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Environmental Flashcards

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1
Q

What are the post intubation priorities in drowning

A
  1. protective lung ventilation and oxygenation - VQ mismatch likely, prevetion of secondary brain injury from hypoxia or hypercarbia
  2. cardiovascular support and fluid as likely cold diuresis and arthymias
  3. rewarm to 34 and prevent shivering to prevent organ dysfunction from hypothermia
  4. disposition planning or retrieval
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2
Q

what is the pathophysiology of acute mountain sickness/high altitude cerebal oedema?

A

vasogenic cerebral oedema as hypoxia causes cerebral vasodilation and increased blood flow
Leaky BBB due to loss of autoregulation and increased permiability

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3
Q

What is the pathophysiology of high altitude acute pulmonary oedema?

What are the risk factors?

What is the treatment?

A

non cardiogenic, hydrostatic oedema
pulmonary vasoconstriction which is widepsread but patchy. this heterogeneity causes diversion to less constricted areas and therefore leaky

Risk factors:
* rapid ascent
* genetics
* exertion
* cold
* pre existing pulmonary hypertension
* sleeping medication

Treatment
* immediate descent
* oxygen
* minimise exertion
* CPAP
* nifidine

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4
Q

What are the clinical features of acute mountain sickness?

A
  • headache worse on bending over
  • anorexia/nausea/vomiting
  • weakness and irritability
  • fluid retention
  • retinal haemorrhages
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5
Q

What is parklands formula?

A

estimates fluids to be given over first 24 hours in burns in ml

%TBSA x 4 x kg

Children 3-4

Half in 8 hours

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6
Q

What is the wallace rule of 9 for burns

A
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7
Q

what are the key features of an examination post drowning

A
  • evidence of other injuries eg c spine
  • temp
  • signs of lung injury/aspiration
  • neurological deficit
  • signs of poor perfusion
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8
Q

how would you prepare the department for a paeds drowing?

A
  • assemble adequate staff, give handover/what is known to team
  • prepare resus bay with paeds equipment including wamer, IO, paeds cannulas etc
  • clearly defined team roles
  • notify anesthetics/paeds
  • prepare drugs eg 20ml/kg fluid, adrenaline 0.1ml kg of 1:10000
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9
Q

when should resus caese following drowning?

A

serum K over 11/lactate I compatible with life
one hour of asystole/apnoe
No cardiac output on echo
One hour post becoming normothermic

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10
Q

what is the conn and modell classification for neurological dysfunction in drowning?

A

A- Awake
B - conscious but obtunded
C - Comatose and can be C1-C3 flex to pain/extend to pain/flaccid

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11
Q

list three diving related causes of confusion at depth

A

nitrogen narcosis
hypoxia eg breathe holding
oxygen toxicity
contaminated gas

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12
Q

what are the differentials and signs of vomiting and ataxia after a rapid diving ascent?

A

**DCI **- delayed onset after exiting water, joint and skin symptoms
Aterial gas emboli - immediate onset, stroke sx. pneumothorax/mediastinum
vestibular dysfunction - nystamus, signs of peripheral vertigo

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13
Q

what are three relatie contraindications to air retrieval post dive injury?

A

DCI or CAGE due to boyles law
intra cranial or spinal air
combative patient
other air if not decompressed eg bowel perf

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14
Q
A
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15
Q

what are two differentials for rash post diving?

A

contact dermatitis from wetsuit
Cutis marmorata - cutaneous decompression illness

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16
Q

what are some risk factors for decompression illness

A
  • increased dive duration
  • multiple dives
  • dehydration
  • strenuous exercise post dive
  • ascent to altitude post dive
  • smoking
  • obesity
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17
Q

what are the advantages or disadvantages for flying to hyperbaric chamber?

What are the key things needed to be done for helicopter transport?

