Weather Gone Wild
What is the clinical definition of heat stroke
Temp >40C + end organ injury
Most sensitive tissue- neural, hepatocytes, nephrons, and vascular endothelium
Often altered mental status- confusion, agitation, bizarre behavior, seizure coma along with oliguria, nausea/vomiting, diarrhea, hyperventilation.
This venom from this snake pictured is known to cause what symptoms
Respiratory paralysis, seizure, bulbar palsies
coral snake- produces neurotoxin- treat with 3-5 vials of anti-venom M. fulvius
Manage with supportive care- respiratory eval- NIF, Vital capacity
In a trauma patient with borderline blood pressure, this commonly used prehospital intervention can worsen mortality by increasing intra-thoracic pressure and reducing venous return
Positive pressure ventilation (especially aggressive BVM or early intubation)
In a MCI, START triage, a patient with respiratory rate >30 is assigned this category
Immediate (Red)
A patient pulled from a house fire has normal SpO₂ but is confused and tachycardic
Carbon monoxide poisoning
Administer 100% O2, decision for hyperbarics is made clinically and in conjunction with carboxyhemoglobin levels
How should you rewarm a patient with frostbite
Circulating warm water
Should use circulating warm water 37C-39C for 20-30minutes until tissue is pliable
Debridement of blisters is controversial. Apply Aloe Vera q6H. Give Tdap. No clear guidance on empiric abx
Make sure to obtain/monitor these blood tests after a Pit viper bite
PLT, Coags, fibrinogen
In addition to local wound edema and tissue necrosis, venom from pit vipers or crotaline snakes can cause hematologic disorder such as thrombocytopenia, coagulopathy, hypofibrinogenemia
A patient with severe asthma is intubated in the field and becomes hypotensive shortly after—this is most likely due to this physiologic mechanism
Dynamic hyperinflation leading to decreased venous return (auto-PEEP)
You are triaging in the ER during an MCI. A patient is found walking, speaking, and bleeding from a large forearm laceration after a building collapse. In START triage, their initial classification is this.
Minor (Green)
A previously healthy young adult collapses during exertion in hot weather. They are tachycardic, confused, and stop sweating. Cooling is initiated, but they develop bleeding from IV sites.
Exertional heat stroke with early coagulopathy/DIC
Last stage of heat stroke is coagulopathy/DIC development
What are 3 methods of management for Acute Mountain sickness
Descent, oxygen to relieve symptoms, acetazolamide, dexamethasone
Acute Mountain Sickness- caused by hypoxia from high altitudes- cerebral vasodilation, capillary leak, and cerebral edema
Decrease in altitude of 300-1000m should provide symptom relief
A patient presents with a bug bite with diffuse muscle aches and spasms. You see a circular targetoid lesion with two small bite marks. What is the likely culprit?
Black widow- can cause muscle fasciculations, HTN, headache, N/V, can rarely cause
-manage with supportive care- pain meds, benzes for muscle spasm
-Lacrodectus antivenom for severe cases refractory to supportive care
In suspected tension pneumothorax, this commonly taught landmark has a higher failure rate due to chest wall thickness
2nd intercostal space, midclavicular line
A patient taken from an explosion site develops hypoxia. There is no signs of external chest trauma. What is the mechanism?
Primary blast lung injury (alveolar hemorrhage/barotrauma)
- can cause things like PTX, air embolism, pulmonary contusion, treat like ARDS on ventilator
A patient is airlifted to you from a mountain climb. It was their 3rd night on the mountain. They are tachypneic, tachycardic, cyanotic.
High Altitude Pulmonary Edema
Usually occurs days 2-4 at high altitude- progressives from dry cough to resting dyspnea
Manage with descent with minimal exertion of patient, O2 supplementation
What are the three most common EKG changes during hypothermia
Bradycardia, J point elevation (Osborn waves), and QT prolongation
Can also see PR and QRS prolongation.
56-year-old man with a history of cirrhosis presents to the emergency department with severe left lower extremity pain that began 8 hours ago after he cut his leg while cleaning fish at a coastal dock. He reports rapidly worsening pain “out of proportion” to exam findings, fever, and confusion. What bacteria must you cover for?
Vibrio
Commonly called fish-handler’s disease- more likely to infection immunocompromised individuals and those with liver disease
Cover with 3rd gen cephalosporin or fluoroquinolone
Prehospital administration of large-volume crystalloids in hemorrhagic shock worsens outcomes primarily due to this physiologic effect
Dilutional coagulopathy
A chemical attack is launched on your city. Patients are presenting with painful skin and mucous membrane blistering, conjunctivitis, and later respiratory complications. What is the most likely agent used?
sulfur mustard (mustard gas)
Early management includes decontamination and supportive care
After prolonged extrication, a trauma patient arrests shortly after being freed. What happened and describe the mechanism
Crush syndrome with re-perfusion injury
When blood returns to muscle that has been crushed and ischemic for prolonged period, the locally accumulated potassium, myoglobin, phosphate CK, organic acids go into systemic circulation and can cause organ failure/arrest
A worker at a lithium battery production plant presents with a chemical burn. How should this be irrigated and managed?
Irrigation with mineral oil- avoid water as it can cause an exothermic reaction- Metal + H₂O → metal hydroxide + hydrogen gas + heat
What is the management of a sting from this creature?
Hot water immersion, irrigation with sea water
Topical lidocaine and corticosteroid can also be helpful. Make sure to remove all tentacles from the skin
An agitated trauma patient with declining mental status is restrained and sedated; the most dangerous missed diagnosis in this scenario is this.
Hypoxic/hypercarbic respiratory failure
TBI-related hypoventilation, tension PTX, pulmonary contusion
There is an explosion at a large chemical plant. Exposed patients are brought in with miosis, bronchorrhea, and bradycardia. What is the management of this toxidrome?
Atropine plus pralidoxime for organophosphate poisoning
Organophosphates overstimulate nicotinic and muscarinic Ach receptors- Atropine blocks the muscarinic receptors to reverse hypotension/bradycardia and bronchospasm/bronchorrhea
Pralidoxime reactivates acetylcholinesterase by removing the organophosphate from the enzyme- this helps with nicotinic effects of muscle weakness and paralysis
You are an ER doc on the Cayman Islands. A patient is brought in by EMS with AMS, reportedly had a seizure en route. He is wearing a diving suit. On exam you notice he is hemiplegic. What likely happened and what is the mechanism?
CAGE- cerebral arterial gas embolism- barotrauma during ascent causes alveolar rupture, arterial air emboli, brain ischemia
As you ascend ambient pressure drops (Boyle’s Law), therefore gas in the lungs expand. If the diver holds their breath or has an air trapping disease like asthma COPD this will rupture alveoli—> air enters pulmonary capillaries—> pulmonary veins—> left heart and arterial circulation