Environmental - Environmental Emergencies Quick &...

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Unformatted text preview: Environmental Emergencies Quick & Dirty Points David Riley, M.D. Director of Emergency Ultrasonography & Resident Ultrasonography Resident Didactics Didactics Department of Emergency Medicine Medicine St. Luke’s Roosevelt Hospital Center Center Columbia University College of Physicians & Surgeons Physicians Six Main Areas 1. Diving Emergencies / Dysbarism 2. Electrical Injury 3. High Altitude Illness 4. Radiation Injury 5. Bites and Stings 6. Hot and Cold Injuries SCUBA Diving: Good clean fun! Diving Emergencies / Dysbarism Boyle’s Law: pressure and volume are inversely related Descent: high pressure=low volume: cavities get squeezed barotitis externa: cerumen traps air in EAC middle ear squeeze: classic triad=Meniere’s : tinnitus, deafness, vertigo sinus squeeze What is the problem here 100 feet under-something went wrong? Diving Emergencies / Dysbarism Descent: Nitrogen Narcosis = “Rapture of the Deep” partial pressure of nitrogen increases nitrogen has anesthetic properties euphoria - judgement loss - hallucinations then ultimately severe confusion and drowning begins at 100 feet below water = how many atmospheres is this? Diving Emergencies / Dysbarism Ascent: the top 33 feet are the most dangerous!!!!! 1 atm pressure=33 feet POPS= pulmonary overpressure syndrome: lung rupture due to expanding trapped gas; pneumothorax/mediastinum +/- tension CHOKES=emboli of gas to pulmonary vessels: pleuritic pain, cough, dyspnea Skin: ruptured skin blood vessels=purpura marmorata Diving Emergencies / Dysbarism Ascent: BENDS or Caison’s Disease= bubbles in joints LETHAL Volume of venous air= 100-150cc MOST COMMON & Dangerous site of arterial gas embolism = cerebrum: stroke / seizure; spinal cord: paralysis: delta MS presentation within 10 minutes of a too rapid ascent RX: HBO (also for CO>25 (NYC)) Electrical Injury Current (AMPS) is more important than Voltage AC is worse than DC AC entrance wound = exit wound DC entrance wound < exit wound (like a bullet) Oral commissure burns (#1-PEDS) = +/-ADMIT due to delayed labial artery bleeding Electrical Injury Electrical energy is converted to HEAT Increased tissue resistance = + or - heat? Tissue conduction: nerve>blood>tissue & muscle>fat>bone Household electrical current = AC 60 c/s “Let go current” = 20-30 mAmp Which current has the greatest risk of inducing V. Fib ? AC or DC ? What voltage exposure is an automatic ADMIT? ? Ie rd 3 Rail What voltage exposure is an automatic ADMIT? >600 Volts Electrical Injury Electrical injury with some current (220V) through the chest: can the patient go home? IF THE ECG IS NORMAL INITIALLY AND AFTER A 3-6 HR ED MONITORING PERIOD = DISCHARGE HOME Lightning Injury Massive DC electrical shock 30% mortality Cataracts Ruptured TM’s (Blast component) Motor Paralysis: pupils unreliable, diphragm dysfunction, hypoxia, myoglobinuria Skin: flash arborescent burns Lichtenberg Figures Due to a Lightning Strike Lightning Injury What if a patient in a disaster setting is in ASYSTOLE due to a lightning strike? Blast Injuries: ie from Lightning Type I: pulse of pressure-barotrauma: TM rupture is #1, pneumothorax=most serious, air embolism(rare) Type II: flying debris: penetrating trauma Type III: flying human: deceleration impact Type IV: toxic gases ie hydrogen sulfide= knock down gas, radiation, burns High Altitude Illness As the altitude increases the pressure decreases & PO2 decreases Temperature decreases 6.5 deg C/1000m & DRY UV penetration increases 4%/300m: Keratitis Ventilation increases: Hypoxic Ventilatory Response: resp alkalosis w/HCO3 excretion=bicarb diuresis & dehydration High Altitude Illness How does UV keratitis look after fluorescein application on slit lamp? High Altitude Illness Increased erythropoietin within 2 hrs Hct increases 5% over 20 days Bicarbonate diuresis + increased Hct = polycythemia (lasix can be lethal in HAPE) Hypoxia: increases 2,3 DPG & Hb O2 disociation right shift Sleep is disturbed PaO2 = 33 torr at 8840meter ( Mt. Everest ) High Altitude Illness SYNDROMES: Due to too rapid ascent Acute Mountain Sickness: SX >2000 meters: N/V, “flu”, decreased hypoxic ventilatory response: RX: What drug 24-48 hrs before ascent may lessen SX? HAPE=pulmonary edema: low partial pressure of O2 leads to pulmonary overperfusion & hydrostatic leakage