral mucosa
- Decreased urine output, darkened urine
- Decreased body weight
20
Q
Prevention and treatment of Dehydration
A
-Insure proper hydration Before activity
-During activity, maintain hydration
~Drink to thirst
~Fluid absorption occurs at around 450-700 mL per hour
~Ensure sodium, potassium, and carbohydrate intake
-Hydrate after activity with meals
-Manage with PO fluids, PO fluids should be mixed to taken with food
21
Q
Rhabdomyolysis
A
-Skeletal muscle injury causes intracellular substances to be dumped into the blood stream
22
Q
Rhabdo Causes
A
- Drugs/Toxins
- Trauma
- Seizures
- Strenuous Exercise
- Dehydration
- Heat Illness
- Electrical injury
- Crush injury
23
Q
Complication of Rhabdo
A
- Renal Failure
- Electrolyte Abnormalities
- Compartment Syndrome
24
Q
Clinical Features of Rhabdo
A
-PUMP ~Pain of the affected muscle group ~Urine *Decrease and/or darkened ~Myalgia *Muscle soreness ~Physical exertion -Muscle cramping
25
Management of Rhabdo
- Discontinue exercise
- Hydrate
- Keep them cooled down
- Evacuate
- More hydration
26
How We Get Cold
```
-Radiation
~Heat loss
-Evaporation
~Dampness
-Conduction
~Cold water
-Convection
~Winds
```
27
What Will Impair Thermoregulation?
- Tight fitting clothing
- Smoking
- DM/PVD Hypovolemia
- Head Injury
- Neoplasm
- Sepsis
28
Characteristics of the Three Zones of Hypothermia
- Mild
- Moderate
- Severe
29
Mild hypothermia
```
-Core Temp
~35.0 C to 33.0C
~95.0 F to 91.4F
-Shivering thermogenesis starts
-Ataxia and apathy develop
```
30
Moderate Hypothermia
-31.0C or 87.8
~Shivering thermogenesis stops
-29.0C or 85.2
~Bradycardia, pupils dilated; paradoxical undressing
-28.0C or 82.4
~Decreased ventricular fibrillation threshold; loss of reflexes and voluntary motion
31
Severe Hypothermia
```
-28.0C or 82.2F
~Ventricular Fibrillation
-18.0C or 64.4
~Asystole
-16.0C or 60.8 F
~Lowest adult accidental hypothermia survival
-15.2C or 59.2
~Lowest infant accidental hypothermia survival
-9.0C or 48.2F
~Lowest therapeutic hypothermia survival
```
32
Hypothermia and Trauma
- Impact on mortality is clear
- 100% of trauma patients with a core temp. <89.6F died, and only 3% died who had core temp. >89.6F
- Hypothermia is an independent predictor of mortality (11 fold if <89.6F
33
Renal System
- Peripheral vasoconstriction with central shift of blood
- Diuresis ensure despite hypovolemia
- Diuresis triples with alcohol
34
Ethanol (alcohol)
- Impairs Thermoregulation
- Peripheral Vasodilation
- Impairs behavioral Adaptation
35
Mild/Moderate Treatment
-Recognition... Wide Spectrum
-Prevent heat loss
-Remove wet clothing, put on dry
-Calories
-Hypothermia wrap +/- heat is okay
~Warm water bottles, body to body, etc.
-"Feed em and beat em?"
~Pretty dangerous method if get them moving too early
36
Hypothermia Wrap
- Tarp
- Sleeping Pad
- Sleeping Bag
- Patient in hat and warm dry clothes in sleeping bag WITH hot bottle
- Another sleeping bag
- Wrap the tarp up
37
Severe Hypothermia Treatment
- *Comatose victims require carful handling*
- Sensitive to VF/asystole
- Treatment should be aimed at preventing further heat loss and evacuation
- Assume irritable myocardium, hypovolemia, large temp, gradient between periphery and core
- Replace wet clothing
- "You are not dead unless you are warm and dead"
38
Risk Factors of Lightning Injuries
- Male sex
- 64% deaths outdoor leisure
- 15% during outdoor work
- 92% May-Set.
- 73% afternoon/early evening
39
Myth or Fact
-The most common cause of death from lightning is burns
~MYTH
-As soon as the rainstorm passes, it is safe to return outside
~MYTH
-If outside in a lightning storm, laying flat on the ground will decrease the likelihood of being struck
~MYTH
-Cars provide protection from lightning due to rubber tires
~MYTH not from rubber tires, but from the metal frame
-Open picnic, bus, golf and rain shelters offer some protection. Tents and othering camping shelters also provide some protection
~MYTH
-The lightning position saves lives
~
-Primary cause of death is cardiovascular and respiratory arrest
~FACT
-Cell phones attract lightning
~MYTH
40
Lightning Bolt Theory
- Ionization in the air
- Stepped Leaders
- Creation of plasma- more conductive medium
- Upward leader
- Attachment
- Return stroke
41
Keraunomedicine
| -Direct Strike
-More likely on the tallest object around- NOT always the case
-Current said to enter orifices
~Eyes
~Ears
~Mouth
-Often deadly
-Is this the most common injury?
