1
Q
What 5 measures do NOT improve outcome of a drowned patient?
A
- Hyperventilation
- Corticosteroids
- Diuresis
- Barbiturate coma
- Neuromuscular blockade
2
Q
Define Drowning
A
the process of experiencing respiratory impairment from submersion/immersion in liquid
3
Q
Define immersion syndrome
A
syncope resulting from cardiac dysrhythmias on sudden contact with water that is at least 5°C lower than body temperature
- risk is proportional to difference btwn body temperature and water temperature
4
Q
List 9 risk factors for drowning
A
Toddler age (1-3)
Age >80
Male
Indigenous
Black
EtOH consumption
Seizure d/o
Autism
Prolonged QT syndrome
5
Q
List 10 complications resulting from aspiration of water (fresh or salt), and how much water?
A
Aspiration of 1-3cc/kg
= destroys integrity of pulmonary surfactant
- alveolar collapse
- atelectasis
- noncardiogenic pulmonary edema
- intrapulmonary shunting
- ventilation-perfusion mismatch
- profound hypoxia
- metabolic acidosis
- respiratory acidosis
- CV collapse
- neuronal injury
- death
6
Q
List 5 factors that influence the pathophysiologic sequence of events in drowning and affect chance of survival
A
- age
- water temperature
- duration and degree of hypothermia
- diving reflex
- effectiveness of resuscitative efforts
7
Q
Define diving reflex
A
= involuntary physiologic response to cold submersion
- apnea
- bradycardia
- increased peripheral vascular resistance
8
Q
List 10 poor prognostic factors for drowning
A
- hypoxia
- hemodynamic instability
- age <3
- submersion >5-10 mins
- start of CPR >10 mins after rescue
- hypothermia
- severe acidosis
- unreactive pupils
- GCS 3
- asystole
- ongoing need for CPR
9
Q
What investigation finding in children w/in 24 hours after drowning is ~100% mortality?
A
abnormal CT head
= ICH or cerebral edema
10
Q
What is the max rewarming temperature goal in a comatose patient?
A
Max 34deg C
Keep in permissive hypothermia around 34deg for 24hr
11
Q
List 3 criteria for drowning patients who can be safely discharged
A
Asymptomatic on presentation
Normal room air sats
No CXR abnormalities
*Can be d/c’d after 8hrs observation
12
Q
List 3 tissues that are most radiosensitive
A
Hematopoietic
Gamete producing tissue
Gastrointestinal
*have greater rates of cellular division
13
Q
What 3 factors are predictors of severe radiation injury?
A
Skin burns
Vomiting
Diarrhea
14
Q
What is the most important prognostic indicator in suspected radiation exposure patients?
A
48-hour absolute lymphocyte count
> 1200 cells/mcL = unlikely that patient has received a clinically significant dose of radiation
100 - 500 cells/mcL = significant or even lethal dose of radiation
15
Q
Define particle radiation
A
Particles that have mass and energy and may carry an electric charge
16
Q
Define Electromagnetic radiation
A
Photons that have energy but no mass or charge
17
Q
Define radioactive decay
A
Process by which a nucleus of an unstable atom loses energy by emitting ionizing radiation in the form of high-energy particles or rays
18
Q
List an example of external and internal radiation exposure
A
External
- exposure to x-rays
Internal
- inhalation
- ingestion
- injection of radioisotopes
19
Q
List an example of direct and indirect effects of ionizing radiation on tissues
A
Direct
- breaking of single and double strand DNA
Indirect
- generation of free radicals that attack other molecules in the cell
20
Q
List 3 processes of radiation exposure
A
Irradiation
= an object or person is exposed to a radioactive source
Contamination
= presence of radioactive matter on or in an object
Incorporation
= radioactive material is taken up by a tissue, cell, or organ
21
Q
List 3 stages of acute radiation syndrome
A
Prodromal
Latent
Manifest
22
Q
List 5 s/s in prodromal stage of Acute Radiation Syndrome
A
anorexia
nausea
vomiting
fatigue
diarrhea
23
Q
List and outline the 3 sub-syndromes in Manifest stage of ARS
A
1) Hematopoietic sub-syndrome
- dose > 1 Gy
- bone marrow suppression
2) Gastrointestinal sub-syndrome
- dose ~6 Gy
- 1 week post-exposure
- n/v, GIB, malabsorption, fluid losses
3) Neurovascular sub-syndrome
- dose >10 Gy
- lethal
- irritability, AMS, seizures, ataxia, hypotension, coma, death
24
Q
Define local radiation injury
A
Radiation injury limited to the skin and the tissues located directly beneath the area of injury
25
List 5 progressive symptoms of local radiation injury
Epilation
Early erythema
Dry desquamation
Wet desquamation
Ulceration & necrosis
26
List 6 investigations for a patient thought to be contaminated with radioactive material
1. Survey them with a contamination survey instrument
2. Baseline CBC, then repeat q6h for first 24hrs
3. Abs lymphocyte count @ 48hr
4. Lipase, LFTs, CRP
5. Nasal and oral swabs for radiation bioassay (If internal exposure)
6. 24hr urine and feces for radiation bioassay (If internal exposure)
27
When should patients be decontaminated and sent to the hospital after radiation exposure?
If stable - decontamination first at the scene (remove clothes)
If unstable - rapid transport to hospital
28
Outline PPE needed to protect from contamination when helping a radioactive contaminated patient
Rubber gloves (can be 2x)
Eye protection
Hair covers
Shoe covers
Respirators
29
How do you decontaminate a patient who was exposed to radiation?
- Remove clothes and put them in a bag
- Wash exposed skin with water and soap
- Re-survey the patient
- Repeat washing until pt's rad level is <2x the background rad level
30
How should wounds be decontaminated after radiation exposure?
High pressure irrigation (saline or water)
31
List treatments for 4 types of internal radio nucleotides
- Potassium iodide for radioactive Iodine
- Bicarbonate for Uranium
- Prussian blue for Cesium
- DTPA for Plutonium and Transuranics
32
Outline 3 treatments for ARS - Hematopoietic Sub-Syndrome
1) GCSF (Colony stimulating factors)
- start when exposure dose >2 Gy
- decrease in lymphocyte count
- if leukopenia expected to last >7days
Start within 24hrs of exposure, continue until absolute lymphocyte count >1000 cells/mcL
2) Bone marrow transplant
- prolonged leukopenia (2-3 weeks) despite cytokine tx
- cannot have other significant organ involvement
3) PPx ABX
- for neutropenia
33
Outline treatment for ARS - Gastrointestinal Sub-Syndrome
Supportive tx =
IVF
ABX
Anti-emetics
Anti-diarrheals
34
Outline treatment for ARS - Neurovascular Sub-Syndrome
Palliative care
- symptoms within 24hrs indicates lethal dose
35
List 4 treatments for local radiation injury
- Wound care
- Topical corticosteroids
- Vit E and pentoxifylline therapy
- HBOT
36
List 5 indications for extended monitoring after electrical injury
Monitor for 12-24hrs if one of:
- significant troponin increase
- EKG shows cardiac injury
- dysrhythmias
- loss of consciousness
- evidence of significant local injury
37
What is the one test indicated for all patients with lightning strike exposure?
EKG
38
List 4 indications for ED discharge after lightning strike
- no symptoms
- no signs of injury
- minor first-degree burns
- normal EKG
39
What voltage defines low vs high
1000 V
40
List 4 types of injuries associated with high voltages?
Death
Traumatic injuries
Blunt head injuries
Spinal cord injuries
41
Outline Physical Effects of Different Amperage Levels
(1mA, 6-9mA, 16mA, 20mA, 100mA, 2A)
1 mA—barely perceptible
6–9 mA—usual range of let-go current
16 mA—maximum current that an average person can grasp and let go
20 mA—paralysis of respiratory muscles
100 mA—ventricular fibrillation threshold
2 A—cardiac standstill and internal organ damage
42
Why is AC (alternating current) more dangerous than DC (direct current)?
- More dangerous than DC @ similar voltage because amperage above the so-called “let-go” current will cause muscular tetanic contractions
- Flexor muscles of the upper extremities are stronger than extensor muscles, these contractions pull the victim closer to the source resulting in prolonged exposure
43
What are arcing injuries?
current that jumps across skin surfaces and resulting in prominent burns across flexor surfaces
44
Outline the Resistance of 7 Body Tissues, from lowest to highest
Nerve
Blood vessels
Muscle
Skin
Tendon
Fat
Bone
45
List common source contact points and ground contact points in electrical current injuries
Source:
- hands
- wrists
- arms
- oral in kids biting things
Ground:
- heels of feet
46
List order of 3 electrical current paths thru the body starting with highest mortality
1. Transthoracic pathways (arm to arm)
2. Vertical currents (leg to arm)
3. Straddle pathways (leg to leg)
47
List 7 Tips to Avoid Lightning Strike
- Seek shelter inside an enclosed building or metal-topped automobile.
- Avoid large flat, open areas or hilltops.
- Avoid contact with metal objects and remove metal objects, such as jewelry or hairpins.
- Avoid trees, boats, and open water.
- If caught on open ground, curl up on your side with hands and feet close together to reduce contact points, or squat with feet together. If possible, place a rubber raincoat under your body or feet to reduce ground current effects.
- If in a forest, seek shelter under a thick growth of shorter trees.
- If indoors, avoid the use of wired phones and contact with plumbing or electrical appliances.
