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Environmental Emergencies Board Review

Environmental Emergencies Board Review. Ted Melnick, MD August 22, 2007. PEER7 58.

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Environmental Emergencies Board Review

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  1. Environmental Emergencies Board Review Ted Melnick, MD August 22, 2007

  2. PEER7 58 • A 22-year-old man presents by amulance with depressed level of consciousness; his roommate had found him lying in the yard that morning after homecoming. He has preserved airway reflexes, is unresponsive, has no signs of traumatic injury, and has a blood pressure of 100/60. Blood glucose is normal, and the serum ethanol level is 260. This is his tracing on cardiac montior:

  3. Which intervention is indicated? • Administration of atropine • Administration of sodium bicarbonate • Hyperbaric oxygen therapy • Intravenous steroids • Rewarming techniques

  4. Which intervention is indicated? • Administration of atropine • Administration of sodium bicarbonate • Hyperbaric oxygen therapy • Intravenous steroids • Rewarming techniques

  5. Hypothermia • Osbourn/J waves and bradycardia pathognomonic for hypothermia • Height inversely correlates with core temp • Not a “wide QRS” • Shiver artifact • Associated with Behavioral impairment: ETOH, CVA, CNS, psych, nitrogen, altitude

  6. Promes 7-1 2. Which of the following is TRUE regarding cold-related injuries? • Chilbain (pernio) is more common in men than women. • Dry heat is the best method for rewarming frostbite. • Early surgical intervention is required for severe frostbite. • Trench foot may result in irreversible damage.

  7. Promes 7-1 2. Which of the following is TRUE regarding cold-related injuries? • Chilbain (pernio) is more common in men than women. • Dry heat is the best method for rewarming frostbite. • Early surgical intervention is required for severe frostbite. • Trench foot may result in irreversible damage.

  8. Frostbite and Cold-related Injuries • Trenchfoot is from wet, cold, but non-freezing exposure • May become permanent if not removed from exposure • Rapid rewarming in warm water is treatment for frostbite • Dry heat may cause thermal damage in addition to cold injury • Eschar may protect, surgery is NOT indicated • Chilbain more in women, associated with Raynaud’s

  9. PEER7 40 3. Paramedics covering a marathon event call in for medical direction in their care of a runner who collapsed halfway through the race. He is disoriented and slightly diaphoretic and has a rectal temperature of 41oC (105.8oF). Rapid diagnostic testing reveals normal serum sodium and blood glucose levels. They are 1 hour from the nearest emergency department. What is the most effective immedicate treatment?

  10. Administer acetaminophen • Peform ice water immersion • Place him in the shade until he recovers • Place ice packs on his axillae and groin • Transport to the emergency department, where evaporative cooling can be performed

  11. Administer acetaminophen • Peform ice water immersion • Place him in the shade until he recovers • Place ice packs on his axillae and groin • Transport to the emergency department, where evaporative cooling can be performed

  12. Heat-related Emergencies • Heat edema, prickly heat, heat tetany, heat syncope, heat exhaustion, heat stroke • Heat stroke: classic or exertional • Core temp >40oC/104oF with CNS dysfunction • Cooling: Immersion (conductive), evaporative (convection with fan), strategic ice packs, invasive, no role for anti-pyretics

  13. PEER7 23 4. Which of the following statements regarding high-altitude pulmonary edema is correct? • Bradycardia is a common sign • ECG findings include left ventricular strain pattern • Nifedipine can be used for prevention • Once present, it is highly refractive to treatment • One episode should preclude future ascents

  14. PEER7 23 4. Which of the following statements regarding high-altitude pulmonary edema is correct? • Bradycardia is a common sign • ECG findings include left ventricular strain pattern • Nifedipine can be used for prevention • Once present, it is highly refractive to treatment • One episode should preclude future ascents