~5%
42
Keraunomedicine
| -Side Splash
-Lightning strikes object (tree, etc.)
-Current flow jumps from initial path
-More common cause of lightning injury
~30%
-May occur from person to person
43
Keraunomedicine
| -Ground Current
-Lightning strikes an object
-Energy travels out along the surface of the ground
-A person near a strike can be a victim of ground current
-Common killer of livestock
-Likely more common
~50%
44
Keraunomedicine
| -Conduction
- Lighting travels along wires or other metal surfaces
- Can affect people indoors through outlets, faucets, cords, etc.
- Common cause of livestock MCI
45
Keraunomedicine
| -Trauma
```
-Barotrauma
~30-50% have ruptured tympanic membranes
-Concussive Injury
~Abdominal compartment syndrome, GI perf
-Musculoskeletal Injury
~Muscle contraction
~Falls
```
46
What Get Damaged
| -Follow the path of least resistance
- Nerves
- Blood Vessels
- Muscle
- Skin
- Tendon
- Fat
- Bone
47
Common Injuries
```
-Potential Fatal
~Disruption to the CNS
*Cessation of Breathing, Paralysis in Medulla
~Cardiovascular
Disruption
*PVC's, V-Tach, V-Fib, A-Fib, Ischemia
*Heart normally recovers more quickly
~Significant Traumas
*Source generally unknown
-Generally Less Harmful
~Burns
*Severe burns not commonly seen
*Immediate Vaporization of Perspiration -Flashover Effect
~Ocular Injuries
~Tympanic Membrane Rupture
```
48
Complex Regional Pain Syndrome
-Regional pain follows trauma
~Associated with electrical injury
-Hyperpathia
-Skin, temp., sweat, edema
-Hours to days
-Postulated to be result of disruption in ANS (Demonstrate by Sympathetic Blockage)
-Treatment limited, generally does not spontaneously resolves
49
Neurologic
-Something Else Entirely?
~American Journal of Emergency Medicine
*Case Report: Acute transient hemiparesis induced by lightning strike
```
-Treatment
~IV rehydration
-Heparin 5000 units q 12 hours
-Physical Therapy
-Complete Recovery
~*Watch out for unique cases...*
```
50
Cardiovascular Effects of Lightning strikes
```
-19 Patients
~4 direct hits
~3 Splash
~12 Ground Strikes
-Direct strike
~Myocardial Injury (3 of 4 direct strikes)
~ST Elevation, Increased CKMB, 1 pericarditis, pericardial effusion
~No torsades, limited prolonged QTc
-Splash
~Non-specific ST changes, mild myocardial injury
-Ground Current
~Lower extremity paresthesia
```
51
Secondary Asystole
- Secondary to prolonged anoxia
- Respiratory Centers can require longer time to recover, a potential culprit for resuscitated death
- Could also be primary brain damage, cardiac damage, ANS damage
52
Initial triage
| -Masses
- Resuscitate the dead
- Reverse triage
- Victims with spontaneous breathing will recover
- Victims that are not immediately in cardiopulmonary arrest have a HIGH likelihood of survival
53
Initial Triage
| -Care
- Initially: CAB
- Assess trauma
- Cervical spine precautions
- Call for help, evacuate
- Stop CPR if no recovery in 20 to 30 minutes?
54
Avoiding Lightning Strike
| -The 30-30 rule
- <30 seconds between lightning and thunder seek cover!