A

advantages
* quick
* direct transfer between hospitals
* less turbu;ence if fixed wing

disadvantages
* helicopters cant be pressurised and requies ascent
* vibration and cold may worsen DCI
* cant fly at night and in certain conditions if helicopter

key things
* fly at sea level
* high flow o2
* lay flat
* go to decompression chamber
* delay leads poorer outcomes

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18
Q

list 5 body systems affected by DCI

A
  1. neuro - confusion, memory loss, LOC
  2. cardioresp- chest pain, hypoxia, APO
  3. MSK - myalgia, arthralgia
  4. skin - rash
  5. vestibular - ataxia
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19
Q
A
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20
Q

list some diving related pathologies that may occur shortly after ascent

A

Pneumothorax/mediastinum
Middle ear pathologies
Sinus pain
Arterial gas embolism esp cerebral
Tooth pain
Abdominal cramps

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21
Q

describe wound

A

deep full thickness burn to plantar aspect of foot
depressed central area
darkened skin

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22
Q
A

AC more dangerous than DC we can’t detach

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23
Q

electric shock

25
what are the types of lightening strike
direct - direct strike to victim contact - from object holding to victim side flash - hits nearby object and transfers to person
26
what features are pathognominic with lightening strike? Other features
**Lichtenberg figues** - feathery cutaneous burns **keraunoparylysis** - temp lower limb paralysis with vascular spasm. flaccid, loss of sensation, mottled with no pulses **Other** delayed cataracts tympanic membrane rupture asystole due to massive depolarisation neuro deficits - flaccid paralysis, confusion, amnesia
27
what are the indications for use of telemetry in electrical injury?
LOC seizures ECG changes previous cardiac disease burns
28
1. safe approach - scene safety 2. trauma assessment 3. humanitarian - analgesia/anaesthesia 4. plan the destination eg burns centre 5. fluid and temp management
29
What are the limb and systemic complications of electric shock?
**Limb** * vasospasm/thtombus * compartment syndrome * avulsion fractures and pain at entry site * trauma from being thrown **Systemic** * cardiac arrhymias * rhabdo * traumatic injury * seizures/loc/coma * skin burns
30
What are some clinical complications associated with drowning
Pulmonary: Chemical Pneumonitis, Atelectasis from surfactant loss, ARDS Hypothermia Hyponatremia Hypoglycaemia Cerebral: Seizures, Hypoxia, Persistent coma
31
name four groups at risk from high temperature
**elderly** - co-morbid, polypharmacy eg diuretics **young** - cant phyisically escape hear eg in car, rely on others **obese** - poor thermoregulation, cant access services **crazy** - lots of meds with impact on cooling and may not actively cool eg on meth **poor** - no air con, cant access services
32
what is the triad needed for heatstroke?
core temp over 40 CNS dysfunction anhydrosis
33
what are the pros and cons of three cooling methods?
34
what are the important history and examination features of someone collapsing in heat from sport?
**history** * normal health - meds, allergies etc * events around collapse - did people see, sudden CP etc * current symptoms - headache/confusion **Examination** * Vitals, esp temp * neuro exam - ?bleed or sign of UMN dysfunction * CV - arrhtymia or dysryhtmia * other injuries
35
collapse post run
Midazolam - 5mg IV hypertonic saline - IV 2-3ml/kg over 10 minutes
36
what are the complications of heat stroke?
* confusion, seizures, cerebral oedema * Rhabdo * pulmonary oedema and shock * AKI from rhabdo * ARDS * DIC * electrolyte derangement
37
initial treatment with endpoints
**rehydration -** cool fluids 20ml/kg to maintain adequare circulating blood volume **urgent cooling **- various methods **support airway **- consider adjuncts monitoring - bsl, rectal probe, ecg consider other causes eg sepsis, ich, snakebbite
38
collapse after marathon - most important abnormalities and significance
High Ur/Creatinine - acute renal impairment High CK - rhabdomyolysis High K+ - ARF/muscle breakdown Elevated Hb - Dehydration Elevated WBC - Dehydration/infection Low plt - tcp/DIC/coagulopathy
39
name four complications of heat stroke from separate organ systems