48
What is the goal of a conducted energy weapon (CEW) ?
barbs lodge in person at a distance from one another, causing an energy arc that results in general muscle contraction and neuromuscular incapacitation (NMI)
49
Define electroporation
Current causes damage to cell membranes & alters membrane solubility, leading to:
- electrolyte abnormalities
- cellular edema
- irreversible damage
- cell death
50
List 3 causes of immediate death in electrical injury
- current-induced cardiac arrest (VF or aystole)
- respiratory arrest (resp muscle paralysis)
- brainstem injury
51
List 4 delayed complications of electrical injuries
Wound infxns
Sepsis
Amputations
Acute renal failure
52
List 4 Types of Burns Associated With Electrical Injury
Entrance and exit site burns
Arc burns (kissing burns)
Thermal burns
Flash burns
53
Describe the burn pattern seen in lightning injuries
Lichtenberg figures:
- usually 1st degree burn
- fern like patterns of erythematous streaks
- current flows over skin rather than thru it
54
Which patients should be treated/resuscitated first at the scene of a multiple-victim lightning strike?
The "Apparent Dead"
-> early resuscitative efforts may prevent death
*hypothesized that the strike leads to a state of suspended animation and cessation of metabolism in all cells, including the brain. This may explain reports of successful resuscitation and full recovery of lightning strike victims after being apneic and pulseless for up to 15 minutes and following resuscitations lasting up to 8 hours.
55
List 5 EKG Changes Seen with Lightning Strike
AFib
STE
Flat Ts or TWI
Long QT interval
MI pattern w/out cardiac sequelae
56
List 5 EKG Changes Seen with Electrical Injury
Anything life-threatening
Sinus tachycardia
Sinus bradycardia
Afib
Ectopic beats
STE/STD without MI
57
List 8 ocular injuries associated with electrical exposure
- Cataracts
- Vitreous chamber hemorrhages
- Anterior chamber hemorrhages
- Retinal detachment
- Macular lacerations
- Ocular foreign bodies
- Corneal burns
- Conjunctival burns
58
List 10 HEENT injuries associated with lightning strikes
- cataracts
- any ocular injury
- fixed & dilated pupils (from autonomic dysfnc)
- asymmetrical pupils (from autonomic dysfnc)
- tympanic membrane rupture
- hearing loss
- tinnitus
- vertigo
- nystagmus
- avulsion of mastoid process
- ossicle damage
- rupture of the Meissner membrane
- strial degeneration
59
List 10 nervous system injuries associated with electrical exposure
*CNS and PNS
- altered mentation
- seizure
- coma
- cerebral infarction
- ICH
- cerebral venous sinus thrombosis
- transient spastic paralysis
- transverse myelitis
- ALS (delayed/chronic manifestation)
- peripheral neuropathies
NeuroPsych
- sleep disturbances
- anxiety
- depressed mood
- flashbacks
- dizziness
- nightmares
- memory impairment
- concentration impairment
- PTSD
- MDD
- executive fnc deficits
60
List 10 nervous system injuries associated with lightning strike
- central apnea
- skull fractures
- ICH
- extra/intra cerebral hematomas
- cerebral edema
- increased ICP
- amnesia to event
- transient LoC
- transient paresthesias
- keraunoparalysis (transient flaccid paralysis w/ extremities appearing cyanotic, mottled, and pulseless)
- neuropathies
- seizures
- cerebellar ataxia
- Horner syndrome
- cognitive dysfnc
- facial nerve palsy
- neuritis
- neuralgia
NeuroPsych
- anxiety
- memeory loss
- prolonged depression
- sleep disturbances
- nocturnal enuresis
- separation anxiety
- hysterical blindness/deafness/muteness
61
List 6 injuries to other viscera in electrical exposure
- myoglobinuria
- renal failure
- stress PUD
- ruptured hollow viscus
- pancreatic necrosis
- gallbladder necrosis
- pulmonary edema
- spontaneous abortions in pregnant pt
- placental abruption 2/2 other trauma
62
When should a specialty service be involved for barb removal after CEW injury? (3)
Barb to
- face
- eyes
- genitals
63
List 8 Findings Suggestive of a Lightning Strike
Clothing wet from rain
Tears or disintegration of clothing
Multiple victims
Lichtenberg figures or superficial linear or punctate burns
TM rupture
Cataracts, especially in younger pt
Magnetization of metal objects on body or clothing
EKG changes
64
List 3 clinical factors after CEW that do not require specific diagnostic investigation
- awake and alert
- asymptomatic
- CEW exposure < 15sec
65
List 3 drugs/drug classes that can be used to treat tachycardia + HTN in lightning strike pts
*Lightning strikes can cause extensive catecholamine release or autonomic stimulation, resulting in transient hypertension and tachycardia
1. Beta blockers
2. Hydralazine
3. Alpha-2 agonists (Clonidine)
66
List 2 indications for 24hr monitoring after lightning exposure
1. Direct lightning strike
2. Abnormal EKG
67
List 1 most common bacterial pathogen in cat & dog bites
Pasteurella species
68
Name the prophylactic antibiotic of choice for dog, cat, and human bites
AmoxClav
*Cipro or Moxi
OR
Clinda + TMPSMX
in penicillin allergy
69
When are ppx ABX most effective after mammalian bite & what is recommended duration?
- Most effective w/in 3hrs of bite
- Recommended 5d
70
List 5 aerobic and 5 anaerobic bacteria commonly found in dog & cat bites
AEROBIC
- Streptococci
- Staphylococci
- Neisseria sp
- Corynebacterium sp
- Moraxella sp
ANAEROBIC
- Capnocytophaga canimorsus
- Pasteurella
- Prevotella
- Fusobacterium
- Bacteroides
- Porphyromonas
- Propionibacterium sp
71
Outline 6 risk factors for systemic illness from Capnocytophaga canimorsus
Age >50yrs
Male
Immunocompromised
Asplenia
Alcoholism
Malignancy
72
List 3 complications of Capnocytophaga canimorsus infection
Local wound infection
Sepsis
DIC
73
List Recommendations for Bite Wound Closure and Prophylactic Antibiotics in:
Canine, Cat, Human, Monkey, Rodent, and other bites
74
List species associated with high & low risk of bite wound infections
HIGH
- Cat (domestic and wild)
- Human
- Monkey
- Pig
- Camel
- Bear
LOW
- Dog (excluding hands and feet)
- Rodent
75
List locations of wounds associated with high & low risk of bite wound infections
HIGH
- hand, especially clenched fist
- foot
LOW
- face
- scalp
76
List wound types associated with high & low risk of bite wound infections
HIGH
- Puncture
- Crush injury or damage to deep structures
- Devitalized tissue
- Delayed presentation >6hr
- Closed primarily
LOW
- Superficial
- Laceration
77
List 10 patient characteristics associated with high risk of bite wound infections
- Age >50
- DM
- Renal failure
- Liver dz
- Alcoholism
- Immune d/o
- Malnutrition
- Use of corticosteroids
- Use of immunosuppressive meds
- Peripheral vascular dz
- Chronic edema of bitten area
78
List empiric PO and IV abx treatments for dog and cat bites
- AmoxClav 875/125mg PO BID x 5d
- Ciprofloxacin 500mg BID x 7-14d
- Moxifloxacin 400mg PO OD x 7-14d
- Clindamycin 300mg PO QID + TMP-SMX 160/800 mg BID x 7-14d
- PipTazo 3.375mg IV q6h x 7-14d
- Meropenem 500mg IV q8h
- Ciprofloxacin 400mg IV BID + Clindamycin 300mg IV QID
- Moxifloxacin 400mg IV OD + Metronidazole 500mg IV QID
79
List empiric PO and IV abx treatments for human and monkey bites
- AmoxClav 875/125mg PO BID x 5d
- Ciprofloxacin 500mg PO BID x 7-14d
- Clindamycin 300mg PO QID + TMP-SMX 160/800 mg PO BID x 7-14d
- Meropenem 500mg IV q8h
- Ertapenem 1g/day IV/IM
- CTX 1g IV BID + Metronidazole 500mg TID
- Clindamycin 600mg IV QID + Ciprofloxacin 400mg IV BID
80
List 3 Structural & 6 Infectious Indications for Admission After an Animal Bite
Structural
- Injury to deep structures (bones, joints, tendons, arteries, or nerves)
- Injuries requiring reconstructive surgery
- Injuries requiring general anesthesia for appropriate wound care
Infectious
- Rapidly spreading cellulitis
- Significant lymphangitis or lymphadenitis
- Evidence of sepsis
- Infection in patients at high risk for complications
- Infections involving bones, joints, tendons
- Infection with failed outpatient therapy
81
List 4 clinical s/s, and 4 local & 4 systemic complications of cat (mammal) bites involving Pasteurella multocida
S/S
- Rapidly spreading cellulitis (w/in 12-24hr)
- Low grade fever
- Serosang or purulent discharge
- Regional LNA
Local
- Tenosynovitis
- Subcut abscess
- Septic arthritic
- Osteomyelitis
Systemic
- Bacteremia
- Endocarditis
- PNA
- Meningitis
82
List viruses of major concern associated with monkey bites
= B viruses
- herpesvirus simiae
- herpesvirus B
- monkey B virus
Similar to human herpes viruses
83
List 5 bacteria associated with monkey bites
AEROBES
- Staphylococcus
- Streptococcus species
- Eikenella corrodens
ANAEROBES
- Bacteroides sp
- Fusobacterium sp
84
List 9 clinical features of monkey-bite B virus infections
- vesicular lesions at exposure site
- influenza symptoms
- ascending paresthesias
- ascending muscle weakness
- altered mental status
- CN palsies
- ataxia
- coma
- respiratory failure
85
List 7 indications where Prophylaxis is Recommended for Monkey Virus B Exposure
Skin (with loss of integrity) or Mucosal exposure to a high-risk source (macaque that is ill, immunocompromised, shedding virus, or has B virus lesions)
Inadequately cleaned skin (with loss of integrity) or mucosal exposure
Deep puncture bite
Laceration of the head, neck, or torso
Needlestick associated with tissue or fluid from the nervous system, eyelids, mucosa, or lesions suspicious for B virus
Puncture or laceration after exposure to objects contaminated with either fluid from monkey oral, genital, or nervous system tissues or any object known to be contaminated with B virus
A post cleaning wound culture is positive for B virus
86
List ppx anti-virals for monkey B virus exposure
1) Valacyclovir 1g PO q8h x 14d
2) Acyclovir 800mg PO 5x/d x 14d
87
List 2 bacteria associated with Rat Bite Fever
- Streptobacillus moniliformis
- Spirillum minus
88
List 4 clinical features of Rat Bite Fever
- Fever
- Migratory polyarthralgia
- Rash on extensor surfaces (maculopapular, petechial, or purpuric)
- Endocarditis
89
List 5 systemic diseases transmitted by rodents
- rat bite fever
- leptospirosis
- tularemia
- sporotrichosis
- murine typhus
- plague
90
List abx tx for rat bite fever
Penicillin IV
91
In what animal bites should rabies immunization be considered?