- No sports until 30 min after storm
- Most lightning strikes occur before storm appears
- Newer recommendations state that if you hear thunder, you should seek shelter
55
Timing is Everything
- Hike mornings
- Leave high exposed areas by noon during summer thunderstorm season
- Heed weather reports
56
Snow Conditions and Lightning
-Sleet and Graupel/Hail
~Soft snow pellets
-May indicate large differences in electric potential in atmosphere
57
Protection from Lightning
- Get off ridges, out of meadows
- 20 meters away from other individuals
- Take cover in area of densely packed small trees (lot of targets- you are unlikely to be one of them
58
Epidemiology
-Worldwide >500,000 drowning fatalities per year
-3rd highest cause of accidental death in US
-Highest Risk Group: Age 1-4
~Residential pools
-2nd Highest: Adolescents/young adults
~Natural bodies of water
-Other risk factors
~Male, alcohol use, age <14, low income, poor education, rural residency, lack of supervision, epilepsy
59
Definitions
-Immersion
~Body entry into a liquid medium
-Submersion
~Entry into liquid medium where the head is below the surface
-Drowning
~Respiratory impairment from submersion or immersion
-Inconsistent classification of submersion injuries
~Drowning, near downing, dry drowning, wet drowning, passive drowning, active drowning, secondary drowning
-Consensus
~Drowning with death, downing with morbidity, drowning without morbidity
60
The Drowning Process
-Submersion
~Airway falls below the surface
-Struggle and Breathing Holding
~Attempts to resurface, actively protect the airway
-Gasp
~Build up of carbon dioxide develops in the person will eventually involuntarily will inhale
-Laryngospasm
~Airway closes as a result of fluid inhalation
~Laryngospasm is overcome by cerebral hypoxia
-No Laryngospasm
~Water freely enters the airway
~Aspiration of water
61
The Drowning Process
| -Hypoxemia leads to loss of consciousness and apena
```
-Sequence of Cardiac Dysrhythmia
~Heart rate speeds up (tachycardia)
~Heart rate slows down (bradycardia)
~Pulseless Electrical Activity
~Asystole
*V-Fib occurs in less than 10% of drowning cardiac arrest
```
62
The Drowning Process
| -The Rescued Patient
-Salt vs Fresh water leads to different fluid shifts
-End result is the same
~Disrupts integrity of membrane
~Increases permeability
~Fluid, plasma, electrolyte shifts
~massive, bloodstained pulmonary edema
63
The Drowning Process
| -Spinal Injuries
- 0.5% of drownings
- History of diving, high falls, motor vehicle accident
- Compression fracture associated with diving injuries
64
Hypothermia
-Can be protective if it occurs before hypoxia
~What were the events leading up to hypoxia?
~Children might be protected more than adults
~Cooling must be rapid (water less than 50 degrees F)
~Cooling of the CNS can occur rapidly and may be protective
-In cold-water drowning, the drowning process can be extended from a few minutes to an hour
65
Hypothermia Drowning Management
```
-Cardiac Arrest
~CPR
*Hypoxic arrest, oxygen/ventilation is very important
~V-Fib is not common
~Water volume in the oral cavity is probably small, attempting abdominal thrusts to remove water will only delay chest compressions
~Regurgitation is common
*65% who require rescue breaths
*86% who require CPR
```
66
Drowning Management
| -Respiratory Support
- Respiratory issues following drowning (even if they do not experience cardiac arrest) is fairly common
- Any difficulty breathing should be taken seriously
67
Remember your own safety
-Do not get in the water to help someone unless you are properly trained
68
A Study
| -Snake Bites in 2000 in USA
- 4,446 bites
- 3 deaths
- 1,117 moderate to severe bites
69
Rattlesnakes
- Southwestern speckled rattlesnake
- Northern black tailed
- Western diamondback
- Western diamond back complex
- Worse is the Mojave Green 6 year old boy needed 42 vials of antivenom
70
All Snakebite
-20-25% rattlesnake "dry" bite in which no venom is injected
-60% coral snake bites dry
-Larger snakes in general inject more venom
-Lower extremity most commonly bitten area
-Upper extremity next most common
~Young, intoxicated male with bite on dominant hand
71
Rattlesnake Bites
```
-Most common injury pattern in soft tissue
~Swelling
~Bruising
~Bleeding
~Necrosis
-Hemotoxin (issues with the blood)
-Widely variable systemic symptoms of illness
~Nausea/ vomiting
~Muscle twitching/spasm
~Sweating
~Low blood pressure
~Elevated heart rate
~Weakness
~Weird talking
~Anaphylaxis
~Pulmonary edema
~Circulatory collapse
```
72
Assessment of Snake-bitten Subject
```
-Your safety and that of the subject
~Where is the snake?
