Environmental Exposure
Lyme disease
RMSF
Mountains
Bites
100
Cold Water Shock is more likely to cause initial...
- metabolic acidosis
- metabolic alkalosis
- respiratory acidosis
- respiratory alkalosis
Respiratory Alkalosis
Sudden exposure to cold water causes reflexive:
Involuntary gasp followed by hyperventilation
Developing Resp Alkalosis and resultant muscle tetany and cerebral hypoperfusion
Hyperventilation and muscle dysfunction lead to drowning before hypothermia develops
100
The most common Tickborne disease is?
- Rocky Mountain Spotted Fever
- Anaplasmosis
- Lyme Disease
- Babesiosis
- Ehrlichiosis
Lyme disease
- Each year 30,000-40,000 cases of Lyme disease are reported to the CDC
- ~500,000 people/year are diagnosed and treated for Lyme.
100
Which of the following ticks is not a known vector for RMSF?
- Wood Tick
- Black-legged Tick
- Common Brown Tick
- American Dog Tick
- Wood Tick --> RMSF
- Black-legged Tick --> Lyme
- Common Brown Tick --> RMSF
- American Dog Tick --> RMSF
100
Name 4 symptoms associated with Acute Mountain Sickness.
Headache, Dizziness, Ataxia, Nausea/Vomiting, Altered Mental Status, Anorexia, Sleep Disturbance, Peripheral Edema, Tachypnea, Fatigue.
100
Patient is bitten by a spider, then develops regional LAD, abdominal rigidity, agitation, myalgia's, tremors, and muscle spasms.
What North American spider is most likely to have caused this?
Black Widow
200
What is the name of this ECG abnormality, seen with Hypothermia?
Osborn "J-wave"
200
This classic rash associated with Lyme disease is called?
Erythema migrans
200
Which of the following is true of diagnosis and treatment of RMSF?
- Start treatment immediately once diagnoses of RMSF is suspected.
- In a patient with fever, headaches, arthralgia with risk of RMSF exposure, wait until rash develops, then initiate treatment at that time as this clinically confirms diagnosis.
- Obtain labs ASAP in suspected diagnosis, initiate treatment immediately once lab confirms diagnosis.
- In patients <8 years old with suspected RMSF, await PCR/culture results as Doxycycline can cause permanenet tooth damage.
Start treatment immediately with Doxycycline in ALL PATIENTS with suspected RMSF. 20-25% of patients will die if you waited for lab results to come in to confirm diagnosis.
200
Which of the following is the most common reason for development of High Altitude Cerebral Edema (HACE)
- Poor aerobic fitness at baseline and leading up to the trip.
- Inadequate acclimatization, ascending too high too fast.
- Patient is >60 years old
- Patient lives at sea-level
Inadequate acclimatization, ascending too high too fast.
Level of fitness, Age, and Gender have minimal to no effect on risks for HACE.
200
A patient is bitten by a spider and monitors the bite site for 10 days, the bite initially blistered then became black/necrotic (~10% of cases) before gradually healing.
What North American spider likely caused this and what is the treatment for this bite? Anti-venom vs Symptomatic
Brown Recluse, treatment is symptomatic
300
Which of the following is preferred method for re-warming a frost bite injury?
- Placing patient in a warm bath maintaining water temperature of 98-108 degrees.
- Avoid removing any clothing even if constrictive or damp to avoid further environmental exposure.
- Utilizing radiant heat from fire or other heat source.
- Massage the affected extremity and work extremity with passive ROM.
Rewarming Strategies:
- Using a circulating water bath at a temperature 37-42C (98-108F)
- Rewarm until skin is pliable and erythematous to the tips
- Allow active ROM but DO NOT massage or passively move
- Avoid use of radiant heat such as fire
- Do not re-warm if there is risk of re-freezing. Do not re-warm if patient is going to need to be transported.
300
Which of the following patients is most likely to benefit from PEP following a tick bite?
- A rounded, engorged tick was found and removed 5 days ago from a patient bit in NY
- A flat, non-engorged tick was removed 24 hours ago from a patient bit in NY
- A rounded, engorged tick removed 24 hours ago from a patient bit in Colorado
- None of these patients are likely to benefit from PEP
None of these patients are likely to benefit from PEP
300
How does rash for RMSF classically spread?
Early: Erythematous Rash affecting wrists, forearms, and ankles, then spreads centrally.
Late: Involves palms/soles, becomes petechial and purpuric
300
What medication can be used to speed up acclimatization and help prevent Acute Mountain Sickness / High Altitude Cerebral Edema.