of fluid in alveoli RX:O2, RAPID DESCENT #1, nifedipine may have a role to decrease the pulmonary HTN, NO STEROIDS High Altitude Illness HACE: cerebral edema: due to increased cerebral blood flow due to a reflex response to the reduced O2 saturation SX: HA, delta MS, N/V, ataxia, seizures, cranial nerve palsies (6th), 50%-papilledema RX: O2, STEROIDS (dexamethasone), RAPID DESCENT, possible mannitol, if no gag GCS=8=tube and hyperventilate PCO2=30-33, HBO Radiation Injury One Gray = 100 Rads Penetration alpha = superficial beta = 8mm penetration gamma = deep penetration & acute radiation poisoning MEDIAN LETHAL DOSE = 450 RADS Radiation Injury EARLY SYMPTOMS INDICATE A HIGHER DOSE AND WORSE PROGNOSIS Survival probable: <200 Rads GI SX: N/V/D = >100 Rads exposure Neuro SX: BAD = >800 Rads = death Radiation Injury Lymphocytes are most sensitive to radiation and the lymphocyte count at 48 hrs is a prognosis marker >1200 = very good prognosis 300-1200 = possibly lethal exposure < 300 = certain death Radiation Injury RX: ABC’s, determine exposure type & dose Decontaminate on scene Soap & water including hair w/ vigorous scrubbing = 95% decontamination MOST PATIENTS WHO DIE FROM RADIATION INJURY, EXCEPT IN HIGH DOSE CRITICAL CASES, DIE OF ? Bites and Stings: clockwise from the top right portion of the figure are a yellow jacket, honeybee, bumblebee, Polistes wasp, and two hornets Bites & Stings #1 KILLER ? Hymenoptera: Bees, Wasps, Ants, Hornets Toxic rxn: >10 stings, presensitization = anaphylaxis ( epi, benadryl, steroids, tagamet); SHOCK= 1:10, 000, 0.1mg IV epi Delayed Rxn: 2 wks later serum sickness Stings around the eye: catatracts, glaucoma Remove stinger by SCRAPING OFF What is the diagnosis? Yellow Jackets Bites & Stings TICKS RMSF: Dermacentor Andersoni, rash, HA Q Fever: influenza like illness Tularemia: rabbits Tick Paralysis: Killer; RX=remove the tick Babesiosis: protozoan/ splenomegaly Lyme disease: Ixodes tick-spirochete Boreliosis: HA, relapsing fever Ehrlichiosis: ricketsial, mono & granulocytic What is the Diagnosis? What is the Diagnosis? What is the Diagnosis? Brown Recluse Spider Brown Recluse Spider: dark violin top, delayed pain, ischemic necrosis, hemolysis; RX: no ice, dapsone, HBO, surgery, no antivenin Black Widow Spider Black Widow Spider: red hourglass bottom, two small puncture marks, immediate pain, N/V/cramps mimics appendicitis; RX: ice, calcium gluconate, anti-venin if neuro Sx, HTN, or severe pain Fire Ants What if you picked up this snakes cut off head after it was shot 30 minutes ago? Bites & Stings Crotalidae: = rattlesnakes, moccasins, copperheads; hemotoxic & neurotoxic, coagulopathy, DIC. How to ID?: bilat pits, triangle shaped head, single row of anal plates mild: swelling, erythema mod: N/V, tachy, mild hypotension severe: DIC (prol. PT, PTT, low platelets & fibrinogen), delta MS, hypotension,compartment syndrome risk RX: antivenin for mod-severe (10vials): New RX: CROFAB (both anti-neuro & anti-hemo toxins!) Which one would you want to bite you? Hint: ICU (delayed respiratory paralysis) vs. Go Home Bites & Stings: Coral Snake Elapidae: = Coral, cobra; severe neurotoxins BIG PROBLEM IS DELAYED AIRWAY PARALYSIS = ICU ADMIT HOW TO ID A CORAL SNAKE VS THE NON-POISONOUS KING SNAKE? Australian Brown Snake MARINE: Bites & Stings Puffer fish: Tetrodotoxin ascending paralysis FUGU chef Man put his hand in a fish tank and was stung by this fish; Rx: ? Which is the most lethal oyster for a liver cirrhosis patient? Warm water raw oysters: Gulf of Mexico, a good idea? Raw oysters w/ vibrio vulnificus especially in a patient with liver disease or immunocomprimise = lethal cellulitis and sepsis: MUST COVER WITH DOXYCYCLINE This is the last thing you want looking at you while swimming the coral reef!! What is it? Stone fish = life threating; RX: antivenin Hypothermia Case 29 y/o woman under the ice in Norway for 79 minutes EMS arrive & patient is clinically dead in asystole with a temp of 14.4C WHAT TO DO NEXT? Key Temperature: 30C / 86F Triggers active core rewarming Lose shivering mechanism J-waves on ECG Increased Risk of dysrhythmias What is the diagnosis? Chilblains / Pernio: itchy & tender Frostbite: what should be done with these blisters? What temperature do you start cooking yourself? 107.5 F You start denaturing your proteins at this temperature! RX: cool patient STAT ...
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