bats, coyotes, wolves, foxes, raccoons, skunks, and stray dogs outside of North America
92
List 2 types of human bites
occlusive bites
clenched fist injuries
93
What 3 complications can occur in fight bites?
osteomyelitis
septic arthritis
tenosynovitis
94
List 5 bacteria involved in human bites
Staphylococcus
Streptococcus
Corynebacterium
Fusobacterium
Eikenella corrodens
95
List 5 Indications for Admission for Human Bites of the Hand
Infection present at the time of presentation
Deep structure violation (tendon or tendon sheath, joint, or bone)
Wounds requiring operative intervention for debridement of devitalized tissue or foreign body removal
Patients at high risk for wound infection
Patients with poor social support or compliance issues
96
Match classic heat stroke and exertional heatstroke by age
Classic heatstroke is dx'd in older patients w/ comorbidities during heat waves
Exertional heatstroke is common in young athletic patients or military personnel
97
In heat stroke, what 1 clinical feature is directly related to increased morbidity and mortality?
duration of core temperature elevation
98
List 2 forms of primary cooling measures
Evaporative cooling
Ice water immersion
99
List 1 paradoxical finding in heatstroke
Heatstroke can cause Rt-sided cardiac dilation + elevated CVP
- clinically resemble pulmonary edema
BUT pts may still require crystalloid resuscitation!
100
List 2 major body mechanisms whereby heat loss can be accelerated
Sweating
Peripheral vasodilation
101
List 5 predisposing factors for classic heatstroke
Advanced age
Psychiatric conditions
Chronic disease
Obesity
Medications
Multiple clothing layers
102
Characterize levels of water depletion by body weight loss
(-) 2-3% = Mild
(-) 5-6% = Moderate
(-) >7% = Severe
103
List pre-disposing factors for heat illness
(think automotive analogy)
1) Environmental heat stress
2) CNS (Thermostat) Malfunction
- hypothalamic hemorrhage
3) Heart (pump) Malfunction
- cardiac disease
- beta blockers
- CCBs
4) Increased Heat Production
- Exercise
- Sympathomimetics
- Fever
- Delirium
- Thyroid storm
- malignant hyperthermia
- NMS
- Seizures
5) Skin (radiator) Malfunction
- Anticholinergics
- Miliaria
- Burns
- Scleroderma
- Cystic fibrosis
- occlusive clothes
6) Low Blood (coolant) Levels
- poor PO intake
- Vomiting
- Diarrhea
- Diuretics
7) Damaged Vasculature (conducting) System
- diabetes
- atherosclerosis
104
Describe miliaria rubra
"Intense, pruritic vesicles on erythematous base"
= Prickly heat
(lichen tropicus, heat rash)
- acute inflammatory disorder of skin that occurs in hot & humid climates
- result of the blockage of sweat gland pores by macerated stratum corneum and secondary staphylococcal infection
105
List 5 diagnostic features of Heat Cramps
Cramps of the most worked muscles
Usually occur after exertion
Copious sweating during exertion
Copious hypotonic fluid replacement during exertion (slat deficiency)
Hyperventilation not present in cool environment
106
List tx for heat cramps
PO or IV salt solutions
107
List 4 Minor Heat Illnesses
Miliaria Rubra
Heat Cramps
Heat Edema
Heat Syncope
108
List 2 Major Heat Illnesses
Heat Exhaustion
Heatstroke
109
Describe Heat Syncope
Multifactorial disorder = temporary loss of consciousness 2/2 heat exposure
- dilation of cutaneous vessels
- intravascular pooling in peripheries
- inadequate central venous return drops Cardiac Output
- cerebral perfusion unable to maintain consciousness
110
List & describe 2 types of heat exhaustion
Water depletion:
- inadequate fluid replacement in hot workers
- incapacitated individuals without free access to water
Salt depletion
- large volumes of thermal sweat are replaced by water with too little salt
111
List 6 diagnostic features of heat exhaustion
Vague malaise, fatigue, headache
Core temperature often normal or <40°C
Mental function essentially intact; no coma or seizures
Tachycardia, orthostatic hypotension, clinical dehydration
Other major illness ruled out
If in doubt, treat as heatstroke
112
List 5 mgmt steps for heat exhaustion
Rest
Cool environment
Assessment of volume status
Fluid replacement
- NS to replete volume if the patient is orthostatic
- replace free water deficits slowly to avoid cerebral edema
Healthy young patients are usually treated as outpatients; consider admission if the patient is older, has significant electrolyte abnormalities, or would be at risk for recurrence if discharged.
113
List 5 diagnostic factors of heatstroke
Exposure to heat stress, endogenous or exogenous
Signs of severe CNS dysfunction (coma, seizures, delirium)
Core temp usually >40.5°C (may be lower)
Hot skin common, sweating may persist
Marked elevation of hepatic transaminase levels
114
Compare/contrast characteristics of Classic vs Exertional Heatstroke
115
List 10 drug classes (or 15 individual drugs) associated with heat stroke
Anticholinergics
- Atropine
- Benztropine
- Oxybutynin
- Scopolamine
Antidepressants
- TCAs
Antiemetics
- Metaclopramide
- Prochlorperazine
- Promethazine
Antiepileptics
- Topiramate
- Zonisamide
Antihistamines
- ALL
Antihypertensives
- Beta blockers
- Calcium channel blockers
Antipsychotics
- All
Diuretics
- Hydrochlorothiazide
- Furosemide
- Spironolactone
Ergogenic (muscle) Aids
- Anabolic steroids
- Creatine
- Ephedra
Sympathomimetics
- Amphetamines
- Cocaine
- Methylphenidate
116
List 3 hyperdynamic cardiovascular findings in heatstroke
- low peripheral vascular resistance
- tachycardia (up to 180 bpm)
- elevated cardiac index
117
List 5 clinical features that predict poor outcomes in heatstroke
- advanced age
- hypotension
- altered coagulation status
- lactic acidosis
- necessity for intubation on ED arrival
118
List 2 acid-base disturbances that may be present in heat stroke
Respiratory alkalosis (CHS)
Lactic acidosis (EHS)
119
What happens to the hemoglobin-oxygen dissociation curve in heat stroke?
- Shifts to the right
- increase in temp denatures the bond between O2 and HGB, decreasing the concentration of oxyhemoglobin
120
List 8 manifestations of abnormal hemostasis in heatstroke
- purpura
- conjunctival hemorrhage
- melena
- bloody diarrhea
- hemoptysis
- hematuria
- myocardial bleeding
- hemorrhage into CNS
121
List 10 Differential Diagnoses of Heatstroke
Central nervous system hemorrhage
Toxins, drugs
Seizures
Malignant hyperthermia
Exercise-induced hyponatremia
Neuroleptic malignant syndrome
Serotonin syndrome
Thyroid storm
High fever, sepsis
Encephalitis, meningitis
Delirium tremens
122
At what core body temp do you stop cooling measures?
39 deg C
123
List 2 preferred & 6 adjunct methods of cooling in heatstroke
Preferred
1) Evaporative cooling with large circulating fans and skin wetting
2) Ice water immersion
Adjuncts
1) Ice packs to axillae and groin
2) Cooling blanket
3) Peritoneal lavage (unproven efficacy in humans)
4) Rectal lavage
5) Gastric lavage
6) ECMO
124
What is the tx of choice for shivering and agitation in heatstroke patients during cooling?
Benzos
125
What is the initial therapy for ALL diving emergencies?
100% O2
126
What is leading cause of death among divers?
Drowning
127
List 6 environmental exposure-related emergencies that scuba divers have, other than dysbarism
- hypothermia
- burns/sun exposure
- motion sickness
- bites
- envenomation
- physical trauma
128
List 2 pathophysiologic categories of diving dysbarism
(1) Barotrauma which is related to pressure
- independent of time
(2) Decompression illness which is related to gas bubbles
- dependent on extended time at depth
129
Define Boyle's law & its significance
At a constant temperature, the absolute pressure and the volume of gas are inversely proportional.