Acetazolemide
300
This spider, native to the PNW, was taken of the venomous spider list in 2017. Its bite wounds are prone to secondary infections and should be treated by cleansing the area with soap and water.
What spider is this?
HOBO Spider!
400
Cold exposure resulting in tissue damage extending through epidermis and dermis resulting in hard edema and clear blisters is consistent with - 1st, 2nd, 3rd, or 4th degree frost bite?
2nd Degree Frost Bite
400
What is the preferred treatment for a patient presenting with bull's eye rash following a tick bite?
Bonus: Acceptable alternative regimens?
Preferred: Doxycycline 100mg PO BID x 10 days
Alternative:
- Amoxicillin 500mg PO q8h x 14 days
- Cefuroxime 500mg PO BID x 14 days
400
In pediatric patients being treated for RMSF with doxycycline, parents should be counseled that...
- Doxycycline will cause damage/staining to pediatric patient teeth, but it remains the preferred treatment.
- Doxycycline RMSF dosing is not associated with permanent damage/staining to pediatric patient teeth.
- Due to damage/staining to pediatric patient teeth, in uncomplicated RMSF cases, pediatric patients can be treated with a longer course of Amoxicillin
- Chloramphenicol 100mg/kg/day is an excepted alternative regimen to Doxycycline with nearly the same efficacy.
- Doxycycline RMSF dosing is not associated with permanent damage/staining to pediatric patient teeth.
- Chloramphenicol is the only alternative drug for treatment of RMSF, but is associated with increased risk of death compared to treatment with Doxy.
400
What is the initial Acid-Base disorder is associated with AMS?
Respiratory Alkalosis
400
Which of the following should you do following a venomous snake bite?
- Suck out the poison
- I&D any forming abscess
- Immobilize the affected extremity
- Try and Capture the Snake for intentification
- Apply an arterial tourniquet to the affected extremity
Immobilize the affected extremity
500
Which of the following is true in relation to CPR and Hypothermia?
- If there are no signs of life after 1 min of auscultation/palpation, then NO CPR.
- If there are any signs of life, you should withhold CPR until body temperature is >86 degrees.
- Fixed/Dilated pupils are a reliable way to call a death in a hypothermic patient.
- If there are no signs of life after 1 min of auscultation/palpation, then NO CPR. FALSE
- If there are any signs of life, you should withhold CPR until body temperature is >86 degrees. TRUE!
- Fixed/Dilated pupils are a reliable way to call a death in a hypothermic patient. FALSE
500
A patient from upstate NY presents to clinic after finding and removing a tick from his back after hiking 1 day prior. Which of the following would be appropriate?
- Draw Lyme IgM and IgG antibody testing in 72 hours
- Give the patient a single oral dose of Doxycycline
- Nothing at this point, monitor the patient for development of signs/symptoms of Lyme disease
- Give patient Lyme immunoglobulin Dose
Patients presenting within 72 hours after tick removal should be treated with single dose Doxycycline (Strong Recommendation with moderate quality evidence)
- Lyme IgM usually will not be positive until 10-14 days after developing infection (or 7-14 days after rash develops).
- This patient should be treated with Doxy, THEN monitored from there.
- Treating with Lyme Immunoglobulins is not a thing...
500
In your best dermatology terms, how would you describe this rash to an attending?
Maculopapular Rash
500
A 32 year male patient is ascending to the top of Mt. Kilimanjaro (p. 19,341') in Tanzania. He develops fatigue, weakness, dry cough, and dyspnea. Symptoms continue to increase, he is experiencing dyspnea at rest with sat 87%.
What diagnosis are you concerned about?
High Altitude Pulmonary Edema (HAPE)
There are a few medications that can help prevent this:
- Nifedipine 30mg q12h (slow release)
- PDE-5 inhibitors: Tadalafil 10mg q12; Sildenafil 50mg q8
500
What country is home to the worlds most deadliest snake? - China, India, Zambia, Brazil
How much is getting bit by a Rattle Snake going to cost? $15,000; $25,000; $90,000; $120,000; $185,000
Where is snake island? Brazil, Taiwan, Mexico, Madagascar, Japan
What is Snake Juice?
India - Russell's Viper
Treatment of Rattle Snake Bite: 6 vials of anti-venom, then 2 vials every 6 hours x 3, at $7,488/vial ~$90,000
Snake Island is in Brazil! (1-5 snake/m^2)