Seizures **renal** rhabdo and and renal failure **cardiac** - heart failure and tachyarrhtymias **resp **- ARDS **haem** - DIC Liver failure
40
list the four types of heat related illnesses and their criteria
**Heat stroke **- temp over 40, CNS dysfunction and anhydrosis **Heat exhaustion** - any heat related illness with volume depletion but normal mental state **heat cramps** - painful involuntary skeletal muscle cramps **prickly heat** - pruritic, erythematous, maculopapular rash
41
remove from heat cooling cautious hydration (pulmonary odema) check metabolic function seek and treat complications consider intubation
42
what investigations would you perform?
x EUC – Low Na, High K, Impaired renal function x CK – High risk muscle damage and rhabdo x Coags/LFTs – Risk of DIC x BSL – Metabolic derangement x UA – Myoglobinuria x ECG – Cardiac arrhythmias x Ongoing core rectal temp
43
how do you define a heat wave?
3 days or more or high maximum and mininum temperatures that is unusual for that location
44
what drug classes increase chance of heat related illness?
**interference with sweating **- beta blockers, anti cholinergics, anti histamines **interference with thermoregulation** - antipsychotincs, cocaine, meth **decreased thirst -** ACEI **dehydration and electrolyte imbalance** - diuretics, alcohol **reduced renal function** - ACEI, NSAIDS
45
What are the ECG changes for hypothermia
bradycardia osborne/j waves very long QT shivering artefact slow af
46
what are the supportive care measures in hypothermia
* core temp measurement * pressure areas if on floor for a long time * treat underlying cause eg sepsis, ICH * airway mangement * careful handling due to risk of VF
47
VF arrest in hypothermia - what are the deviations away from standard ALS protocol?
* withold defibrillation until over 30 degress * withhold drugs until over 30 degress and then double interval between doses * extend CRP until patient warm then one hour after * hero measures - early ECMO NB aggressive rewarming likely resistance to shocks and drugs high chance of electrolyte dysfunction
48
list the organ complications of hypothermia
Resp - aspiration, resp depression Cardiac - bradyarrtyhmias, VF CNS - decreased LOC Renal - AKI/rhabdo Haem - DIC metabolic acidosis pancreatitis
49
what are the pros and cons of intubation with hypothermia eg for CT
**Pros** * protects airway from aspiration * facilitates rapid rewarming * correction of resp component of acidosis * optimeses oxygenation * optimal conditions for good CT images - still patient **Cons** * high risk of arrhtymia with manipulation of airway * modified drug therapy - slow onset, prolonged action * resource heavy * could avoid if correct temp in short term
50
differentials for low temp and low GCS
hypothermia hypoglycaemia seizure ICH cold sepsis drug overdose
51
what do you get with acute radiation sickness?
**1 - Haematopoetic bone marrow suppresion -** bleeding fatgiue and immune suppresion. treat with stem cell transplant and GCSF - good prognosis **2 GI **- vomiting, fever, diarrhoea - treat as normal - 50% mortality **3 Cerebral/vascular** - capillary leakage, CV collapse, coma and cerebral oedema - death
52
what are the burn patterns with lightening?
Linear skin folds Lichtenberg Thermal injury eg heat
53
alterations for rescue with lightening
reverse disaser triage dont use pupils unreliable motor response
54
what are the types of rewarming?
* Passive external warming - remove wet clothes, blankets, warm room * Active external warming - heating fans, warm baths * Active Internal - warm fluids, endovascular rewarming, ECMO
55
compliations of rewarming
hypoglycaemia ventricular arrthymias hyperthermia thermal burns electrolyte disturbance
56
What are the three types of altitude sickness?
**Acute mountain sickness **- headache, nausea, vomiting fatigue - usually occues in first day and resolves within 1-3 days if not ascending **High altitude cerebral oedema **- severe hedaches, ataxia, confusion, coma, death - ascend, oxygen, CPAP, nifidipine **High altitude pulmonary oedema** -SOB, chest pain, frothy cough. need to descent and oxygen
57
Thoracic lavage methid
Place two 32-36 F intercostal catheters: one anterior and one posterior lateral Use 3L bags of 40-42 C saline Use a Level 1 Fluid Warmer to pump warm fluids into the anterior chest tube (e.g. 180 mL/min) attach auto-transfuser or pleur-evac to posterior-lat chest tube to allow continuous emptying
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