- As pressure increases, the gas volume is reduced
- as pressure is reduced, gas volume increases
--> Significant in scuba diving and decompression
130
Define Pascal's law & its significance
A pressure applied to any part of a liquid is transmitted equally throughout
--> Significant in inner ear barotrauma and middle ear barotrauma
131
Define Charles' law & its significance
At a constant pressure, the volume of a gas is directly proportional to the change in the absolute temperature
--> Significant in filling scuba tanks
132
Define Dalton's law & its significance
The total pressure exerted by a mixture of gases is equal to the sum of the partial pressures of each different gases making up the mixture
- with each gas acting as if it alone is present and occupies the total volume.
- Nitrogen under pressure acts as if other gases are not present
133
Define Henry's law & its significance
The amount of a gas that will dissolve in a liquid at a given temperature is directly proportional to the partial pressure of that gas.
- More nitrogen is taken into solution (e.g., serum) at high pressures than comes out of solution at lower pressures
--> Significant in decompression sickness
134
List 6 disorders related to diving descent
middle ear barotrauma
external ear barotrauma
inner ear barotrauma
barosinusitis
facial barotrauma
alternobaric vertigo
135
List s/s of middle ear barotrauma (ear squeeze)
- sensation of fullness
- tinnitus
- vertigo
- nystagmus (if uni TM ruptures)
- facial nerve palsy
136
List s/s of external ear barotrauma
- pain
- hemorrhages w/in wall of external auditory canal
137
List s/s of inner ear barotrauma
- hearing loss
- severe vertigo
- nausea
- tinnitus
- fullness in the affected ear
- severe nystagmus
- positional vertigo
- ataxia
- vomiting
138
List s/s of barosinusitis
- facial pain
- epistaxis
139
List s/s of facial barotrauma (mask squeeze)
- facial edema
- diffuse facial petechial hemorrhages
- conjunctival edema
- subconjunctival hemorrhages
- optic nerve damage
140
List 3 disorders occurring in divers at depth
Nitrogen narcosis
Oxygen toxicity
Carbon monoxide poisoning
141
List 3 features of nitrogen narcosis
- impairment of psychomotor coordination
- alterations in mood (euphoria or anxiety)
- altered behaviour (lowered inhibitions, impaired reasoning)
*Symptoms require time at depth and may become apparent at depth of 100 ft (30 m)
* resolves with gradual and controlled ascent
142
List 10 features of oxygen toxicity
Pulmonary
- burning pain with inspiration
- coughing
- pneumonitis
- fibrosis
CNS
- headache
- dizziness
- irritability
- anxiety
- visual changes
- extremity tingling
- extremity twitching
- tinnitus and hearing abnormalities
- nausea
- seizures
143
List s/s of alternobaric vertigo
- vertigo
- nausea
- vomiting
143
List 8 disorders occurring in divers during ascent
- alternobaric vertigo
- barodontalgia
- GI barotrauma
- pulmonary barotrauma
- pulmonary edema
- decompression sickness I & II
- arterial gas embolism
144
List s/s of GI barotrauma in divers
- belching
- flatulence
- bloating
- crampy abdominal pain
- gastric rupture
- incarcerated hernia
- strangulated hernia
145
List 4 complications of pulmonary barotrauma in divers
- pneumothorax
- pneumomediastinum
- subcutaneous emphysema
- alveolar hemorrhage
* can also cause AGE!
146
List 6 factors that increase risk of pulmonary barotrauma in asthmatics
1. Bronchospasm and mucus plugging can cause local lung injury
2. Compressed air is denser, contributes to greater turbulent flow through narrow airways
3. During scuba diving, there is a reduction in breathing capacity related to the effects of immersion, reduces as you go deeper
4. Compressed air expands in the scuba regulator before delivery to lungs as it cools (Charles’ law). Breathing chilled air may trigger bronchospasm in cold-induced asthmatics
5. Exercise-induced asthmatics may experience bronchospasm with exertion
6. Compressed air may be contaminated by pollen and allergens
147
List 6 rules/recommendations for asthmatic scuba divers
1) Need thorough history + physical by trained physician
2) Asthma should be well controlled
3) Have normal spirometry
4) Have successful completion of bronchial provocation challenge
5) Cannot have cold, exercise, or emotion induced asthma
6) Cannot require rescue medication within 48 hours of a dive
148
What is the cause of decompression sickness?
Formation of small bubbles of nitrogen gas in blood and tissue upon ascent
149
List 10 risk factors for DCS
- increased length of dive
- increased depth of dive
- male
- age
- obesity
- fatigue
- heavy exertion
- dehydration
- fever
- cold ambient temperatures after diving
- diving at high altitude
- flying soon after diving
- presence of a PFO
- presence of left-to-right cardiac shunt (ASD/VSD)
150
List 3 organ systems affected in DCS I
MSK
Skin
Lymphatics
151
List 3 organ systems affected in DCS II
Neurologic
Vestibular
Pulmonary
* and any other system
152
List 15 common symptoms of DCS (in general)
- joint pain
- muscle pain
- girdle pain
- numbness/paresthesias
- HA
- lightheadedness
- inappropriate fatigue
- malaise
- nausea/vomiting
- anorexia
- vertigo
- motor weakness
- cutaneous
- altered mental status
- dyspnea
- cough
- coordination impairment
- loss of consciousness
- bladder symptoms
- bowel symptoms
- cardiovascular symptoms
153
What maneuver can confirm the dx of DCS I?
placement of a BP cuff inflated to 150-200 mmHg on an affected joint produces relief of pain
154
List 3 s/s of DCS I
- joint pain (elbow and shoulders)
- pruritis
- extremity edema
155
List 15 s/s of DCS II
Skin
- cutis marmorata
Spinal Cord
- limb weakness
- paralysis
- paresthesias
- numbness
- low back pain
- abdominal pain (from lumbar spinal cord involvement)
- urinary retention
- bladder incontinence
- fecal incontinence
- priapism
CNS
- headache
- blurred vision
- diplopia
- dysarthria
- unusual fatigue
- inappropriate behaviour
Vestibular (Inner Ear)
- nausea
- vomiting
- vertigo
- nystagmus
- hearing loss
Pulmonary (gradual onset)
- dyspnea
- cough
- chest pain
- cyanosis
- respiratory arrest
156
List fetal complications possible in pregnant scuba divers
- low-birth-weight infants
- prematurity
- congenital malformations
- stillbirths
- spontaneous abortions
157
What causes arterial gas embolism?
barotrauma with air forced across the alveolar-capillary membrane through the pulmonary venous circulation into the arterial system
158
Which organ system arteries have the most serious consequences with AGE?
coronary arteries
- myocardial ischemia/infarction
- dysrhythmias
- cardiac arrest
cerebral arteries
- ACA stroke
- MCA stroke
159
List 10 common s/s of AGE
- aLoC
- HA
- dizzy
- convulsions
- vision changes
- CN deficits
- unilateral wekaness
- u/l or b/l sensory loss
- ataxia
- speech changes
- dyspnea
- pleuritic chest pain
- hemoptysis
160
What dx should be suspected in any diver breathing compressed air at any depth underwater and who surfaces unconscious or who loses consciousness within 10 minutes of reaching the surface?
AGE
161
Compare & contrast IEBT, MEBT, and ABV by signs and symptoms
162
Differentiate DCS vs AGE by dive hx, risk factors, s/s, and tx
163
What EKG finding may be present in DCS?
Right sided strain
164
List 4 Diving Disorders That Require Recompression Therapy
Decompression sickness type I
Decompression sickness type II
Arterial gas embolism (AGE)
Contaminated air (carbon monoxide poisoning)
165
List the preferred commercial aircraft cabin pressurization, and the preferred altitude of a helicopter, while transporting a diving accident patient.
Commercial aircraft cabin should be pressurized to <1000 ft
Helicopters should fly no higher than 500 ft
166
List adjunct tx's for pts with DCS and AGE
- anti-coagulation to prevent VTE
- decompress any PTX
- interrmittent pneumatic compression devices
- benzos for seizures
- urinary catheter, balloon filled with NS
- ETT balloon filled with NS
- transport in flat supine position
167
List diving d/o's that DO NOT require HBOT/recompression therapy
Middle ear barotrauma (MEBT)
External ear barotrauma
Inner ear barotrauma (IEBT)
Barosinusitis
Facial barotrauma
Nitrogen narcosis
Oxygen toxicity
Pneumothorax
Pneumomediastinum
Subcutaneous emphysema
Alveolar hemorrhage
Alternobaric vertigo (ABV)
Barodontalgia
Gastrointestinal barotrauma
Avascular osteonecrosis
168
List 2 ppx medications that can reduce the incidence and severity of MEBT
pseudoephedrine 60mg PO 30 mins pre-dive
oxymetazoline nasal spray
169
Outline post-dive flight recommendations
Dive <2hrs in last 48hrs = Fly >12hrs post-dive
Unlimited diving = Fly >24hrs post-dive
Pts recompressed after DCS/AGE = Fly >72hrs post-recompression
170
List 2 main treatments for altitude illness
O2 therapy
Rapid descent
171
List diagnostic criteria for Acute Mountain Sickness
- presence of HA (bitemporal, throbbing, worse at night, upon waking, and suddenly upright)
- recent elevation change >8000 ft
PLUS >1 of:
- nausea
- vomiting
- anorexia
- fatigue
- general weakness
- dizziness
- lightheadedness
172
List s/s of High-Altitude Pulmonary Edema
- dyspnea at rest
- tachypnea at rest
- productive cough w/ frothy sputum
- altered mentation
173
List s/s of High-Altitude Cerebral Edema
- aLoC
- cerebellar ataxia
174
List PPx meds for Acute Mountain Sickness & High-Altitude Pulmonary Edema
AMS:
- Acetazolamide 125mg PO q12h
- Dexamethasone 4mg PO q12h
HAPE:
- Nifedipine 30mg SR q12h (reduces PVR, SVR, BP)
- Acetazolamide 125 q12h (inhibit hypoxic pulmonary vasoconstriction)
- Sildenafil 50mg q8h or Tadalafil 10mg q12h (PDE5's, augment NO effects)
- Salbutamol (enhances removal of alveolar fluid)
- Dexamethasone 8mg PO q12h (increase NO production)
175
Define moderate, high, very high, and extreme altitude
Moderate = 5k-8k ft
High = 8k-14k ft
Very high = 14k-18k ft
Extreme = >18k ft
176
Hypoxemia triggers what physiologic responses?
