environmental injuries part ii
TRANSCRIPT
![Page 1: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/1.jpg)
LOGO
Environmental Injuries Part II
![Page 2: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/2.jpg)
Heat EmergenciesDrowningLightning Injuries
![Page 3: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/3.jpg)
Heat Emergencies
![Page 4: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/4.jpg)
MODELS OF HEAT INJURY
Classic heat injury occurs during periods of high environmental heat
stress High-risk populations: the elderly, the young, and
those with psychological, physiologic, and pharmacologic impairments of heat loss mechanisms (e.g., diabetes; Raynaud's disease; drugs such as anticholinergics, diuretics, antipsychotics, cocaine).
![Page 5: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/5.jpg)
Exertional heat injury usually affects individuals who are participating in
athletic events or performing jobs under conditions of high heat stress
Confinement hyperpyrexia special category of nonexertional hyperpyrexia occur in several circumstances: when children
are left inside cars, when stowaways are abandoned inside closed vehicles or railroad cars, and when workers are occupationally exposed to heat inside enclosed spaces
![Page 6: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/6.jpg)
MINOR HEAT ILLNESSES
Heat edemaPrickly HeatHeat crampsHeat Stress
![Page 7: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/7.jpg)
Heat edema
self-limitedmild swelling of dependent extremitiescutaneous vasodilation and pooling of interstitial
fluid Treatment
elevation of the extremities compressive stockings Diuretics: exacerbate volume depletion, avoided
![Page 8: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/8.jpg)
Prickly Heat
Lichen tropicus, miliaria rubra, or heat rash
vesiculopapular eruption
clothed areas of the body
![Page 9: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/9.jpg)
Prickly Heat
inflammation and obstruction of sweat ductsTx: Antihistamines, low potency topical
corticosteroids, or calamine lotionAdvise patients to wear light, loose fitting
clothing.
![Page 10: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/10.jpg)
Heat cramps
painful muscle spasmsOccur when individuals replace evaporative
losses with free water but not with saltTreatment
rest administration of oral electrolyte solution or IV
normal saline
![Page 11: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/11.jpg)
Heat Stress
headache, nausea, vomiting, malaise, dizziness, and muscle cramps as well as signs of dehydration, such as tachycardia and orthostatic hypotension or near-syncope
Because of the ill-defined and nonspecific symptoms, heat stress is often a diagnosis of exclusion.
![Page 12: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/12.jpg)
Heat Stress
Tx: volume and electrolyte replacement, rest Removal from the heat-stressed environment mild heat stress: oral electrolyte solutions significant tissue hypoperfusion: rapid infusion of
moderate amounts of IV fluids (1-2 L of normal saline)
![Page 13: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/13.jpg)
HEAT STROKE
acute life-threatening emergency with high mortality and is fatal if left untreated
![Page 14: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/14.jpg)
HEAT STROKE
Exertional heat stroke usually occurs after strenuous physical activity in
a hot environmentNonexertional heat stroke
more commonly affects chronically ill or debilitated patients and persons at the extremes of age, especially during a prolonged heat wave
![Page 15: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/15.jpg)
HEAT STROKE
cardinal features hyperthermia (core temperature > 40°C) altered mental status
Anhidrosis / profuse sweating Prominent neurologic abnormalities
confusion, agitation, bizarre behavior, ataxia, seizures, obtundation, and coma
![Page 16: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/16.jpg)
HEAT STROKE
Diagnosis no diagnostic tests for heat strokedetermined by history and clinical presentation,
and exclusion of other processes
![Page 17: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/17.jpg)
![Page 18: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/18.jpg)
HEAT STROKE
Diagnosis Laboratory abnormalities
Respiratory alkalosis lactic acidosis hypoglycemia, hypophosphatemia and
hypokalemia, elevated liver enzymes due to hepatocellular damage, hypercalcemia and an elevated hematocrit due to hemoconcentration, and elevated creatine phosphokinase and myoglobin from rhabdomyolysis
DIC, renal failure
![Page 19: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/19.jpg)
HEAT STROKE
Treatmentgoals of therapy: immediate cooling and
aggressive support of organ system function
![Page 20: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/20.jpg)
HEAT STROKE
Emergency Department Care and DispositionABCEvaporative cooling
Place fans near the completely disrobed patient and spray the patient with tepid water.