  15. Altitude • AMS: HACE, HAPE (and HAFE!) • HAPE Risks: cold, exertion, altitude, pulm HTN, rapid ascent, genetic • Noncardiogenic • Hypoxic pulmonary vasoconstriction resulting in capillary leakage • Decreased performance, dry cough to dyspnea at rest, tachypnea/tachycardia, pink sputum, resp distress, death • Rx: oxygen, descent, nifedipine, hyperbarics

  16. PEER7 129 5. With regard to arterial gas embolism and decompression sickness associated with diving, which of the following is correct? • Almost all cases of arterial gas embolism occur within the first 10 minutes of surfacing • Decompression sickness results from the formation of small oxygen bubbles in the blood and tissues • Decompression sickness will not develop unless the victim experiences barotrauma • Loss of consciousness in CNS decompression sickness is common • Only arterial gas embolism requires recompression therapy

  17. PEER7 129 5. With regard to arterial gas embolism and decompression sickness associated with diving, which of the following is correct? • Almost all cases of arterial gas embolism occur within the first 10 minutes of surfacing • Decompression sickness results from the formation of small oxygen bubbles in the blood and tissues • Decompression sickness will not develop unless the victim experiences barotrauma • Loss of consciousness in CNS decompression sickness is common • Only arterial gas embolism requires recompression therapy

  18. Decompression sickness DCS Nitrogen bubbles in tissues Not always due to barotrauma, slow onset LOC is rare Recompression therapy Arterial gas embolism AGE (coronary and cerebral!) From rapid ascent, within 10 minutes LOC is common Assumed if surface unonscious or seize Recompression therapy Complications of Diving Recompression-ETT balloon filled with water, no flying after

  19. PEER7 75 6. Regarding submersion injuries, which of the following statements is correct? • Complete recovery in 48 hours is typical of sumbersion victims who never require CPR • Electrolyte measurement should be routine • Prolonged attemps at resuscitation of asystolic peidatric patients after warm-water submersion should be pursued • Prophylactic antibiotics are usually indicated • The Heimlich maneuver is of proven efficacy in removing aspirated fluid

  20. PEER7 75 6. Regarding submersion injuries, which of the following statements is correct? • Complete recovery in 48 hours is typical of sumbersion victims who never require CPR • Electrolyte measurement should be routine • Prolonged attemps at resuscitation of asystolic peidatric patients after warm-water submersion should be pursued • Prophylactic antibiotics are usually indicated • The Heimlich maneuver is of proven efficacy in removing aspirated fluid

  21. Near-Drowning • Don’t need electrolytes unless you aspirate in the Dead Sea • No role for the Heimlich • Pulmonary and CNS damage determines outcome • ARDS might develop, peaks at 24-36 hrs • Bacterial pneumonia is rare • Prolonged resuscitation on cold water patients

  22. Promes 7-6 7. Which of the following is TRUE regarding marine envenomations? • Jellyfish nematocysts are inactivated by fresh water rinsing • Sponge dermatitis is treated with antibiotics against gram-negative organisms • Hot water immersion is an effective pain reliever for venomous fish and stingray injuries • Tetrodotoxin poisoning from an octopus bite may be reversed with antivenin

  23. Promes 7-6 7. Which of the following is TRUE regarding marine envenomations? • Jellyfish nematocysts are inactivated by fresh water rinsing • Sponge dermatitis is treated with antibiotics against gram-negative organisms • Hot water immersion is an effective pain reliever for venomous fish and stingray injuries • Tetrodotoxin poisoning from an octopus bite may be reversed with antivenin

  24. Marine Envenomations • Hot water immersion can relieve pain • Fresh water may make stings worse • Vinegar is treatment of choice • Sponge dermatitis is an inflammatory reaction treated with antihistamines • If superinfected, usually normal skin flora • No antivenin exists for tetrodotoxin, supportive care only, usually full recovery