- Increased minute ventilation
- leads to increased CO2 exhalation
- leads to respiratory alkalosis
- kidneys excrete HCO3 (acetazolamide increases the excretion)
177
What does HAPE result from?
- hypoxia-induced acute pulmonary hypertension
- leads to stress failure of pulmonary capillaries
- consequent alveolar and interstitial edema
178
What does AMS and HACE result from?
- CNS hypoxemia leads to impaired vascular autoregulation, causing increased pressures within the brain’s capillary beds.
- hypertension from strenuous exercise at high altitude may overwhelm the brain vasculature, resulting in transcapillary leakage and vasogenic edema
179
List 10 DDx for Acute Mountain Sickness
- Tension headache
- Viral syndrome
- Alcohol intoxication/toxidrome
- CO poisoning
- Dehydration
- Caffeine withdrawal
- Migraine headache
- Infectious (meningitis, encephalitis/viral syndrome)
- Intracranial hemorrhage or mass
- CNS aneurysm
- Venous sinus thrombosis
- Abdominal process (e.g., gastroenteritis)
- Acute angle closure glaucoma/ocular process
180
What are 2 preferred anti-emetics in AMS?
prochlorperazine
ondansetron
181
List the dose for acetazolamide for peds and adults for ppx/tx of AMS
Peds:
2.5 mg/kg/dose q6-8h
Adults:
125mg q12h
(max 250mg)
182
List 5 benefits of acetazolamide use in AMS
- enhances renal HCO3 diuresis
- improves sleep + decreases nocturnal periodic breathing
- lowers CSF volume + pressure
- relaxation of smooth muscle
- increased fluid resorption in lungs
183
List adverse reactions/side effects of acetazolamide use in AMS
- paresthesias
- polyuria
- nausea
- diarrhea
- drowsiness
- tinnitus
- transient myopia
- makes carbonated drinks taste bad
- cross-reactivity as sulfa-drug
184
List 2 benefits of dexamethasone use in moderate to severe AMS
- reduce cerebral blood flow
- euphoric affects
185
List low, moderate, high risk factors for AMS
LOW:
- Individuals with no prior history of altitude illness and ascending to ≤9200 feet
- Individuals taking ≥2 days to arrive at 8200 to 9800 feet with subsequent increases in sleeping elevation <1600 feet per day
MODERATE:
- Individuals with prior history of AMS and ascending to 8200 to 9200 feet in 1 day
- No history of AMS and ascending to >9200 feet in 1 day
- All individuals ascending >1600 feet per day (increase in sleeping elevation) at altitudes above 9800 feet
HIGH:
- History of AMS and ascending to ≥9200 feet in 1 day
- All individuals with a prior history of HAPE or HACE
- All individuals ascending to >11,500 feet in 1 day
- All individuals ascending >1,600 feet per day (increase in sleeping elevation) above >11,500 feet
- Very rapid ascents
186
Outline dose of dexamethasone to prevent AMS
initial dose of 8 mg
then 2mg q6h
or 4mg q12h
187
List 10 DDx for HAPE
- High altitude bronchitis (Khumbu cough)
- High altitude pharyngitis
- CO poisoning
- PNA
- PTX
- PE
- Pleural effusion
- ACS
- CHFe
- Acute exacerbation of pulmonary hypertension
- COPDe
- Acute asthma flare
- Acute exacerbations of valvular disease (insufficiency and stenosis)
188
List features of HAPE on CXR
- patchy infiltrates with clearing btwn them
- rare pleural effusions
189
List EKG findings in HAPE
- Rt heart strain
- RAD
- P wave abnormalities
- tall R waves in the precordial leads
- S waves in the lateral leads
190
List s/s of HACE
- ataxia
- altered mental status
- slurred speech
- emotional lability
- confusion
- hallucinations
- obtundation
- coma
- death
- generalized seizures
- focal neuro deficits
- retinal hemorrhage
- papilledema
- CN palsy
* and any s/s of AMS and HAPE
191
List 10 DDx of HACE
- CVA
- TIA
- ICH
- Hypoglycemia
- CO poisoning
- Meningitis/encephalitis
- Hypothermia
- Intracranial mass
- Vertebral/carotid dissection or stenosis
- Acute toxidrome (alcohol, other)
- Acute alcohol withdrawal/delirium tremens
- Seizure
- Transient global amnesia
192
List tx options for HACE
- descent
- O2
- dexamethasone
- careful furosemide
- careful mannitol
- hyperbaric tx
193
List features of High-Altitude Retinal Hemorrhage (HARH)
- usually spares macula
- if macula involved, get central scotomas
- increased risk if previous had HARH or on anticoagulation
- resolve in 2-3wk w/out tx
194
List 4 medical conditions that make travel to high altitude contraindicated
Sickle cell anemia (with history of crises)
Severe COPD
Symptomatic pulmonary hypertension
Uncompensated CHF
195
List 10 medical conditions that should take CAUTION when traveling to high altitude
Sickle cell trait
Moderate COPD
Asymptomatic pulmonary hypertension
Compensated CHF
Morbid obesity
Sleep apnea syndromes
Troublesome arrhythmias
Stable angina or CAD
High-risk pregnancy
Cerebrovascular diseases
Any cause of restricted pulmonary circulation
Seizure disorder (not taking medication)
Radial keratotomy
196
List specific indications for active rewarming
- trauma
- cardiovascular instability
- temp <32°C
- poor rate of passive rewarming
- endocrine insufficiency
197
What 3 things are suggested by failure to rewarm (w/ good technique)?
- infection
- endocrine insufficiency
- futile resuscitation
198
Define Hypothermia
core temperature below 35°C
199
List 2 most common causes of accidental hypothermia
- convective heat loss to cold air
- conduction & convection in cold water
200
Outline 4 zones of hypothermia
Cold-Stressed / Mild
33-37
Moderate
29-32
Severe
22-28
?Extreme
4.2-20
201
List Physiologic Characteristics of Cold-Stressed / Mild Hypothermia
- Increased shivering thermogenesis; increase in metabolic rate
- Normal BP
- ataxia
- apathy
- amnesia
202
List Physiologic Characteristics of Moderate Hypothermia
- Stupor
- decrease in O2 consumption
- increased shivering
- Afib + dysrhythmias
- dilated pupils
203
List Physiologic Characteristics of Severe Hypothermia
- VF/VT susceptible
- loss of reflexes
- no response to pain
- no corneal reflex
204
List DDx of Osborn J waves
- hypothermia
- local cardiac ischemia
- sepsis
- CNS lesions
- hypercalcemia
205
Define core temperature afterdrop
- decrease in core temperature after removal from the cold
- Temperature equilibration by conduction of heat from core to cooler peripheral tissue contributes to afterdrop, but countercurrent cooling of blood perfusing cold tissues in periphery before returning to warmer core results in greater decrease in core temperature
206
List factors that predispose to hypothermia: decreased heat production
Endocrine failure
Hypopituitarism
Hypothyroidism
Diabetes
Insufficient fuel
Hypoglycemia
Malnutrition
Marasmus
Kwashiorkor
Extreme exertion
Neuromuscular inefficiency
Age extremes
Impaired shivering
Inactivity
Lack of adaptation
207
List factors that predispose to hypothermia: increased heat loss
Environmental
Immersion
Nonimmersion
Induced vasodilation
Pharmacologic
Toxicologic
Ethanol intoxication
Erythrodermas
Burns
Psoriasis
Ichthyosis
Exfoliative dermatitis
Iatrogenic
Emergency deliveries
Cold infusions
Heatstroke treatment
208
List factors that predispose to hypothermia: impaired thermoregulation
Peripheral failure
Neuropathy
Acute spinal cord transection
Diabetes
Central neurologic failure
Central nervous system trauma
Cerebrovascular accident
Toxicologic
Metabolic
Subarachnoid hemorrhage
Pharmacologic
Hypothalamic dysfunction
Parkinson disease
Anorexia nervosa
Cerebellar lesion
Neoplasm
Congenital intracranial anomalies
Multiple sclerosis
209
List 7 major risk factors for hypothermia in trauma patients
- extremes of age
- severe injury
- intoxication
- large transfusion requirements
- prolonged field time
- prolonged ED time
- prolonged OR times
210
List 20 presenting signs of Hypothermia
HEENT:
- Mydriasis
- Decreased corneal reflexes
- Extraocular muscle abnormalities
- Erythropsia (altered color perception)
- Flushing
- Facial edema
- Epistaxis
- Rhinorrhea
- Strabismus
CARDIOVASCULAR:
- Initial tachycardia
- Subsequent bradycardia
- Dysrhythmias
- Decreased heart tones
- Hepatojugular reflux
- Jugular venous distention
- Hypotension
RESPIRATORY:
- Initial tachypnea
- Adventitious sounds
- Bronchorrhea
- Progressive hypoventilation
- Apnea
GASTROINTESTINAL:
- Ileus
- Constipation
- Abdominal distention or rigidity
- Poor rectal tone
- Gastric dilation in neonates or in adults with myxedema
GENITOURINARY:
- Anuria
- Oliguria
- Polyuria
- Testicular torsion
NEUROLOGIC
- Depressed level of consciousness
- Ataxia
- Hypesthesia
- Dysarthria
- Antinociception
- Amnesia
- Initial hyperreflexia
- Anesthesia
- Hyporeflexia
- Areflexia
- Central pontine myelinolysis
PSYCHIATRIC:
- Impaired judgment
- Perseveration
- Mood changes
- Flat affect
- Altered mental status
- Paradoxical undressing
- Neuroses
- Psychoses
- Suicide
- Organic brain syndrome
MSK:
- Increased muscle tone
- Shivering
- Rigidity or pseudo–rigor mortis
- Paravertebral spasm
- Opisthotonos
- Compartment syndrome
DERMATOLOGIC:
- Erythema
- Pernio
- Pallor
- Frostnip
- Cyanosis
- Frostbite
- Icterus
- Popsicle panniculitis (inflammation of cheeks, “cold panniculitis”)
- Sclerema (hardening of subcutaneous tissue)
- Cold urticaria
- Ecchymosis
- Necrosis
- Edema
- Gangrene
211
List 8 infections that can lead to hypothermia
- gram-negative sepsis
- pneumonia
- meningitis
- encephalitis
- bacterial endocarditis
- brucellosis
- malaria
- syphilis
- typhoid
- miliary tuberculosis
- trypanosomiasis
212
List 8 DDx for hypothermia
- hypothyroidism
- hypopituitarism
- diabetes
- hypoglycemia
- malnutrition
- intracranial and spinal cord injuries
- sedative-hypnotic intoxication
- alcohol intoxication
213
List medical conditions associated with hypothermia
- carcinoma
- pancreatitis
- peritonitis
- cerebrovascular disease
- infusion of MgSO4 in pregnancy
- MI
214
Outline treatment goals as in the Canada "cold card"
215
To what depth should esophageal and rectal thermometers be inserted?