-History
-Wound location size
-Bleeding
-Other injuries
-Vital signs
```
73
Initial Treatment
- Presume venomous bite
- Remove tight fitting clothing and jewelry
- Irrigate/ clean wound
- If extremity bite, loosely splint at level of heart
- Limit patient movement
- Sharpie outline
- Control pain
- Rapid evacuation and transport to hospital
74
What NOT to DO
- Tourniquet
- Sucking/aspirating venom out of bite
- Cut-downs
- Ice
- Heat
- Attempt to kill, capture snake
75
Sawyer Extractor
- 8 volunteers injected
- Extractor applied 3 mins later
- Removed means of 0.04% of toxin
- Not recommended
76
Coral Snake
-Western Coral Snake
~Few bites due to reclusive nature
~15 to 20 bites per year in US
~Short fangs hard to penetrate clothing
~Powerful neurotoxin
~Antivenom stock expired in 2008, extended to 2013
~Some stock still around... call poison control center
-May often be delayed up to 12 hours post-bite
-Symptoms progress rapidly once they begin
-Nausea, vomiting usually first
-Predominantly neurologic symptoms follow
~Headaches
~Numbness, tingling
~Shooting pains in bitten extremity
~Altered mental status
~Double vision
~Difficulty speaking and swallowing
~Paralysis
77
Snake Identification
- Red on yellow deadly fellow
| - Red on black friendly jack
78
Key Points Snakebites
- Avoid contact with snakes
- Don't try to kill or capture a snake who has bitten
- Vital signs, outline, rinse and splint
- Rapidly evacuate snakebite victims
- Call Poison Center if need help sorting things out
79
Latrodectus (Black Widows)
- 32 species worldwide
- Females are typical appearance, males are half the size
- Sexual cannibalism... usually observed in lab cages where males could not escape
- Use fangs to insert digestive enzymes liquefying prey's organs
- Generally not aggressive
80
Black Widow
-Over 800 a year reported to poison control centers a year
-No deaths reported since the 50s
-Large study
~24,000 bites reported to poison control centers
*Minor effects: 65%
*Moderate: 34%
*Major: 1% (life threating or causing residual disability)
81
Illness caused by widow spiders
-Latrotoxin
~Causes massive release of neurotransmitters (Ach, norepi, GABA, dopamine)
~Acts on muscles directly preventing relaxation
~Pain, muscle rigidity, vomiting, diaphoresis
~Other symptoms
*Tremor
*Weakness
*Shaking of extremity
*Paresthesia
*Headache
*Nausea/Vomiting
~Has been mistaken for a variety of abdominal surgical emergencies
*Resolves within 24 to 72 hours
82
Your Differential
-Diagnosis can only be considered if both of the following occur
~A spider was observed inflicting the bite
~The spider was recovered, collected, and identified
-If the above is not met, other conditions must be ruled out... What would these be?
83
Treatment Black Widow
- Symptoms self resolve within hours to days
- Think comfort
- Opiates
84
Black Widow Antivenom
-Less common used in US common for redback in Australia
-Used for at risk patients or those with severe pain
-Horse Protein
~Anaphylaxis
~Intradermal skin test of normal horse serum can be used
-1 out of 58 had allergic reaction in 2011 sturdy
85
Brown Widow
- Common in US
| - Less potent venom
86
Prevalence (Scorpion)
- 1,000+ known species, only 25 have venom that is deadly to humans
- Mostly belonging to the Buthidae family
- 5,000 deaths worldwide annually
- Deaths rare in US
87
Bark Scorpion
-C. exilicauda
~Due to its preference for residing near trees
-4 to 6 CM long
~Found in AZ, NM, W-TX, S-CA, Lake Mead NV
-Causes severe pain, numbness, tingling, vomiting, electrical volts, respiratory dysfunction
~Lasting between 24 to 72 hours
-Fatalities are rare in the US and limited to small pet/kids, adults with compromised immune systems
-2 recorded fatalities in AZ since 1968, thousands estimated to be stung each year in AZ
88
Bark Scorpion
| -Venom
-Complex mix of histamine, neurotoxin, etc.
~Neurotoxin cause incomplete activation of Na channels during depolarization that results in slow inward sodium current (repetitive uncontrolled firing of axons)
89
Bark Scorpions
| -Extreme Reaction
- Numbness
- Paralysis
- Seizures
90
Fat Tailed Scorpion
- Middle/East Africa
| - Powerful neurotoxin
91
Deathstalker
- Egypt, Sudan, Afghanistan, etc.
| - Powerful neurotoxin
92
Loxosceles Reclusa (Brown Recluse)
- Not aggressive
- Bite frequently not felt
- Hemotoxin venom
- 49% of bites do not result in necrosis
- Bites are self limited and heal without any medication intervention
93
Emotional Considerations
| -Caring for someone in an emergency can create emotional distress
```
-Common reaction
~Anxiety
~Trembling or shaking
~Sweating
~Nausea
~Fast breathing
~Pounding heartbeat
-This is normal
-Calm yourself and acknowledge your limitations as a provider
```
94
Emotional Consideration
| -When an emergency is over, a provider is often left alone
```
-With limited time for closure, you can experience a variety of reaction
~Feeling abandoned or helpless
~Recalling event over and over
~Self-doubt about not doing enough
~Difficulty concentrating
~Heaviness in chest
~Upset stomach or diarrhea
~Difficult sleeping or nightmares
```
95
Emotional Consideration
| -These feelings are normal and should pass with time; actions that help
- Share your feelings
- Talk with someone you trust to listen without judgement
- Get back to normal routine ASAP
- Accept it will take time to resolve emotions
- If unpleased feelings persist, formal assistance from a professional counselor may be helpful