  25. Promes 7-9 8. Which of the following patients does NOT require referral to a specialized burn care center? • 60 yo diabetic with a full-thickness burn of his entire forearm • 25 yo woman with full thickness burns of both hands and lower arms • 35 yo man with a few small areas of partial-thickness burns on his back and small full-thickness burns on his upper arm • 40 yo house fire victim with a few small partial-thickness burns on her arms, soot in her nasal pharynx, and wheezing

  26. Promes 7-9 8. Which of the following patients does NOT require referral to a specialized burn care center? • 60 yo diabetic with a full-thickness burn of his entire forearm • 25 yo woman with full thickness burns of both hands and lower arms • 35 yo man with a few small areas of partial-thickness burns on his back and small full-thickness burns on his upper arm • 40 yo house fire victim with a few small partial-thickness burns on her arms, soot in her nasal pharynx, and wheezing

  27. Thermal Burns • Criteria for burn center admission • Age 10-50 yo with partial-thickness >25% BSA • Full-thickness >10% BSA • Age <10 yo or >50 yo with partial thickness >20% BSA • Affected face, hands, feet, perineum, crossing major joins, circumferential limb burns • Burn + inhalation injury • Electrical burns • Burn + medical problems/trauma/elderly/infants

  28. Thermal Burns • 1st degree • Epidermis only, no blisters, sunburn • 2nd degree • Dermis involved, blisters, sensation intact • 3rd degree • Full thickness, insensate, white/waxy/eschar • 4th degree • Muscle, fascia and bone

  29. Promes 7-11 9. Which of the following is TRUE regarding electrical injuries? • Household voltage (110 V) may cause Vfib without evidence of electrical burns • Low-voltage AC is more likely to produce transient ventricular asystole, and high-voltage AC is more likely to cause Vfib • Labial artery bleeding commonly occurs immediately after oral electrical burns • Delayed cardiac arrhythmias are common after household voltage electrical injuries

  30. Promes 7-11 9. Which of the following is TRUE regarding electrical injuries? • Household voltage (110 V) may cause Vfib without evidence of electrical burns • Low-voltage AC is more likely to produce transient ventricular asystole, and high-voltage AC is more likely to cause Vfib • Labial artery bleeding commonly occurs immediately after oral electrical burns • Delayed cardiac arrhythmias are common after household voltage electrical injuries

  31. Electrical Injuries • Household voltage produces Vfib and no burn in 40% of electrocution deaths • High-voltage cause severe burns and transient asystole more than Vfib • Little risk of delayed arrhythmias • Extent of injury depends on current and tissue resistance • Labial artery bleeding is a common delayed complication from oral electrical burns

  32. PEER7 113 10. Which of the following statements regarding lightning strikes is correct? • Absence of pupil reactivity is a reliable examination finding to help confirm brain death • In mass-casualty incidents involving lightning, cardiopulmonary arrest victims mandate the highest priority • Lower extremity paralysis is typically permanent • Most common cause of death is intracranial injury • Vitreous hemorrhage is the most frequently observed ocular sequela

  33. PEER7 113 10. Which of the following statements regarding lightning strikes is correct? • Absence of pupil reactivity is a reliable examination finding to help confirm brain death • In mass-casualty incidents involving lightning, cardiopulmonary arrest victims mandate the highest priority • Lower extremity paralysis is typically permanent • Most common cause of death is intracranial injury • Vitreous hemorrhage is the most frequently observed ocular sequela

  34. Lightning Injuries • Reverse triage • 30% mortality • Respiratory paralysis can outlast arrest • No findings to burns, ferning, TM rupture, amnesia, confusion, temporary lower extremity paralysis, interrupted pupilllary response, rapid--deep injury rare • Most common opthalmic injury is cataract

  35. Promes 7-4 11. What is the MOST common finding in a patient with a brown recluse spider bite? • Severe itching • Local tissue necrosis • Severe muscle cramps • Anaphylaxis

  36. Promes 7-4 11. What is the MOST common finding in a patient with a brown recluse spider bite? • Severe itching • Local tissue necrosis • Severe muscle cramps • Anaphylaxis

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