Esophageal = 24cm below the laryx, in lower 1/3 of esophagus
Rectal = 15 cm in, not in cold feces
216
In hypothermic ACLS, when will be defibrillation be most successful?
At core temp >30 degC
217
In which hypothermic pts should empiric ABX be given?
Peds < 3mos
Geriatric
Or adults with:
Cellulitis
Myositis
Bacteriuria
CXR infiltrate
218
List 3 clinical indications to start empiric thyroid hormone in hypothermic pts
* If you think they have myxedema
Thyroid hormone should be replaced if history of:
- hypothyroidism
- suggestive neck scar
- failure to rewarm
Levothyroxine 250-500 mcg IV 'load',
then 50-100mcg IV q24h x 5-7d
Can add hydrocortisone 100mg IV
219
At what temp is shivering the major source of heat production?
Core temp >32 degC
220
List 7 Indications for Active Rewarming
- Cardiovascular instability
- Mild to severe hypothermia
- Inadequate rate of passive rewarming or failure to rewarm
- Endocrine insufficiency (hypopituitarism, adrenal insufficiency, hypothyroidism, & Wernicke encephalopathy)
- Trauma
- Traumatic or toxicological peripheral vasodilation
- Secondary hypothermia impairing thermoregulation (CNS impairment)
221
List 6 methods of active external rewarming
- plumbed garments that circulate warm fluids
- hot water bottles
- heating pads
- forced air warming systems (bearhugger)
- Arteriovenous anastomosis (AVA) = limbs up to elbows and knees in hot water 44-45degC
- radiant sources
222
List 10 methods of active core rewarming
- airway rewarm with humidified air
- peritoneal dialysis
- closed thoracic lavage
- direct myocardial lavage
- GI irrigation
- endovascular rewarming
- venovenous rewarming
- hemodialysis
- continuous arteriovenous (AV) rewarming
- extracorporeal circulation–cardiopulmonary bypass or ECMO
223
List 4 types of Extracorporeal Blood Rewarming
- venovenous rewarming
- hemodialysis
- continuous arteriovenous (AV) rewarming
- extracorporeal circulation–cardiopulmonary bypass or ECMO
224
List 4 complications of rapid rewarming
- DIC
- pulmonary edema
- hemolysis
- acute tubular necrosis
225
List 5 significant predictors of poor outcomes in hypothermia
- asphyxia
- prehospital cardiac arrest
- low or absent blood pressure
- high BUN
- need for endotracheal or nasogastric intubation in ED
226
List 4 lab values that are grave prognosticators for pts we can leave "cold and dead"
- Fibrinogen < 50 mg/dL = evidence of intravascular thrombosis
- Ammonia > 250 mmol/L
- hyperK > 10–12 = cell lysis
- if asphyxiated/avalanche, hyperK >7 = death
227
What type of skin bleb is more favourable in frost bite?
Early formed clear blebs better than delayed hemorrhagic blebs
228
Define frostbite
When tissue is supercooled well below 0degC
= ice crystals form in tissues, microvascular thrombosis
229
Outline 3 phases of Freezing Injury Cascade
1) Prefreeze Phase
- Superficial tissue cooling
- Increased viscosity of vascular contents
- Microvascular constriction
- Endothelial plasma leakage
2) Freeze-Thaw Phase
- Extracellular fluid ice crystal formation
- Water movement across cell membrane
- Intracellular dehydration and hyperosmolality
- Cell membrane denaturation
- Cell shrinkage and collapse
3) Vascular Stasis and Progressive Ischemia
- Vasospasticity and stasis coagulation
- Arteriovenous shunting
- Vascular endothelial cell damage and prostanoid release
- Interstitial leakage and tissue hypertension
- Necrosis, demarcation, mummification, or slough
230
List 15 Risk Factors for worsened peripheral cold injury
1) PHYSIOLOGIC
- Genetic
- Core temperature
- Previous cold injury
- Lack of acclimatization to altitude
- Dehydration
- Overexertion
- Trauma (multisystem, extremity)
- Dermatologic disease
- Physical conditioning
- Diaphoresis, hyperhidrosis
- Hypoxia
2) MECHANICAL
- Constricting or wet clothing
- Tight boots
- Vapor barrier, neoprene liners
- Inadequate insulation
- Immobility or cramped positioning
3) PSYCHOLOGICAL
- Mental status
- Fear, panic
- Attitude
- Peer pressure
- Fatigue
- Intense concentration on tasks
- Hunger, malnutrition
- Intoxicants
4) ENVIRONMENTAL
- Ambient temperature
- Humidity
- Duration of exposure
- Wind chill factor
- Altitude and associated conditions
- Quantity of exposed skin area
- Heat loss (conductive, evaporative)
- Aerosol propellants
5) CARDIOVASCULAR
- hTN
- Atherosclerosis
- Arteritis
- Raynaud syndrome
- Anemia
- Sickle cell disease
- DM
- Vasoconstrictors, vasodilators
231
Define frostnip
superficial freezing injury manifested by transient numbness and tingling that resolves after rewarming
232
List s/s of frostbite
- numbness
- clumsiness/"block of wood" feeling
- anesthesia
233
List positive and negative features of rewarmed tissues
POSITIVE
- normal sensation
- warmth
- good colour
- soft pliable tissue
- clear blebs
NEGATIVE
- violaceous hue
- hemorrhagic blebs
- lack of edema formation
234
Define mild (superficial) frostbite and severe (deep) frostbite
Mild = no tissue loss
Severe = yes tissue loss
235
Outline Frostbite Classification
*Clinical staging using extent of cyanosis immediately after rapid thawing in warm water
GRADE 1
- Absence of initial lesion
- no amputation
GRADE 2
- Initial lesion on distal phalanx
- soft tissue amp
GRADE 3
- Initial lesion on intermediary and proximal phalanx
- bone amp
GRADE 4
- Initial lesion on carpal/tarsal
- predicts limb amp
236
List 6 NEUROPATHIC Sequelae of Frostbite and Nonfreezing Cold Injuries
Pain
- Phantom pain
- Complex regional pain syndrome
- Chronic pain
Sensation
- Hypesthesia
- Dysesthesia
- Paresthesia
- Anesthesia
Thermal sensitivity
- Heat
- Cold
Autonomic dysfunction
- Hyperhidrosis
- Raynaud syndrome
237
List 8 MSK Sequelae of Frostbite and Nonfreezing Cold Injuries
Atrophy
Compartment syndrome
Rhabdomyolysis
Tenosynovitis
Stricture
Epiphyseal fusion
Osteoarthritis
Osteolytic lesions
Subchondral cysts
Necrosis
Amputation
238
List 5 DERMATOLOGIC Sequelae of Frostbite and Nonfreezing Cold Injuries
Edema
Lymphedema
Chronic or recurrent ulcers
Epidermoid or squamous cell carcinoma
Hair or nail deformities
239
List 6 Systemic/Miscellaneous Sequelae of Frostbite and Nonfreezing Cold Injuries
Core temperature afterdrop
ATN = Acute tubular necrosis
Electrolyte fluxes
Psychological stress
Gangrene
Sepsis
240
List imaging techniques used for frostbitten pts being considered for thrombolytic therapy
CTA
MRA
Doppler US
Radionucleotide scanning
241
Name imaging technique most helpful in determining physial injury in frostbitten pediatric patients
MRI of developing hyaline cartilage
242
Outline 3 steps of ED Rewarming Protocol
1) Prethaw
- Assess Doppler pulses and appearance
- Protect part (no friction massage)
- Stabilize core temperature.