Goal: core temperature <39°C
![Page 21: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/21.jpg)
HEAT STROKE
![Page 22: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/22.jpg)
HEAT STROKE
![Page 23: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/23.jpg)
HEAT STROKE
Emergency Department Care and DispositionSeizures: benzodiazepinesRhabdomyolysis: IV hydrationMonitor serum electrolytes every hour initially. admission to the ICU
![Page 24: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/24.jpg)
Drowning
![Page 25: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/25.jpg)
CLINICAL FEATURES
aspirate water into their lungs have washout of surfactant
diminished alveolar gas transfer, atelectasis,
ventilation perfusion mismatch, and hypoxia
Noncardiogenic pulmonary edemaMental status: normal - comatosehypothermia
![Page 26: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/26.jpg)
DIAGNOSIS AND DIFFERENTIAL
Evaluate patients for associated injuries (spinal cord) and underlying precipitating disorders including syncope, seizures, hypoglycemia, and acute myocardial infarction or dysrhythmias.
Respiratory acidosis metabolic acidosisEarly electrolyte disturbances: unusualA CXR is usually obtained but is frequently
normal in patients who are otherwise asymptomatic.
![Page 27: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/27.jpg)
![Page 28: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/28.jpg)
EMERGENCY DEPARTMENT CARE AND DISPOSITION
![Page 29: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/29.jpg)
![Page 30: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/30.jpg)
![Page 31: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/31.jpg)
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Measure core temperature. Treat hypothermia if present.
Data do not support routine antibiotic prophylaxis for pulmonary aspiration.
Efforts at “brain resuscitation,” have not shown benefit. mannitol, loop diuretics, hypertonic saline, fluid
restriction, mechanical hyperventilation, controlled hypothermia, barbiturate coma, and intracranial pressure monitoring
![Page 32: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/32.jpg)
EMERGENCY DEPARTMENT CARE AND DISPOSITION
Hypothermic victims of cold-water submersion with cardiac arrest should undergo prolonged and aggressive resuscitation maneuvers until they are normothermic or considered not viable.
![Page 33: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/33.jpg)
LIGHTNING INJURIES
![Page 34: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/34.jpg)
most common in fishermen, but also occur in other outdoor recreational activities such as golf and camping
Approximately 70%-90% of persons struck by lightning survive, but as many as ¾ of these survivors have permanent sequelae.
![Page 35: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/35.jpg)
![Page 36: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/36.jpg)
PATHOPHYSIOLOGY
often travels over the surface of the body in a phenomenon called flashover
less likely to cause internal cardiac injury or muscle necrosis
Lightning emits brief but intense thermal radiation that produces rapid heating and expansion of the surrounding air.
Tympanic membrane perforation and internal organ contusion may occur.
![Page 37: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/37.jpg)
PATHOPHYSIOLOGY
Stunning (keraunoparalysis)produce a variety of neurologic signs and
symptomsKeraunoparalysis is associated with successful
resuscitation after cardiorespiratory arrest.
![Page 38: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/38.jpg)
TYPES OF LIGHTNING STRIKES
Both cardiac and respiratory arrest may be present without evidence of external injury.
![Page 39: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/39.jpg)
CARE AT THE SCENE
In contrast to patients with cardiac arrest caused by mechanical trauma, persons with lightning injury who appear to be dead (in respiratory arrest, with or without cardiac arrest) should be treated first.
Such victims may have little physical damage, and they have a reasonable chance of successful resuscitation.
Prolonged CPR is sometimes successful.
![Page 40: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/40.jpg)
ED DIAGNOSIS AND TREATMENT
ABCsLightning victims in cardiac arrest have a better
prognosis than those in cardiac arrest from coronary artery disease, so aggressive resuscitative efforts are indicated.
Initial ancillary studies: CBC, serum electrolyte levels, creatinine level, BUN level, glucose level, creatine kinase level, urinalysis, and ECG.
![Page 41: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/41.jpg)
![Page 42: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/42.jpg)
Lichtenberg figures
![Page 43: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/43.jpg)
Diagnosis and Differential
Considered in any critically ill patient found outside during or after a thunderstorm
Differential diagnosis stroke or intracranial hemorrhage seizure disorder cerebral, spinal cord, or other neurologic trauma
![Page 44: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/44.jpg)
Emergency Department Care and Disposition
provide aggressive resuscitation in patients with respiratory and cardiac arrest due to lightning strike
Treat traumatic injuries using standard trauma protocols.
Treat arrhythmias using standard ACLS protocols.
Treat seizures with standard therapy.
![Page 45: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/45.jpg)
Treat keraunoparalysis with expectant management.
Administer tetanus prophylaxis, if not up to date.Admit
persistent musculoskeletal symptoms, neurologic, cardiac rhythm or vascular abnormalities, or significant burns
Patients with minor injuries and a negative workup may be discharged with outpatient follow-up to assess delayed effects of lightening injury.
![Page 46: Environmental injuries part ii](https://reader034.vdocument.in/reader034/viewer/2022042907/587a2b821a28abbd388b63b1/html5/thumbnails/46.jpg)
ANY QUESTION?