- Address medical and surgical conditions.
- Administer volume replacement as indicated.
2) Thaw
- Provide parenteral opiate analgesia prn
- Administer ibuprofen 400–600 mg (or aspirin 325 mg).
- Immerse part in circulating water at 37°C–39°C monitored by thermometer.
- Encourage gentle motion
3) Postthaw
- Dry and elevate.
- Aspirate or débride clear vesicles.
- Débride broken vesicles + apply topical antibiotic or sterile aloe vera ointment q6h
- Leave hemorrhagic vesicles intact.
- Administer tetanus prophylaxis if indicated.
- Provide streptococcal prophylaxis if high risk.
- Consider phenoxybenzamine in severe cases.
- Perform imaging, including angiography, if thrombolysis may be indicated.
- Carry out thrombolysis, if indicated and available.
- Obtain admission photographs.
243
Outline indications for thrombolysis in frostbite
Grade 3 or 4
(injury more proximal than IP)
- tissue has not undergone freeze-thaw-refreeze
- tPA w/in 24hrs of thawing
- no contraindications
244
Outline dosing for intra-arterial tPA and heparin in frostbite injuries
tPA 2-4mg bolus, then 0.5-1mg/hr
Heparin 500 u/hr
Tx stopped when perfusion restored or at 48h
245
Outline dosing for IV alteplase and enoxaparin in frostbite injuries
Alteplase 0.15mg/kg IV over 15mins,
then 0.15mg/kg/hr x 6hr
Then Enoxaparin 1mg/kg subcut q12h x 14d
* Use technetium-99m bone scan pre and post tx to evaluate for reperfusion
246
List 2 nonfreezing cold injuries
Immersion injury
Pernio
247
Define trench foot (immersion injury)
prolonged exposure (days) to wet cold at temperatures too high to cause frostbite
248
Define chilblains (pernio)
cold sores to face, dorsal hands + feet, pretibial area
form of cold injury that often follows repetitive exposure to cold in susceptible individuals
* or without exposure to cold in people with underlying autoimmune disease
ex) SLE
249
Outline 4 stages of immersion injury
1) During cold exposure
- numbness
- extremities pale or white 2/2 extreme vasoconstriction
2) During rewarming
- cold/numb to pain/edema
- extremities mottled blue
3) Hyperemia
- extremity hot/red, bounding pulses by slow cap refill
- severe pain/hyperalgesia
- edema, may have bullae or necrosis
4) Following hyperemia
- limb generally normal unless tissue lost
- pain may persist
250
List risk factors for pernio
- Young women
- Raynauds
- SLE
- APLAS = antiphospholipid antibodies
251
Name analgesia of choice for pain associated with immersion injuries
Amitriptyline 50-100mg PO qHS
252
Name medication of choice for treatment of severe pernio
Nifedipine 20-60mg PO daily
253
What is the max rewarming temp for nonfreezing cold injuries?
30 degC
254
List 2 goals in dealing with HazMat incidents
1) Contain the hazardous material
2) Evacuate exposed victims
255
List 5 chemical exposures where hydrotherapy is CONTRAindicated
Lithium
Potassium
Sodium
Lye
Phenol
256
Name 1 major electrolyte abnormality in hydrofluoric acid burns
Systemic hypoCa
257
List 4 categories of chemical weapons
Nerve agents
Vesicants
Choking agents
Cyanide
258
Define a hazardous material (HazMat)
a substance, including gases, solids, or liquids, that has potential to cause harm to people or environment.
259
Compare acidic and alkaline tissue injuries
Acid
- protein denaturation
- coagulative necrosis
- eschar formation prevents further tissue penetration
Alkali
- saponification
- liquefactive necrosis
- penetrates deeper into tissues 2/2 no eschar
260
Which HazMat pts require admission
- Systemic toxicity
- Significant opioid analgesia needs
- Require systemic antidote
261
List clinical features of ocular chemical exposure
- conjunctival injection
- chemosis
- cutaneous eyelid burns
- subconjunctival hemorrhage
- various degrees of vision impairment
262
Describe ocular irrigation
- Irrigate with tap water, LR, or balanced salt solution
- can utilize Morgan lens
- 2L of irrigation over 30 mins
- then test with litmus paper
- continue flushing until near or at pH 7.4
- Evert lids
- Slit lamp with fluorescence staining to look for corneal abrasion
- can utilize topical anesthetics
- +/- ocular antibiotics
- Topical corticosteroids = fluorometholone 1% or prednisolone 0.5% x 7d
- consult Ophtho
263
List one unique aspect of hydrofluoric acid injury
Despite being an acid, can cause liquefactive necrosis like an alkali
264
Outline clinical features of hydrofluoric acid injury
Metabolic:
- Free fluoride ions scavenge Ca, Mg = hypoCa & hypoMg
- Causes HyperK
Dermal:
- progressive tissue destruction
- intense pain out of proportion
- skin indurated, whitish, w/ vesicles
Cardiac:
- QT prolongation
- hTN
- Ventricular dysrhythmias
Inhalational:
- Pulmonary edema -> death
- ARDS
- delayed pneumonitis
Gastrointestinal:
- N/V
- Abdo pain
Ocular:
- penetration + necrosis of anterior chamber structures
265
Outline dx testing to do in suspected hydrofluoric acid exposure
K, Ca, Mg bloodwork
EKG
CXR for inhalation
Eye exam, slit lamp, fluorescein staining, visual acuities
266
Outline mgmt of hydrofluoric acid burns
- Copious irrigation w/ H2O x15-30min
- Debride blisters, remove fingernails affected
- Apply 2.5% CaGluconate gel topically, put a latex glove over the hand to secure
- Infiltrate deeper burns w/ equal mixture of 5% CaGluc + 0.9% NS using 27g needle subcutaneously
- IV or Intrarterial infusion of 10% CaGluc 10mL + NS 50mL over 4h
- Consider regional anesthesia for pain control
- Call for surgical consult
267
What is the time frame for preventing tissue necrosis after hydrofluoric acid burn?
W/in 6hrs
268
Outline mgmt of hydrofluoric acid respiratory exposures
- Prompt airway control
- ETT if needed
- CaGluc 2.5-5% sol'n nebulized
- Epi or Salbutamol neb for bronchospasms
269
Outline mgmt of hydrofluoric acid ocular exposures
- Copious irrigation w/ H2O or NS
- Use of hexafluorine after irrigation
270
Outline clinical features of formic acid exposure
- cutaneous injury by inducing coagulative necrosis
- systemic toxicity occurs after absorption
- metabolic acidosis
- GIB
- bowel perforation
- hemolysis
271
Outline mgmt of formic acid exposure
- Copious irrigation
- Tx acidosis (pH <7.3) w/ NaHCO3
- Mannitol to expand plasma volume & promote osmotic diuresis if hemolysis
- Folinic acid to convert Formic to CO2 + H2O
- Hemodialysis
- Exchange transfusion for refractory cases
272
Outline clinical features of anhydrous ammonia exposure
- stored at temps -33degC = tissue necrosis + frostbite
- chemical burns by liquefaction necrosis
- inhalation = proximal airway damage
- ARDS
- conjunctivitis
- full tissue loss
273
Outline mgmt of anhydrous ammonia exposure
- Copious irrigation
- Airway protection + intubation w/ large bore tube
- Burn centre admission
274
Outline 3 types of cement burns
1) Chemically abrasive
- most common
2) Heat-related
3) Blast-induced
275
Outline mgmt of cement burns
- remove all contaminated clothing
- copious irrigation
- Plastic Surgery consult
276
Outline clinical features of Phenol & derivative exposures
(Carbolic acid)
- Concentration inversely related to depth of burn
- coagulative necrosis
- CNS toxicity = lethargy, seizure, coma
- Cardiac toxicity = tachy or brady
- hTN
- Hypothermia
- Metabolic acidosis
277
Outline mgmt of Phenol & derivative exposure
- WIPE skin w/ low molecular weight PEG, or Isopropyl Alcohol
- Irrigation with LOW FLOW/PRESSURE water
- fast flow, rubbing, wiping can make things WORSE
278
Outline clinical features of phosphorus exposure
- corrosive acid = exothermic rxn = thermal burn
- partial-full thickness chemical burn
- HypoCa + HyperPO4
- Bradycardia, QT long, ST/T changes
WHITE PHOSPHORUS:
Toxicity in 3 stages
1) GI tract irritation 8-24hr
- n/v/d
- abdo pain
- GI hemorrhage
- garlic-like odorous stool w/ smoking appearence
2) Latent 1-3d
- symptoms seem to improve
3) Multisystem organ failure
- hepatic, renal, CNS depression
279
Outline mgmt of phosphorus exposure
- remove contaminated clothing
- submerge injured skin in cool H2O
- Irrigate burned skin w/ NS
- Can use UV light/Wood's lamp to see where particles remain
- Burn surgeon consult
280
Outline mgmt of thermal burns from asphalt exposure
- polymyxin-neomycin-bacitracin ointment applied, removed and reapplied q1hr
281
Outline mgmt of thermal burns from hot tar exposure
TAR adheres to HAIRS on skin, not skin itself
- Add COLD H2O at scene of exposure to wash away
- Then warm pt w/ towels to prevent systemic hypothermia
- In ED, use surface-active agents to remove, polymyxin-neomycin-bacitracin ointment
- Can also use Sunflower oil, Baby oil, Mayo, takes 30-90mins to remove
282
Outline clinical features of chlorine gas exposure
Upper + Lower airway edema
Wheeze, cough, dyspnea
Acute lung injury or ARDS
283
Outline clinical features of phosgene gas exposure
Cough
Chest tightness
Dyspnea
Delayed pulmonary edema
N/V/D
Abdo pain
Coma
hTN
Renal failure
284
Outline mgmt for chlorine gas exposure
Remove person from exposure
Irrigate eyes
Protect airway/ETT prn
Nebulized NaHCO3
Supportive care
285
List 5 Nerve Agents that can be Weapons of Mass Destruction, and their Treatment
Tabun (GA)
Sarin (GB)
Soman (GD)
Cyclosarin (GF)
VX
- Atropine + Pralidoxime (2PAM)
286
List 5 Vesicants that can be Weapons of Mass Destruction, and their Treatment
Mustard gas, sulfur mustard (H)
Distilled mustard, sulfur mustard (HD)
Nitrogen mustard (HN1, HN2, HN3)
Lewisite (L) = Arsenic based
Phosgene oxime (CX)
- Hydrotherapy
- Moist dressing on blisters
- Supportive care
287
List 4 Choking Gas/Pulmonary Intoxicant Agents that can be Weapons of Mass Destruction, and their Treatment
Phosgene (CG)
Chlorine (CL)
Military smoke (HC)
Chloropicrin (PS)
- Supportive care
- 'choking' related to pulmonary edema
288
List mgmt/tx options for Cyanide agent toxicity
ABCs:
- airway protect & oxygenation
- antiarrhythmic meds for dysrhythmias
- NE for hTN
Decontamination:
- Remove pt from exposure
- Brush off Cyanide Salts from skin
- Irrigation of skin
Antidotes:
CYANO-KIT = Hydroxocobalamin 5g IV over 15min, can repeat x1
- 70mg/kg in peds
- pt's skin turns red colour
- urine is red/purple
Cyanide Detoxification:
Sodium thiosulfate 12.5g IV (250mg/kg in peds) IV x1
- consider if severe
- in separate IV line from Cyanokit
----------------------
MetHgb Inducers:
- Amyl nitrite (inhaled w/ EMS)
- Sodium nitrite 300mg IV over 2min
Don't give nitrites in fire-victims
289
Outline pathophysiology of Nerve Agents
- Prevent Acetylcholinesterase from breaking down ACh
- ACh builds up in the synapse
- Massive effect at Muscarinic receptors = Excess secreations + Smooth muscle contractions
290
Outline clinical features of Nerve agent toxicity (Sarin)
DUMBBELS:
Diarrhea
Urination
Miosis
Bronchoconstriction
Bronchorrhea
Emesis
Lacrimation
Salivation
or
SLUDGE:
Salivation
Lacrimation
Urination
Defecation
Gastrointestinal Emesis
- basically wet everywhere
+ Nicotinic = Muscle fasciculations & Weakness
291
Outline mgmt/tx of nerve gas exposures
Decontamination:
- Remove clothing
- Large-volume, Low-pressure irrigation w/ H2O
ABCs:
- Airway protection prn
Reversal:
- Atropine 2mg IV q5min to desired effect (drying bronchorrhea)
- Pralidoxime 30mg/kg (max 2g) IV over 30min, then 8-10mg/kg/hr (max 650mg) IV infusion
Supportive care:
- Benzos/Lorazepam 1-2mg IV for seizures
Dispo:
- 6hr observation then home
- ICU admit for severe
292
Outline clinical features of mustard gas (vesicant) expsoure
- manifestations occur several hours to days after exposure
- people smell like garlic
Dermal:
- burning, itching, erythema
- hyperpigmentation, vesicle formation, bullae
GI:
- N/V
Heme:
- myelosuppression
- leukopenia, thrombocytopenia
Resp:
- mucosal damage
- bronchiolar damage, hemorrhage
293
Outline mgmt/tx of vesicant exposures
Decontamination:
- Remove pt from environment
- Remove clothing
- Irrigation of skin w/ alkaline hypochlorite solution, or diluted household bleach
- Avoid irrigating open sores/skin
Antidote:
- BAL/Dimercaprol for Lewisite, NOT for Mustard
294
Outline pathophysiology of cyanide
= Cellular toxin
- binds Fe2+ and Cobalt
- inactivates enzyme Cytochrome Oxidase
- therefore inhibits Oxidative Phosphorylation
295
Outline clinical features of Cyanide poisoning
- Smells like Bitter Almonds
- Sudden CV collapse
- Coma
- Profound Metabolic Acidosis
- Lactate >10
- O2 unable to be used by cells, so PvO2 is relatively HIGH
- Pulse Ox reading may be normal
- Shortened QT
- T on R phenomenon
296
List clinical features of CO poisoning
MILD:
- HA
- Nausea/Vomiting
- Dizziness
- Myalgia
- Confusion
SEVERE:
- AMS
- Seizure
- Coma
- hTN
- Cardiac arrest
- Metabolic acidosis
DELAYED:
- Neuro effects
- Focal deficits
- Seizure
- Apathy
- Memory deficits
297
List 2 risk factors for development of delayed neurologic sequelae after CO poisoning
Extremes of age
Loss of consciousness
298
Outline tx of CO poisoning
1) 100% O2 therapy to reduce half-life of COHgb
- takes 5hr @ room air
- 1hr @ 100% O2
- 30min @ 3atm HBOT
2) Prevent delayed neuropsychiatric sequelae
= primary indication of HBOT
- efficacy decreases if delyaed >6hr after exposure to CO
299
Outline Recommendations for Hyperbaric Oxygen after CO Exposure
COHb independent of clinical findings:
- >25% w/ normal clinical findings
- >15% in pregnancy or fetal distress
OR
Elevated COHb w +1 of following findings:
- Syncope
- Coma
- Seizure
- Altered mental status (GCS <15)
- Confusion
- Abnormal cerebellar function
- Prolonged CO exposure w/ minor clinical findings (“soaking”)
---------------
Probably MI or Dysrhythmias too
300
In smoke inhalation victims, outline 5 indications to give Cyano-Kit or Sodium Thiosulfate
- Coma
- hTN
- Severe acidosis
- CV collapse
- Cyanide poisoning cannot be rapidly excluded
301
List imaging studies to identify FB in the orbit or globe
XR - AP + Lat
CT orbits
U/S
302
Outline 3 options for a pt w/ critical airway obstruction & impending or actual respiratory arrest
1) Forced expulsion of foreign body
2) Laryngoscopy or Fibre-optic scope w/ attempted manual removal w/ Magill forceps
3) Control the airway
- Cricothyroidotomy to bypass an obstruction
- Intubation to push foreign body distally into right mainstem bronchus
303
Outline 3 areas where esophageal FBs are most likely to get stuck
1) Proximal esophagus at level of cricopharyngeal muscle & thoracic inlet
- @ Clavicles on XR
2) Midesophagus at level of aortic arch & carina
3) Distal esophagus just proximal to esophageal-gastric junction
- @ 2-4 VBs above gastric bubble on XR
304
List 5 pt populations at higher risk for FBs
- Neurologically impaired
- Edentulous individuals
- Pts w/ certain psychiatric diagnoses
- Incarcerated individuals
- Extremes of age
305
Outline 2 areas where FBs in the otic canal are most likely to get stuck
1) near inner end of cartilaginous portion of the canal
2) point of bony narrowing called the isthmus
306
List 7 complications of otic FBs
- External ear canal bleeding
- Otitis externa
- Tympanic membrane perforation
- Chronic otitis
- Hearing loss
- Facial palsy
- Mastoiditis
307
Describe penetration syndrome, as it relates to airway FB
Choking sensation accompanied by wheezing & coughing
308
List 4 CXR findings of airway FBs
1) Unilateral hyperinflation
- on expiratory views
2) Subglottic space narrowing
3) Atelectasis
4) PNA (later)
309
List 9 complications of prolonged impaction time of esophageal FBs
- Esophageal erosion
- Esophageal perforation
- Tracheal compression
- Mediastinitis
- Esophagus-to-airway or Esophagus-to-vascular fistulae
- Spondylodiskitis
- Extraluminal migration
- Abscess development
- Formation of strictures or false esophageal diverticula
310
List 2 medications to manage esophageal FBs
Glucagon 0.5-2mg IV
Nitroglycerin 0.4mg tab dissolved in 10cc H2O
311
List 2 sites in the GI tract (distal to esophagus) where FBs can become impacted
Gastric outlet
Ileocecal valve
312
List 3 U/S findings of soft tissue foreign bodies
1) Hyperechoic foci (most common)
2) Posterior acoustic shadowing
3) Halo sign indicating infection (fluid around FB)
Rosen's 10th
flashcards
Decks in class (23)
# Cards
-
Toxicology346
-
General3
-
Electrolytes, Metabolism, Endocrine, & Rheum197
-
Pediatrics207
-
GI258
-
Ortho394
-
Infectious Disease389
-
Trauma312
-
Psych89
-
Enviro313
-
Cardiovascular475
-
Respiratory157
-
Neuro418
-
Ophtho139
-
OBGYN + Urology316
-
Nephro24
-
Heme/Onc168
-
Dermatology116
-
Resuscitation146
-
Head & Neck94
-
Bonus Chapters107
-
Special Populations & Geriatrics49
-
Hard Stuff/High Yield93
